Storylines of family medicine II: foundational building blocks-context, community and health.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'II: foundational building blocks-context, community and health', authors address the following themes: 'Context-grounding family medicine in time, place and being', 'Recentring community', 'Community-oriented primary care', 'Embeddedness in practice', 'The meaning of health', 'Disease, illness and sickness-core concepts', 'The biopsychosocial model', 'The biopsychosocial approach' and 'Family medicine as social medicine.' May readers grasp new implications for medical education and practice in these essays.

Identifying Facilitators and Barriers to Increasing COVID-19 Vaccination and Trial Participation in Vaccinated Vietnamese Americans.

Background: Preventing morbidity and mortality from COVID-19 requires reaching diverse communities. Purpose: To identify facilitators and barriers to COVID-19 immunization and COVID-19 clinical trial participation in the vaccinated Vietnamese American population in Houston, TX. Methods: Community-based qualitative study using focus groups and key informant interviews. Results: Themes that emerged included culturally appropriate language, generational differences, and a collectivist approach. Conclusion: Promoting science-based information through trusted messengers, improving awareness and access, and illuminating benefits to the community could increase the uptake of COVID-19 vaccines and volunteering for therapeutic trials among Vietnamese Americans.

Medical School Characteristics, Policies, and Practices That Support Primary Care Specialty Choice: A Scoping Review of 5 Decades of Research.

BACKGROUND AND OBJECTIVES: The United States, like many other nations, faces a chronic shortage of primary care physicians. The purpose of this scoping review was to synthesize literature describing evidence-based institutional practices and interventions that support medical students' choices of primary care specialties, published in the United States, Canada, Australia, and New Zealand. METHODS: We surveyed peer-reviewed, published research. An experienced medical librarian conducted searches of multiple databases. Articles were selected for inclusion based on explicit criteria. We charted articles by topic, methodology, year of publication, journal, country of origin, and presence or absence of funding. We then scored included articles for quality. Finally, we defined and described six common stages of development of institutional interventions. RESULTS: We reviewed 8,083 articles and identified 199 articles meeting inclusion criteria and 41 related articles. As a group, studies were of low quality, but improved over time. Most were quantitative studies conducted in the United States. Many studies utilized one of four common methodologic approaches: retrospective surveys, studies of programs or curricula, large-scale multi-institution comparisons, and single-institution exemplars. Most studies developed groundwork or examined effectiveness or impact, with few studies of planning or piloting. Few studies examined state or regional workforce outcomes. CONCLUSIONS: Research examining medical school interventions and institutional practices to support primary care specialty choice would benefit from stronger theoretical grounding, greater investment in planning and piloting, consistent use of language, more qualitative methods, and innovative approaches. Robust funding mechanisms are needed to advance these goals.

Impact of Curricula and Electives on Primary Care Specialty Choice: A Narrative Synthesis.

BACKGROUND AND OBJECTIVES: Educational components and electives that may influence medical student choice of primary care careers have been studied individually, but not reviewed or synthesized. Examining educational components and electives in a comprehensive manner may inform evidence-based approaches to raise the number of primary care physicians in the United States and help optimize use of finite resources. We sought to determine evidence-based educational components and electives associated with increased medical student choice of primary care careers. METHODS: We searched PubMed, Scopus, and CINAHL for undergraduate medical education articles in English describing an educational component or elective and outcome relevant to primary care specialty choice. We assessed titles, then abstracts, and finally full texts for inclusion in a narrative synthesis. RESULTS: The searches returned 11,211 articles and we found 42 that met the inclusion criteria. The most described components were outpatient clinical rotations, preclinical courses, and preceptorships. The most common electives were international health, summer preceptorships, and rural medicine. While most articles described curricula that appeared to have a positive correlation with primary care specialty choice, six articles found limited benefit. In sum, results were mixed. CONCLUSIONS: The current literature is limited, and many contemporary electives have not been studied with respect to primary care choice. Increased attention and funding to studying the impact of electives and other educational components on primary care specialty choice is warranted.

Black Lives Matter: Moving from passion to action in academic medical institutions.

The year 2020 opened the eyes of many to the structures of racism that persist in our country. As the visceral urgency of those galvanizing moments fade, organizations must move beyond releasing supportive statements and determining how they can live up to their stated values. To truly support Black lives, academic medical centers (AMCs) must commit to critically examine and improve the manner in which daily practices, culture, and context uplift Black students, health care professionals, and patients to achieve health equity. One step is to create a culture that is willing to listen and improve when people express discomfort or report mistreatment in order to retain people who are underrepresented in medicine (URiM) in a welcoming environment. Academic centers should address microaggressions to create a safe work and learning atmosphere. Then, ensure that faculty, trainees, and staff represent the demographics of the communities in which institutions are situated. Recruiting and retaining an inclusive health care workforce must be systematic and intentional to achieve representation. Studies have shown that racial and ethnic concordance between providers and patients improves patient satisfaction and health outcomes. Further, business studies have shown that racially diverse leadership teams outperform teams that are more homogenous. Diversity benefits colleagues, learners, and patients by considering different perspectives and improving problem solving. Additionally, AMCss should teach about structural racism as a social determinant of health to raise awareness of a common cause of health disparities and understand why patients of color may distrust the medical system. Furthermore, academic centers should work with local leaders to assess needs and provide community benefits and advocate for policies that meet those needs. While there are some challenges in starting these conversations in our institutions, changing the status quo is necessary to achieve health equity for all.

