Storylines of family medicine III: core principles-primary care, systems and family.

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 'III: core principles-primary care, systems, and family', authors address the following themes: 'Continuity of care-building therapeutic relationships over time', 'Comprehensiveness-combining breadth and depth of scope', 'Coordination of care-managing multiple realities', 'Access to care-intersectional, systemic, and personal', 'Systems theory-a core value in patient-centered care', 'Family-oriented practice-supporting patients' health and well-being', 'Family physician as family member' and 'Family in the exam room'. May readers develop new understandings from these essays.

Addressing Sexual Harassment and Gender Bias: Mandatory Modules Are Not Enough.

BACKGROUND AND OBJECTIVES: Despite decades of new policy guidelines and mandatory training modules, sexual harassment (SH) and gender bias (GB) continue in academic medicine. The hierarchical structure of medical training makes it challenging to act when one experiences or witnesses SH or GB. Most trainings designed to address SH and GB are driven by external mandates and do not utilize current educational techniques. Our goal was to design training that is in-person, active, and directed toward skills development. METHODS: Our academic family medicine (FM) department began by surveying our faculty and residents about their lived experiences of SH and GB. We used these data, incorporating principles of adult learning, to deliver voluntary, experiential, interactive workshops throughout 2019. The workshops took place during faculty development meetings and an annual retreat. We used interactive techniques that included case-based and Theater of the Oppressed formats. OUTCOMES: Eighty percent of faculty and residents participated in at least one of our voluntary training sessions. In April of 2020, we administered a retrospective, pre/postsurvey on confidence in recognizing, responding to, and reporting SH and GB. We found significant improvements in all domains surveyed; many participants reported using the skills in the 6 months prior to completing the surveys. CONCLUSION: We demonstrated that voluntary, interactive training sessions using the recommendations of the National Academies of Science Engineering and Medicine Report on the Sexual Harassment of Women improve participants' reported confidence in recognizing, responding to, and reporting SH and GB in one academic FM department. This training intervention is practical and can be disseminated and implemented in many settings.

Evaluating the Uptake of Antiracism Training, Policies, and Practices in Departments of Family Medicine.

BACKGROUND: Recent attention and focus on, antiracism training in health care has potential to accelerate our path to social justice and achieve health equity on a national scale. However, theoretical frameworks and empirical data have yet to emerge that explain the uptake of antiracism trainings and their efficacy. OBJECTIVE: This goal of this study was to test hypotheses regarding uptake of antiracism training in Family Medicine departments using Diffusion of Innovation Theory. METHODS: In 2021, we incorporated 10 survey items in the Council of Academic Family Medicine Educational Research Alliance's national omnibus survey for Department of Family Medicine Chairs (n = 104). We used DOI (Diffusion of Innovation) attributes (ie, relative advantage, compatibility, complexity, trialability, and observability) as a guiding framework to assess perceived innovation of antiracism training. We also evaluated the mode of training (eg, didactic, experiential) and whether any subsequent policy or practice-level antiracist actions occurred. We used c2 tests to examine associations between DOI attributes and antiracist actions; and logistic regression to determine odds of association. RESULTS: Ninety-two percent of respondents indicated antiracism training was happening in their department. Relative advantage, compatibility and observability were positively associated with antiracist actions, P < .05. Perceived relative advantage was associated with implementation of antiracist action (OR 1.94, 1.27-2.99). Complexity and trialability were not statistically significantly associated with action. CONCLUSION: Our findings provide evidence of DOIs influence on antiracism uptake in Departments of Family Medicine. We believe our findings can facilitate the future implementation of antiracism training activities and actionable antiracist policies and practices.

Training Family Medicine Residents to Address the COVID-19 Pandemic: A National Survey of Program Directors.

