[Relations with emergency medical care and primary care doctor, home health care].

Medical care for an ultra-aging society has been shifted from hospital-centered to local community-based. This shift has yielded the so-called Integrated Community Care System. In the system, emergency medical care is considered important, as primary care doctors and home health care providers play a crucial role in coordinating with the department of emergency medicine. Since the patients move depending on their physical condition, a hospital and a community should collaborate in providing a circulating service. The revision of the medical payment system in 2014 clearly states the importance of "functional differentiation and strengthen and coordination of medical institutions, improvement of home health care". As part of the revision, the subacute care unit has been integrated into the community care unit, which is expected to have more than one role in community coordination. The medical fee has been set for the purpose of promoting the home medical care visit, and enhancing the capability of family doctors. In the section of end-of-life care for the elderly, there have been many issues such as reduction of the readmission rate and endorsement of a patient's decision-making, and judgment for active emergency medical care for patient admission. The concept of frailty as an indicator of prognosis has been introduced, which might be applied to the future of emergency medicine. As described above, the importance of a primary doctor and a family doctor should be identified more in the future; thereby it becomes essential for doctors to closely work with the hospital. Advancing the cooperation between a hospital and a community for seamless patient-centered care, the emergency medicine as an integrated community care will further develop by adapting to an ultra-aging society.

The pace of change in medical practice and health policy: collision or coexistence?

Medical practice and health policy are both changing rapidly. While the adopting of changes is not new for physicians, the pace of change in standards of care, marked by advances and reversals, has accelerated over the course of the past decade. A recurring new theme in medical practice has been an emphasis on tailoring treatment plans to individual patients. Physicians have had to simultaneously absorb new processes in the health care system brought about by the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 and the Affordable Care Act (ACA) in 2010. The ability of physicians to maintain standards of care that focus on individual patients may conflict with changes resulting from new health policies that emphasize population health management. Primary care physicians may be one of the few collective voices capable of identifying areas where population-level health policies conflict with the care of individual patients, and policymakers should include practicing primary care physicians in the form of community boards in order to ensure the development of new health policies that provide sustainable high-value patient care.

[Prevention of noncommunicable diseases in a local therapist's practice: content, problems, solution ways, and prospects].

High-risk and secondary prevention strategies for noncommunicable diseases in primary health care are mainly implemented by local therapists. The large-scale clinical examination of an adult population (a high-risk strategy), which has been launched in the country since 2013 to solve the problems of detecting people with noncommunicable diseases and their risk factors and making a prevention counseling, is simultaneously a mechanism for the formation of a full therapeutic area passport to identify follow-up groups (a secondary prevention strategy). Currently, there is an obviously insufficient follow-up of inadequate quality. The reasons for this situation are a lack of regular training of local doctors in follow-up in addition to staff shortages. Medical teachers and professional communities working on the basis of common guidelines must be attracted to solve this problem. The actual introduction of a local therapist's efficient performance measures, the setting up of special structures in charge of primary care prevention in the health authorities, and the active involvement of medical prevention and health centers (for people at high risk in the absence of proven non-communicable diseases) in this process will be able to enhance the efficiency of a follow-up. Information technologies, including a tele-follow-up, are an important reserve in implementing the high-risk and secondary prevention strategies.

The implications of the feminization of the primary care physician workforce on service supply: a systematic review.

There is a widespread perception that the increasing proportion of female physicians in most developed countries is contributing to a primary care service shortage because females work less and provide less patient care compared with their male counterparts. There has, however, been no comprehensive investigation of the effects of primary care physician (PCP) workforce feminization on service supply. We undertook a systematic review to examine the current evidence that quantifies the effect of feminization on time spent working, intensity and scope of work, and practice characteristics. We searched Medline, Embase, and Web of Science from 1991 to 2013 using variations of the terms 'primary care', 'women', 'manpower', and 'supply and distribution'; screened the abstracts of all articles; and entered those meeting our inclusion criteria into a data abstraction tool. Original research comparing male to female PCPs on measures of years of practice, time spent working, intensity of work, scope of work, or practice characteristics was included. We screened 1,271 unique abstracts and selected 74 studies for full-text review. Of these, 34 met the inclusion criteria. Years of practice, hours of work, intensity of work, scope of work, and practice characteristics featured in 12%, 53%, 42%, 50%, and 21% of studies respectively. Female PCPs self-report fewer hours of work than male PCPs, have fewer patient encounters, and deliver fewer services, but spend longer with their patients during a contact and deal with more separate presenting problems in one visit. They write fewer prescriptions but refer to diagnostic services and specialist physicians more often. The studies included in this review suggest that the feminization of the workforce is likely to have a small negative impact on the availability of primary health care services, and that the drivers of observed differences between male and female PCPs are complex and nuanced. The true scale of the impact of these findings on future effective physician supply is difficult to determine with currently available evidence, given that few studies looked at trends over time, and results from those that did are inconsistent. Additional research examining gender differences in practice patterns and scope of work is warranted.

Assessment of Physician Priorities in Delivery of Preventive Care.