Hyperpigmentation of the legs.

Was a drug or a comorbidity to blame for this patient's hyperpigmentation?

Formal Advocacy Curricula in Family Medicine Residencies: A CERA Survey of Program Directors.

BACKGROUND AND OBJECTIVES: Health advocacy has been declared an essential physician skill in numerous professional physician charters. However, there is limited literature on whether, and how, family medicine residencies teach this skill. Our aim was to determine the prevalence of a formal mandatory advocacy curriculum among US family medicine residencies, barriers to implementation, and what characteristics might predict its presence. METHODS: Questions about residency advocacy curricula, residency characteristics, and program director (PD) attitudes toward family medicine and advocacy were included in the 2017 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency PDs. We used univariate and bivariate statistics to describe residency characteristics, PD attitudes, the presence of a formal advocacy curriculum, and the relationship between these. RESULTS: Of 478 PDs, 261 (54.6%) responded to the survey and 236/261 (90.4%) completed the full advocacy module. Just over one-third (37.7%, (89/236)) of residencies reported the presence of a mandatory formal advocacy curriculum, of which 86.7% (78/89) focused on community advocacy. The most common barrier was curricular flexibility. Having an advocacy curriculum was positively associated with faculty experience and optimistic PD attitudes toward advocacy. CONCLUSIONS: In a national survey of family medicine PDs, only one-third of responding PDs reported a mandatory advocacy curriculum, most focusing on community advocacy. The largest barrier to implementation was curricular flexibility. More research is needed to explore the best strategies to implement these types of curricula and the long-term impacts of formal training.

Factors Affecting Specialty Choice Among Doctors Who Received Tuition Scholarships.

BACKGROUND AND OBJECTIVES: The United States is projected to have a shortage of up to 46,000 primary care physicians by 2025. In many cases, medical students appear to select other specialties for financial reasons, including educational debt. Physicians who were part of two BS/MD programs and received full tuition and fee scholarships for college and medical school were surveyed to examine factors that may have impacted their specialty choice. This population of US students was selected because they do not have educational debt, so their choices could be examined independent of this influence. METHODS: One hundred forty physicians who graduated from the programs as of June 2013 were invited to complete a 32-question online survey. Descriptive statistics described the population. χ2 tests and nonparametric Wilcoxon rank-sum (Mann-Whitney) tests compared primary care and nonprimary care physicians as well as those initially interested in primary care who changed before medical school graduation versus those who went into primary care. Factor analysis and Student t-test examined trends among Likert scale questions. RESULTS: For the physicians for whom contact information was available, 74 (53%) responded. Out of 74 respondents, 18 (24%) went into primary care. Perceptions of family medicine, comments from faculty, and lifestyle played a role in deterring students from primary care. CONCLUSIONS: Full tuition and fee scholarships alone were not associated with more students choosing primary care.

Public health implications of overscreening for carotid artery stenosis, prediabetes, and thyroid cancer.

BACKGROUND: Overscreening occurs when people without symptoms undergo tests for diseases and the results will not improve their health. In this commentary, we examine three examples of how campaigns to screen and treat specific vascular, metabolic, and oncologic diseases in asymptomatic individuals have produced substantial overdiagnosis and may well have contributed to more harm than good. These conditions were chosen because they may not be as well known as other cases such as screening for breast or prostate cancer. MAIN TEXT: Screening for carotid artery stenosis can be a lucrative business using portable equipment and mobile vans. While this fatty buildup of plaque in the arteries of the neck is one risk factor for ischemic stroke, current evidence does not suggest that performing carotid dopplers to screen for CAS reduces the incidence of stroke or provide long-term benefits. After a positive screening, the follow-up procedures can lead to heart attacks, bleeding, strokes, and even death. Similarly, many organizations have launched campaigns for "prediabetes awareness." Screening for prediabetes with a blood sugar test does not decrease mortality or cardiovascular events. Identifying people with prediabetes could lead to psychological stress and starting medication that may have significant side effects. Finally, palpating people's necks or examining them with ultrasounds for thyroid cancer is common in many countries but ineffective in reducing mortality. Deadly forms of thyroid cancer are rare, and the overall 5-year survival rate is excellent. Interventions from treatment for more prevalent, less aggressive forms of thyroid cancer can lead to surgical complications, radiation side effects, or require lifelong thyroid replacement therapy. CONCLUSIONS: Screening for carotid artery stenosis, prediabetes, and thyroid cancer in an asymptomatic population can result in unnecessary, harmful, and costly care. Systemic challenges to lowering overscreening include lack of clinician awareness, examination of conflicts of interests, perverse financial incentives, and communication with the general public.