BACKGROUND AND OBJECTIVES: Public health training became particularly important for family medicine (FM) residency training programs amid the COVID-19 pandemic; the Accreditation Council for Graduate Medical Education (ACGME IV.C.19) requires a structured curriculum in which residents address population health. Our primary goal was to understand if, and to what extent, public health interventions trainings were incorporated into FM residency training programs amid the COVID-19 pandemic. We hypothesized programs with more resources (eg, university affiliates) would be better able to incorporate the training compared to those without such resources (ie, nonuniversity affiliates). METHODS: In 2021, we incorporated items addressing COVID-19 public health training competencies into the 2021 Council of Academic Family Medicine Educational Research Alliance national survey of FM residency program directors. The items addressed the type of training provided, mode of delivery, barriers to providing training, perceived importance of training, and support in delivering training. RESULTS: The overall survey response rate was 46.4% (n=287/619). All programs offered at least some training to residents. There were no statistically significant differences in training intensity between university and nonuniversity affiliates. The length of time an FM residency director spent in their position was positively associated with training intensity (r=0.1430, P=.0252). The biggest barrier to providing the trainings was the need to devote time to other curriculum requirements. CONCLUSIONS: FM residency programs were able to provide some public health interventions training during the pandemic. With increased support and resources, FM resident training curricula may better prepare FM residents now in anticipation of a future pandemic.

Sexual Harassment and Gender Bias in Family Medicine: Divergent Experiences of Men and Women.

BACKGROUND AND OBJECTIVES: Awareness of sexual harassment (SH), gender bias (GB), and gender discrimination (GD) has spread throughout popular culture and has been highlighted at universities across the United States. More nuanced data is needed to inform policies that address these issues. However, there are currently limited qualitative studies examining the nature of SH, GB, and GD in academic medicine, particularly family medicine. METHODS: In 2018, we conducted a series of gender-specific focus groups with faculty and residents in a department of family medicine (DFM) to understand their experiences with and responses to SH, GB, and GD. The focus groups were transcribed verbatim. We used immersion-crystallization and an adapted SH Experiences model to review the transcripts and identify patterns or themes during the immersion process. RESULTS: Participants identified the potential for patients, colleagues, faculty, and themselves as perpetrators and victims of SH, GB, and GD. Results suggested that GB was often implicit. SH was experienced verbally and physically. Women participants, especially, reported that both SH and GB occurred frequently and had lasting psychological effects. Gender, age, and position (faculty vs trainee) moderated SH and GB experiences. The effects seemed to be mediated by moral distress. CONCLUSIONS: This study emphasizes the importance of recognizing differences in experiences across gender, age, and position of SH, GB, and GD in academic family medicine. Our findings can be leveraged to develop antiharassment policies and set cultural expectations.

Leveraging Integrated Primary Care to Address Patients' and Families' Unmet Social Needs: Aligning Practice with National Academy of Sciences, Engineering and Medicine Recommendations.

Primary care is well-poised to address unmet social needs that affect health. Integrated primary care is increasingly common and can be leveraged to facilitate identification of practice and clinician-level modifiable characteristics and assist practices to address unmet social needs for patients and families. A recent National Academies of Sciences, Engineering, and Medicine (NASEM)'s consensus report identified 5 critical system-level activities to facilitate the integration of addressing social needs into health care: awareness (ask patients), adjustment (flexible intervention delivery), assistance (intervention to address the social need), alignment (link with community resources), and advocacy (policy change). This article outlines how integrated primary care characteristics, such as routine screening, functional workflows, interprofessional team communication, and patient-centered practices, exemplify the NASEM report's activities and offer robust biopsychosocial tools for addressing social needs. We provide a case to illustrate how these strategies might be used in practice.

Teaching family-oriented care to family medicine residents: Evaluation of a family skills curriculum.

INTRODUCTION: Family-oriented care is at the heart of family medicine (FM) practice, yet research suggests an unmet need for family skills training in FM residencies. The purpose of this study is to evaluate family-oriented (FO) attitudes and observed skills of FM residents before and after completion of a longitudinal family skills curriculum. METHOD: We assessed FO attitudes and observed skills of second-year FM residents (N = 12) using the "Family in Medicine" Q-sort exercise (Q-sort) and the Family-Centered Observation Form (FCOF) before and after completion of the family systems "Practicum" portion of a 20-week psychosocial medicine curriculum. Residents were observed in 19 pre- and 15 post-Practicum encounters. RESULTS: With regard to attitudes, 10 of 12 (83%) residents had a moderate to strong affinity for the FO viewpoint pre-Practicum; 9 of 12 (75%) maintained or strengthened their FO viewpoint post-Practicum. With regard to observed skills, FO visit content increased post-Practicum; 10/15 (67%) post-Practicum encounters included FO comments or questions compared to 5/19 (26%) pre-Practicum encounters. DISCUSSION: In this curriculum evaluation, we found our FM residents to have strong baseline FO attitudes that generally became stronger after a family skills curriculum. FO behaviors increased post-Practicum, though were still demonstrated relatively infrequently, which may be related to a variety of factors. Future directions include increasing experiential FO learning opportunities during Practicum and revising and validating the FCOF. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

