How Early Career Family Medicine Women Physicians Negotiate Their First Job After Residency.

BACKGROUND: Nested within a growing body of evidence of a gender pay gap in medicine are more alarming recent findings from family medicine: a gender pay gap of 16% can be detected at a very early career stage. This article explores qualitative evidence of women's experiences negotiating for their first job out of residency to ascertain women's engagement with and approach to the negotiation process. METHODS: We recruited family physicians who graduated residency in 2019 and responded to the American Board of Family Medicine 2022 graduate survey. We developed a semistructured interview guide following a modified life history approach to uncover women's experiences through the transitory stages from residency to workforce. A qualitative researcher used Zoom to interview 19 geographically and racially diverse early career women physicians. Interviews were transcribed verbatim and analyzed using NVivo software following an Inductive Content Analysis approach. RESULTS: Three main themes emerged from the data. First, salary was found to be nonnegotiable, exemplified by participants' inability to change initial salary offers. Second, the role of peer support throughout residency and early career was crucial to uncovering and rectifying salary inequity. Third, a pay expectation gap was identified among women from minority and low-income households. CONCLUSION: To rectify the gender pay gap in medicine, a systems-level approach is required. This can be achieved through various levels of interventions: societally expanding the use of and removing the stigma around parental leave, recognizing the importance of contributions not currently valued by productivity-based payment models, examining assumptions about leadership; and institutionally moving away from fee-for-service systems, encouraging flexible schedules, increasing salary transparency, and improving advancement transparency.

Relationship Between Primary Care Physician Capacity and Usual Source of Care.

BACKGROUND: The NASEM Primary Care Report and Primary Care scorecard highlighted the importance of primary care physician (PCP) capacity and having a usual source of care (USC). However, research has found that PCP capacity and USC do not always correlate. This exploratory study compares geographic patterns and the characteristics of counties with similar rates of PCP capacity but varying rates of USC. METHODS: Our county-level, cross-sectional approach includes estimates from the Robert Graham Center and data from the Robert Wood Johnson County Health Rankings (CHR). We utilized conditional mapping methods to first identify US counties with the highest rates of social deprivation (SDI). Next, counties were stratified based on primary care physician (PCP) capacity and usual source of care (USC) terciles, allowing us to identify 4 types of counties: (1) High-Low (high PCP capacity, low USC); (2) High-High (high PCP capacity, high USC); (3) Low-High (low PCP capacity, high USC); and (4) Low-Low (low PCP capacity, low USC). We use t test to explore differences in the characteristics of counties with similar rates of primary care capacity. RESULTS: The results show clear geographic patterns: High-High counties are located primarily in the northern and northeastern US; High-Low counties are located primarily in the southwestern and southern US. Low-High counties are concentrated in the Appalachian and Great Lakes regions; Low-Low counties are concentrated in the southeastern US and Texas. Descriptive results reveal that rates of racial and ethnic minorities, the uninsured, and social deprivation are highest in counties with low rates of USC for both high PCP and low PCP areas. CONCLUSIONS: Recognizing PCP shortages and improving rates of USC are key strategies for increasing access to high-quality, primary care. Targeting strategies by geographic region will allow for tailored models to improve access to and continuity of primary care. For example, we found that many of the counties with the lowest rates of USC are found in non-Medicaid expansion states (Texas, Georgia, and Florida) with high rates of uninsured populations, suggesting that expanding Medicaid and improving access to health insurance are key strategies for increasing USC in these states.

Measuring Primary Care Spending in the US by State.

This case series identifies states' estimates of primary care spending and recommends steps policymakers can take toward standardizing these estimates.

The Gender Wage Gap Among Early-Career Family Physicians.

PURPOSE: Numerous studies have documented salary differences between male and female physicians. For many specialties, this wage gap has been explored by controlling for measurable factors that influence pay such as productivity, work-life balance, and practice patterns. In family medicine where practice activities differ widely between physicians, it is important to understand what measurable factors may be contributing to the gender wage gap, so that employers and policymakers and can address unjust disparities. METHODS: We used data from the 2017 to 2020 American Board of Family Medicine (ABFM) National Graduate Survey (NGS) which is administered to family physicians 3 years after residency (n = 8608; response rate = 63.9%, 56.2% female). The survey collects clinical income and practice patterns. Multiple linear regression analysis was performed, which included variables on hours worked, degree type, principal professional activity, rural/urban, and region. RESULTS: Although early-career family physician incomes averaged $225,278, female respondents reported incomes that were $43,566 (17%) lower than those of male respondents (P = .001). Generally, female respondents tended toward lower-earning principal professional activities and US regions; worked fewer hours (2.9 per week); and tended to work more frequently in urban settings. However, in adjusted models, this gap in income only fell to $31,804 (13% lower than male respondents, P = .001). CONCLUSION: Even after controlling for measurable factors such as hours worked, degree type, principal professional activity, population density, and region, a significant wage gap persists. Interventions should be taken to eliminate gender bias in wage determinations for family physicians.