Importance: Primary care physicians have limited time to discuss preventive care, but it is unknown how they prioritize recommended services. Objective: To understand primary care physicians' prioritization of preventive services. Design, Setting, and Participants: This online survey was administered to primary care physicians in a large health care system from March 17 to May 12, 2017. Physicians were asked whether they prioritize preventive services and which factors contribute to their choice (5-point Likert scale). Results were analyzed from July 8, 2017, to September 19, 2019. Exposures: A 2 × 2 factorial design of 2 hypothetical patients: (1) a 50-year-old white woman with hypertension, type 2 diabetes, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of breast cancer; and (2) a 45-year-old black man with hypertension, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of colorectal cancer. Two visit lengths (40 minutes vs 20 minutes) were given. Each patient was eligible for at least 11 preventive services. Main Outcomes and Measures: Physicians rated their likelihood of discussing each service during the visit and reported their top 3 priorities for patients 1 and 2. Physician choices were compared with the preventive services most likely to improve life expectancy, using a previously published mathematical model. Results: Of 241 physicians, 137 responded (57%), of whom 74 (54%) were female and 85 (62%) were younger than 50 years. Physicians agreed they prioritized preventive services (mean score, 4.27 [95% CI, 4.12-4.42] of 5.00), mostly by ability to improve quality (4.56 [95% CI, 4.44-4.68] of 5.00) or length (4.53 [95% CI, 4.40-4.66] of 5.00) of life. Physicians reported more prioritization in the 20- vs 40-minute visit, indicating that they were likely to discuss fewer services during the shorter visit (median, 5 [interquartile range {IQR}, 3-8] vs 11 [IQR, 9-13] preventive services for patient 1, and 4 [IQR, 3-6] vs 9 [IQR, 8-11] for patient 2). Physicians reported similar top 3 priorities for both patients: smoking cessation, hypertension control, and glycemic control for patient 1 and smoking cessation, hypertension control, and colorectal cancer screening for patient 2. Physicians' top 3 priorities did not usually include diet and exercise or weight loss (ranked in their top 3 recommendations for either patient by only 48 physicians [35%]), although these were among the 3 preventive services most likely to improve life expectancy based on the mathematical model. Conclusions and Relevance: In this survey study, physicians prioritized preventive services under time constraints, but priorities did not vary across patients. Physicians did not prioritize lifestyle interventions despite large potential benefits. Future research should consider whether physicians and patients would benefit from guidance on preventive care priorities.

Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review.

PURPOSE: The authors conducted a systematic review of the medical literature to determine the factors most strongly associated with localizing primary care physicians (PCPs) in underserved urban or rural areas of the United States. METHOD: In November 2015, the authors searched databases (MEDLINE, ERIC, SCOPUS) and Google Scholar to identify published peer-reviewed studies that focused on PCPs and reported practice location outcomes that included U.S. underserved urban or rural areas. Studies focusing on practice intentions, nonphysicians, patient panel composition, or retention/turnover were excluded. They screened 4,130 titles and reviewed 284 full-text articles. RESULTS: Seventy-two observational or case-control studies met inclusion criteria. These were categorized into four broad themes aligned with prior literature: 19 studies focused on physician characteristics, 13 on financial factors, 20 on medical school curricula/programs, and 20 on graduate medical education (GME) programs. Studies found significant relationships between physician race/ethnicity and language and practice in underserved areas. Multiple studies demonstrated significant associations between financial factors (e.g., debt or incentives) and underserved or rural practice, independent of preexisting trainee characteristics. There was also evidence that medical school and GME programs were effective in training PCPs who locate in underserved areas. CONCLUSIONS: Both financial incentives and special training programs could be used to support trainees with the personal characteristics associated with practicing in underserved or rural areas. Expanding and replicating medical school curricula and programs proven to produce clinicians who practice in underserved urban or rural areas should be a strategic investment for medical education and future research.

Investigating the sustainability of careers in academic primary care in the United Kingdom.

BACKGROUND: The UK Society for Academic Primary Care (SAPC) is re-examining the sustainability of careers in academic primary care (APC). The motivation for this is a number of significant changes within the context of APC since the last such investigation (SAPC, 2003). It is now timely to review the current situation. METHODS: As a first phase, semi-structured interviews were undertaken with 15 SAPC members from different disciplines and career stages. RESULTS: Findings show that lack of clarity about APC career pathways persist, but important factors linked with sustainability were identified at individual and organisational levels. These include being proactive, developing resilience, mentorship and a positive organisational culture with a strong shared vision about why APC is important. FURTHER RESEARCH: Sustainability is undermined by funding difficulties, lack of integration of members of different APC disciplines, leading to disparities in career progression and lack of clarity about what APC is. Phase 2 will comprise a UK-wide survey.

Incorporating population medicine into primary care residency training.

BACKGROUND AND OBJECTIVES: Expanded competencies in population health and systems-based medicine have been identified as a need for primary care physicians. Incorporating formal training in preventive medicine is one method of accomplishing this objective. METHODS: We identified three family medicine residencies that have developed formal integrated pathways for residents to also complete preventive medicine residency requirements during their training period. Although there are differences, each pathway incorporates a structured approach to dual residency training and includes formal curriculum that expands resident competencies in population health and systems-based medicine. RESULTS: A total of 26 graduates have completed the formally combined family and preventive medicine residencies. All are board certified in family medicine, and 22 are board certified in preventive medicine. Graduates work in a variety of academic, quality improvement, community, and international settings utilizing their clinical skills as well as their population medicine competencies. Dual training has been beneficial in job acquisition and satisfaction. CONCLUSIONS: Incorporation of formal preventive medicine training into family medicine education is a viable way to use a structured format to expand competencies in population medicine for primary care physicians. This type of training, or modifications of it, should be part of the debate in primary care residency redesign.