"Am I Making More of It Than I Should?": Reporting and Responding to Sexual Harassment.

BACKGROUND AND OBJECTIVES: Health professionals may face sexual harassment from patients, faculty, and colleagues. Medicine's hierarchy deters response to sexual harassment. Current evidence consists largely of quantitative data regarding the frequency and types of sexual harassment. More information is needed about the nature of the experience and how or why professionals choose to report or respond. METHODS: We developed and administered a semistructured interview guide to elicit family medicine faculty and residents' experiences with sexual harassment and gender bias. Facilitators led a series of focus groups divided by faculty (N=28) and residents (N=24). We ensured voluntary consent and groups were audiotaped, transcribed and deidentified. We coded the transcripts using immersion-crystallization theory to identify emergent themes. RESULTS: Sexual harassment from patients and colleagues was described as witnessed or personally experienced by faculty and resident participants in 100% of the focus groups. Respondents identified the presence of mentors, clear reporting process and follow-up, history of good organizational response to reporting, and education and training as facilitators to reporting sexual harassment. Barriers to reporting included fear of retaliation, lack of trust of the system to respond, lack of clarity about "what counts," and confusion with the reporting process. CONCLUSIONS: It is important to capitalize on facilitators to reporting sexual harassment, starting with acknowledging the frequency of sexual harassment and gender discrimination. Addressing barriers to responding through education and training for our learners and faculty is critical. Clarifying the reporting process, having clear expectations for behavior, and a continuum of responses may help increase the frequency of reporting.

Compassion, gratitude and awe: The role of pro-social emotions in training physicians for relational competence.

On April 28, 2019, Dr. Beat Steiner, president of the Society of Teachers of Family Medicine (STFM), proposed that we as family medicine educators focus on increasing kindness and compassion in our lives and the world around us. As teachers of Family Medicine, we are poised in the intersections among healing, teaching, training, and caregiving. Faculty are held accountable for ensuring that our learners achieve certain milestones by demonstrating defined clinical competencies. We have a long list of topics, biomedical and psychosocial, to be sure our learners understand, and procedures of all types that our learners must do. This paper discusses the importance of extending kindness to ourselves, our colleagues, and patients, and explores three "pro-social" emotions-compassion, gratitude, and awe, which health professions educators can model for trainees in the service of developing self-aware, relationally competent, and well-rounded clinicians.

Journal editing: Reflections on 6 years of collaborative practice.

In this editorial, the authors reflect on their 6 years of serving as coeditors of Families, Systems, and Health. The uncertain and delightful product of these 6 years is that their relationship transcended personal and professional boundaries to evolve into a rich collaborative experience. Leaving this role prompts them to reflect on their work, their field, on challenges they faced, and on recurring themes. They want to share some of these reflections with journal readers in the hope that some of this will benefit readers in their work. (PsycINFO Database Record

"Imagine a clinical world without family systems thinking": Response.

Replies to comments made by B. J. Jacobs (see record 2018-27937-015) on the authors' original editorial (see record 2017-56601-001). While Fogarty and Mauksch agree with Dr. Jacobs that reviving the Doherty and Baird Levels of family involvement would be helpful, as would training clinicians to engage family members as partners in care, Fogarty and Mauksch want to reemphasize that helping trainees recognize systemic thinking and learn systemic problem solving is a necessary precursor to any form of family focused action. Clinicians should pursue shared decision-making partnerships with patients and their family members. (PsycINFO Database Record

Behavioral health integration and the risks of reductionism.