Racial Inequities in Female Family Physicians Providing Women's Health Procedures.

Patient-physician race concordant dyads have been shown to improve patient outcomes; the race and ethnicity of family physicians providing women's health procedures has not been described. Using self-reported data, this analysis highlights the racial disparities in scope of practice; underrepresented in medicine (URiM) females are less likely to perform women's health procedures which may lead to disparities in care received by minority women.

Duration of Residence and Hypertension in Black Foreign-Born Residents: NHIS, 2004-2017.

BACKGROUND: Black Americans have the highest prevalence of hypertension in the USA. Black immigrants, who, by definition, have time-limited exposure to the USA, may provide insight into the relationship between exposure to the US environment, Black race, and hypertension. METHODS: This is a cross-sectional analysis of pooled National Health Interview Survey (2004-2017) data of foreign-born White European and Black adults (N = 11,516). Multivariable robust Poisson regressions assessed the relationship between self-reported hypertension and duration of the residency (< 5, 5-9, 10-14, ≥ 15 years) among Black, Black African, Black Caribbean, and White European foreign-born residents. RESULTS: In multivariable analyses-controlling for age, sex, education, poverty-to-income ratio, insurance status, recent encounter with a clinician, and BMI-Black foreign-born residents (PR = 1.40, 95% CI = 1.03, 1.90) and Black Africans (10-14 years.: PR = 1.70, 95% CI = 1.13, 2.56; ≥ 15 years.: PR = 1.56, 95% CI = 1.04, 2.34) with a duration of residency of at least 15 and 10 years, respectively, had a greater prevalence of hypertension than those with duration less than 5 years. A nonsignificant positive association between a duration of residency of at least 15 years (compared to less than 5 years) and self-reported hypertension was observed for White Europeans (PR 1.49, 95% CI = 0.88, 2.51) and Black Caribbeans (PR = 1.09, 95% CI = 0.69, 1.72). CONCLUSION: Duration of residency is particularly associated with hypertension among Black Africans after migration to the USA. This discrepancy may be explained by differences in primary care utilization and awareness of hypertension diagnoses among recent African immigrants, along with greater stress associated with living in the USA.

Migraine care practices in primary care: results from a national US survey.

BACKGROUND: Primary care clinicians play a critical role in diagnosis and treatment of migraine, yet barriers exist. This national survey assessed barriers to diagnosis and treatment of migraine, preferred approaches to receiving migraine education, and familiarity with recent therapeutic innovations. METHODS: The survey was created by the American Academy of Family Physicians (AAFP) and Eli Lilly and Company and distributed to a national sample through the AAFP National Research Network and affiliated PBRNs from mid-April through the end of May 2021. Initial analyses were descriptive statistics, ANOVAs, and Chi-Square tests. Individual and multivariate models were completed for: adult patients seen in a week; respondent years since residency; and adult patients with migraine seen in a week. RESULTS: Respondents who saw fewer patients were more likely to indicate unclear patient histories were a barrier to diagnosing. Respondents who saw more patients with migraine were more likely to indicate the priority of other comorbidities and insufficient time were barriers to diagnosing. Respondents who had been out of residency longer were more likely to change a treatment plan due to attack impact, quality of life, and medication cost. Respondents who had been out of residency shorter were more likely to prefer to learn from migraine/headache research scientists and use paper headache diaries. CONCLUSIONS: Results demonstrate differences in familiarity with migraine diagnosis and treatment options based on patients seen and years since residency. To maximise appropriate diagnosis within primary care, targeted efforts to increase familiarity and decrease barriers to migraine care should be implemented.

Comparable quality performance between telemedicine and office-based care for abnormal BMI screening and management.