Faculty development in family medicine education: what is needed?

A growing number of countries are embracing graduate training in the specialty of Family Medicine as a core component of global health systems reform. One significant challenge for new programs is to adequately prepare for educational excellence and leadership. Promising residents are often encouraged to remain in their program as faculty, but may not have had the benefit of specific training in teaching, curriculum development, learner assessment or educational leadership. Faculty Development is a potential avenue to providing these skills to new Family Medicine Faculty and to encourage new graduates to consider teaching. We are currently seeking to further clarify what the current needs and future possibilities are for Family Medicine Faculty Development in Sub-Saharan Africa.

Current Status of Family Medicine Faculty Development in Sub-Saharan Africa.

BACKGROUND AND OBJECTIVES: Reducing the shortage of primary care physicians in sub-Saharan Africa requires expansion of training programs in family medicine. Challenges remain in preparing, recruiting, and retaining faculty qualified to teach in these pioneering programs. Little is known about the unique faculty development needs of family medicine faculty within the sub-Saharan African context. The purpose of this study was to assess the current status and future needs for developing robust family medicine faculty in sub-Saharan Africa. The results are reported in two companion articles. METHODS: A cross-sectional study design was used to conduct a qualitative needs assessment comprising 37 in-depth, semi-structured interviews of individual faculty trainers from postgraduate family medicine training programs in eight sub-Saharan African countries. Data were analyzed according to qualitative description. RESULTS: While faculty development opportunities in sub-Saharan Africa were identified, current faculty note many barriers to faculty development and limited participation in available programs. Faculty value teaching competency, but institutional structures do not provide adequate support. CONCLUSIONS: Sub-Saharan African family physicians and postgraduate trainee physicians value good teachers and recognize that clinical training alone does not provide all of the skills needed by educators. The current status of limited resources of institutions and individuals constrain faculty development efforts. Where faculty development opportunities do exist, they are too infrequent or otherwise inaccessible to provide trainers the necessary skills to help them succeed as educators.

Future of Family Medicine Faculty Development in Sub-Saharan Africa.

BACKGROUND AND OBJECTIVES: High-quality family medicine education is needed in sub-Saharan Africa to facilitate the future growth of primary care health systems. Current faculty educators recognize the value of dedicated teacher training and ongoing faculty development. However, they are constrained by inadequate faculty development program availability and institutional support. METHODS: A cross-sectional study design was used to conduct a qualitative needs assessment comprised of 37 in-depth, semi-structured interviews of individual faculty trainers from postgraduate family medicine training programs in eight sub-Saharan African countries. Data were analyzed according to qualitative description. RESULTS: Informants described desired qualities for a family medicine educator in sub-Saharan Africa: (1) pedagogical expertise in topics and perspectives unique to family medicine, (2) engagement in self-directed, lifelong learning, and (3) exemplary character and behavior that inspires others. Informant recommendations to guide the development of faculty development programs include: (1) sustainability, partnership, and responsiveness to the needs of the institution, (2) intentional faculty development must begin early and be supported with high-quality mentorship, (3) presumptions of teaching competence based on clinical training must be overcome, and (4) evaluation and feedback are critical components of faculty development. CONCLUSIONS: High-quality faculty development in family medicine is critically important to the primary care workforce in sub-Saharan Africa. Our study describes specific needs and recommendations for family medicine faculty development in sub-Saharan Africa. Next steps include piloting and evaluating innovative models of faculty development that respond to specific institutional or regional needs.

In rat inner medullary collecting duct, NH uptake by the Na,K-ATPase is increased during hypokalemia.

In rat terminal inner medullary collecting duct (tIMCD), the Na,K-ATPase mediates NH uptake, which increases secretion of net H(+) equivalents. K(+) and NH compete for a common binding site on the Na,K-ATPase. Therefore, NH uptake should increase during hypokalemia because interstitial K(+) concentration is reduced. We asked whether upregulation of the Na,K-ATPase during hypokalemia also increases basolateral NH uptake. To induce hypokalemia, rats ate a diet with a low K(+) content. In tIMCD tubules from rats given 3 days of dietary K(+) restriction, Na,K-ATPase beta(1)-subunit (NK-beta(1)) protein expression increased although NK-alpha(1) protein expression and Na,K-ATPase activity were unchanged relative to K(+)-replete controls. However, after 7 days of K(+) restriction, both NK-alpha(1) and NK-beta(1) subunit protein expression and Na,K-ATPase activity increased. The magnitude of Na,K-ATPase-mediated NH uptake across the basolateral membrane (J) was determined in tIMCD tubules perfused in vitro from rats after 3 days of a normal or a K(+)-restricted diet. J was the same in tubules from rats on either diet when measured at the same extracellular K(+) concentration. However, in either treatment group, increasing K(+) concentration from 10 to 30 mM reduced J >60%. In conclusion, with 3 days of K(+) restriction, NH uptake by Na,K-ATPase is increased in the tIMCD primarily from the reduced interstitial K(+) concentration.