This editorial focuses on the topic of behavioral health integrations. It discusses the differences in types of integrated care and provides examples of practice elements that could be included under the umbrella of integrated care. (PsycINFO Database Record

Carry on.

Presents a poem about a patient of the author who is experiencing grief at the loss of his wife. (PsycINFO Database Record

"Imagine a clinical world without family systems thinking."

Collaborative family health care acknowledges the importance of family and social context to yield a comprehensive understanding of health. In this editorial, we return to the concept of family systems thinking. (PsycINFO Database Record

Seeking a wider lens for scientific rigor in emerging fields: The case of the primary care behavioral health model.

In response to widespread recognition of the need to blend biomedical and psychosocial health care efforts, the primary care behavioral health (PCBH) model has achieved rapid uptake across the United States. Reports of its application come from military sectors, community health centers, and a variety of health care systems, large and small. Examining the PCBH model's appeal, evidence, and design forces us to confront important questions. These questions and much more are addressed in this issue of Families, Systems, & Health. (PsycINFO Database Record

Team Training in Family Medicine Residency Programs and Its Impact on Team-Based Practice Post-Graduation.

OBJECTIVE: Our objective was to examine perceptions of adequacy in team-based care training during residency and whether this influences practice choice post- residency training. METHODS: We analyzed self-administered survey data from recent residency graduates collected as part of the Preparing Personal Physicians for Practice (P4) Project to characterize residents' perceptions of adequacy of training they received on team-based care. Multivariable logistic regression was used to assess the association between adequacy of team-based care training and joining practices that use team-based care after residency graduation, adjusting for differences in demographics. RESULTS: A total of 241 residency graduates were included in these analyses with response rates to surveys of 80.8%-98.1%. They reported practicing in 31 different US states or districts and four other countries. Over 82% of residency graduates reported being adequately trained in team-based care, 9.5% reported being overtrained, and 7.9% reported receiving no team-based care training over the study period. Seventy-six percent of P4 graduates joined practices that used team-based care in 2011, which increased to 86% (81/94) in 2013. The adjusted odds of practicing in settings with team-based care was 5.7 times higher for residents who reported being adequately prepared for team-based care compared to those who reported receiving no team-based care training and was 12.5 times higher for those who reported being over-prepared compared to those who reported no training/under-prepared. CONCLUSIONS: The majority of residency graduates perceive they were well trained in team-based care, which is significantly associated with joining practices that use team-based care post graduation.

Collaborative family health care, civil rights, and social determinants of health.

Social and economic disadvantage and civil rights infringement, worsens overall health (Adler, Glymour, & Fielding, 2016; McGowan, Lee, Meneses, Perkins, & Youdelman, 2016; Teitelbaum, 2005). While addressing these challenges is not new, there is reason to believe that the administration of Donald Trump and a republican majority in congress will exacerbate these challenges and their effects. How can collaborative family health care (CFHC) practitioners and our field help? The editors pondered this question and also asked a selection of leaders in the field. The editors will first share their ideas about the potential of CFHC to make a difference in daily interactions with patients. Next, they will identify key areas of risk and vulnerability. Finally, using the contributions of respected colleagues, they will propose a partial agenda for CFHC clinicians and the field. (PsycINFO Database Record

Our continuing exploration of medically unexplained symptoms.

In this issue, the reader will find three articles examining different but converging perspectives on medically unexplained symptoms (MUS). In the first article, Gates, Petterson, Wingrove, Miller, and Klink (2016) examined 110,000 office visits to primary care providers between 2002 and 2010. In the second article, Clarke (2016), an internist and gastroenterologist, presents a model for diagnosing and treating MUS. The person most referenced in the first two articles and author of the landmark study-Kroenke (2016) writes the third article, an invited commentary. Kroenke eloquently reviews the major issues confronting health care clinicians dealing with MUS. We hope that readers of the three articles on MUS in this issue will reflect on their own practice, share these articles and their impressions with colleagues, and consider ways to improve the service and consultation designs in their practice settings. Those who teach behavioral health clinicians and physicians will surely be reinforced or reinvigorated to focus on ways to help patients and colleagues. (PsycINFO Database Record