Background: Despite widespread adoption during COVID-19, there is limited evidence supporting the quality of telemedicine care in managing patients with abnormal BMI. Objective: To evaluate the comparability of telemedicine and in-person (office) quality performance for abnormal body mass index (BMI kg/m2) screening and management in primary care. Methods: This retrospective cohort study measured Healthcare Effectiveness Data and Information Set (HEDIS) quality performance for abnormal BMI screening (patients with BMIs <18.5 or >25 kg/m2 and a qualifying documented follow up plan) across an 8-hospital integrated health system seen via primary care from 4/1/20 - 9/30/21. Encounters were divided into three exposure groups: office (excluding telemedicine), telemedicine (excluding office), and blended telemedicine (office + telemedicine). Demographic stratification compared group composition. Chi squared tests determined statistical differences in quality performance (p = <0.05). Results: Demographics of sub-groups for the 287,387 patients (office: 222,333; telemedicine: 1,556; blended-telemedicine: 63,489) revealed a modest female predominance, majority ages 26-70, mostly White non-Hispanics of low health risk, and the majority BMI representation was overweight, followed closely by class 1 obesity. In both HEDIS specified and HEDIS modified performance, blended-telemedicine performed better than office (12.56%, 95% CI 12.29%-13.01%; 11.16%, 95% CI: 10.85%-11.48%; p < 0.0001); office performed better than telemedicine (4.29%, 95% CI 2.84%-5.54%; 4.79%, 95% CI 3.99%-5.35%; p < 0.0001). Conclusion: Quality performance was highest for blended-telemedicine, followed by office-only, then telemedicine-only. Given the known cost savings, adding telemedicine as a care venue might promote value within health systems without negatively impacting HEDIS performance.

Relationships Matter: Primary Care Physicians and Usual Sources of Care.

There are benefits to having a primary care physician or a usual source of care. Adults with a primary care physician have higher rates of preventive care, have improved communication with their care team, and receive more attention to social needs.1-3 Yet, not all individuals have equitable access to a primary care physician. The overall percentage of U.S. patients who reported having a usual source of care declined from 84% in 2000 to 74% in 2019, with wide variations across states, patient race, and insurance status.

Racial/Ethnic Minority Identifying Family Physicians Are More Likely to Work in Solo Practices.

While the overall proportion of family physicians who work in solo practices has been steadily declining, Black, Hispanic/Latino, and Asian family physicians are more likely to work in these settings. Given their association with high levels of continuity and improved health outcomes, and given patient preference for racial concordance with their physicians, policy makers and payors should consider how to support family physicians in solo practice in the interest of promoting access to and quality of care for ethnic/racial minorities.

Female Family Physicians Are More Racially Diverse Than Their Male Counterparts in Federal Sites.

Supporting a diverse family physician workforce is an integral component of achieving health equity. This study compared the racial/ethnic composition of Federal family physicians (Military, Veterans Administration/Department of Defense) to the entire cohort of family physicians and stratified by gender. Female family physicians serving at Federal sites were more diverse than the overall population of female family physicians and, also than their male Federal counterparts. This gendered trend among Federal physicians needs further exploration.

The Association of Practice Type and the Scope of Care of Family Physicians.

INTRODUCTION: Comprehensiveness is a defining principle of primary care and Family Medicine but is declining in some settings. This study explores the relationship between practice setting and comprehensiveness among family physicians (FPs). METHODS: Using 2014 to 2016 American Board of Family Medicine survey data to generate scope of practice (SOP) scores (0 to 30) for FPs. We ran univariate and bivariate analyses for services by practice organization type. Our principal independent variable was practice organization type and dependent variable, the SOP score. RESULTS: Among 25,117 total respondents, FPs at rural health centers (RHC) had the widest scope of practice (SOP score of 17.7) whereas FPs in federal, urgent care and other safety net clinics had the narrowest with mean SOP score of 14.0 or less. Higher rates of FPs practicing in Federally Qualified Health Centers and academic health centers were providing a women's health service, except for deliveries, whereas FPs in rural health centers were providing obstetric services (24%). The proportion of FPs providing newborn care was highest in RHCs and lowest in the urgent care setting (85%, vs 26%). A higher proportion of FPs in RHCs provided joint injections and skin procedures than FPs in other practice organizations. CONCLUSIONS: Significant variation in FP comprehensiveness exists across different practice types. FPs in practice types commonly associated with large health systems had narrower breadth of practice, concerning amid increasing practice consolidation. Given associations between comprehensiveness and desirable health care outcomes, policy makers should encourage payment/accountability models that incentivize broader SOP.

Family Medicine Research Is Not a Federal Priority.

Research in family medicine produces clinical information and improves care delivery, but it has yet to receive equitable federal investment. The National Institutes of Health (NIH) is the primary funder of medical research in the United States. In 2021, the NIH received $45 billion.1 Between 2017 and 2021, the NIH spent only 0.2% of its budget on family medicine research (Figure 1). Although other funding organizations exist, the NIH is the largest funder of biomedical research, and because it continues to undervalue family medicine research, its underinvestment impacts clinical care.

Reflections From Family Medicine Residents on Training During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Given their broad scope of training, family medicine residents were uniquely situated to care for the American public throughout the COVID-19 pandemic, yet little has been written about their experiences. The objective of this report is to capture the diversity of experiences and contributions of family medicine residents across the United States to the care of the American public during the COVID-19 pandemic. METHODS: Investigators recruited resident interviewees from four residencies throughout the United States via convenience sample. These residencies represented a diversity of geography, rurality, and structure (hospital based vs community based). Investigators conducted 30 to 60-minute, semistructured interviews with family medicine residents. Interviews were recorded and examined for themes. RESULTS: Three major themes emerged through the interview process. First, family medicine residents were a critical component of the inpatient response to COVID-19 in a variety of geographies from urban centers to rural towns to Native American reservations. Second, family medicine residents continued to provide expanded outpatient care to include telehealth, immunization clinics, and public health campaigns to meet the needs of the community. Finally, not only did these residents have an immense impact in the response to COVID-19, but the pandemic also had an immense impact on them, both personally and professionally. CONCLUSIONS: The story of family medicine contributions to the care of the public during COVID-19 reflects the history of COVID-19 in the United States, and the critical role trainees and family medicine physicians have in the US health care system.

Comparison of Quality Performance Measures for Patients Receiving In-Person vs Telemedicine Primary Care in a Large Integrated Health System.

Importance: Despite its rapid adoption during the COVID-19 pandemic, it is unknown how telemedicine augmentation of in-person office visits has affected quality of patient care. Objective: To examine whether quality of care among patients exposed to telemedicine differs from patients with only in-person office-based care. Design, Setting, and Participants: In this retrospective cohort study, standardized quality measures were compared between patients with office-only (in-person) visits vs telemedicine visits from March 1, 2020, to November 30, 2021, across more than 200 outpatient care sites in Pennsylvania and Maryland. Exposures: Patients completing telemedicine (video) visits. Main Outcomes and Measures: χ2 tests determined statistically significant differences in Health Care Effectiveness Data and Information Set (HEDIS) quality performance measures between office-only and telemedicine-exposed groups. Multivariable logistic regression controlled for sociodemographic factors and comorbidities. Results: The study included 526 874 patients (409 732 office-only; 117 142 telemedicine exposed) with a comparable distribution of sex (196 285 [49.7%] and 74 878 [63.9%] women), predominance of non-Hispanic (348 127 [85.0%] and 105 408 [90.0%]) and White individuals (334 215 [81.6%] and 100 586 [85.9%]), aged 18 to 65 years (239 938 [58.6%] and 91 100 [77.8%]), with low overall health risk scores (373 176 [91.1%] and 100 076 [85.4%]) and commercial (227 259 [55.5%] and 81 552 [69.6%]) or Medicare or Medicaid (176 671 [43.1%] and 52 513 [44.8%]) insurance. For medication-based measures, patients with office-only visits had better performance, but only 3 of 5 measures had significant differences: patients with cardiovascular disease (CVD) receiving antiplatelets (absolute percentage difference [APD], 6.71%; 95% CI, 5.45%-7.98%; P < .001), patients with CVD receiving statins (APD, 1.79%; 95% CI, 0.88%-2.71%; P = .001), and avoiding antibiotics for patients with upper respiratory infections (APD, 2.05%; 95% CI, 1.17%-2.96%; P < .001); there were insignificant differences for patients with heart failure receiving ß-blockers and those with diabetes receiving statins. For all 4 testing-based measures, patients with telemedicine exposure had significantly better performance differences: patients with CVD with lipid panels (APD, 7.04%; 95% CI, 5.95%-8.10%; P < .001), patients with diabetes with hemoglobin A1c testing (APD, 5.14%; 95% CI, 4.25%-6.01%; P < .001), patients with diabetes with nephropathy testing (APD, 9.28%; 95% CI, 8.22%-10.32%; P < .001), and blood pressure control (APD, 3.55%; 95% CI, 3.25%-3.85%; P < .001); this was also true for all 7 counseling-based measures: cervical cancer screening (APD, 12.33%; 95% CI, 11.80%-12.85%; P < .001), breast cancer screening (APD, 16.90%; 95% CI, 16.07%-17.71%; P < .001), colon cancer screening (APD, 8.20%; 95% CI, 7.65%-8.75%; P < .001), tobacco counseling and intervention (APD, 12.67%; 95% CI, 11.84%-13.50%; P < .001), influenza vaccination (APD, 9.76%; 95% CI, 9.47%-10.05%; P < .001), pneumococcal vaccination (APD, 5.41%; 95% CI, 4.85%-6.00%; P < .001), and depression screening (APD, 4.85%; 95% CI, 4.66%-5.04%; P < .001). Conclusions and Relevance: In this cohort study of patients with telemedicine exposure, there was a largely favorable association with quality of primary care. This supports telemedicine's value potential for augmenting care capacity, especially in chronic disease management and preventive care. This study also identifies a need for understanding relationships between the optimal blend of telemedicine and in-office care.