The Impact of Family Medicine Interest Groups and Student-Run Free Clinics on Primary Care Career Choice: A Narrative Synthesis.

BACKGROUND AND OBJECTIVES: Student-directed activities such as family medicine interest groups (FMIG) and student-run free clinics (SRFC) have been examined to discover their impact on entry into family medicine and primary care. The objective of this review was to synthesize study results to better incorporate and optimize these activities to support family medicine and primary care choice. METHODS: We conducted a comprehensive literature search using PubMed, Scopus, and CINAHL to identify all English-language research articles on FMIG and SRFC. We examined how participation relates to entry into family medicine and primary care specialties. Exclusion criteria were nonresearch articles, review articles, and research conducted outside the United States, Canada, Australia, and New Zealand. We used a 16-point quality rubric to evaluate 18 (11 FMIG, seven SRFC) articles that met our criteria. RESULTS: Of the nine articles that examined whether FMIG participation impacted entry into family medicine, five papers noted a positive relationship, one paper noted unclear correlation, and three papers noted that FMIG did not impact entry into family medicine. Of the seven articles about SRFC, only one showed a positive relationship between SRFC activity and entry into primary care. CONCLUSIONS: Larger-scale and higher quality studies are necessary to determine the impact of FMIG and SRFC on entry into family medicine and primary care. However, available evidence supports that FMIG participation is positively associated with family medicine career choice. In contrast, SRFC participation is not clearly associated with primary care career choice.

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.

The Influence of Role Modeling and Mentorship on Primary Care Career Choice: What Can Be Gleaned From 30 Years of Research?

BACKGROUND AND OBJECTIVES: Role modeling and mentoring are key aspects of identity formation in medical school and likely influence student specialty choice. No reviews have examined the ways that mentorship relationships impact primary care career choice. METHODS: We conducted a systematic literature search to identify articles describing the influence of role models and mentorship on primary care interest, intention, or choice. A content analysis of the included articles determined which articles focused on mentorship versus role modeling and the definitions of each. We coded articles as groundwork, effectiveness, or impact depending on the methodology and outcomes of each study. RESULTS: Searches yielded 362 articles, of which 30 met inclusion criteria. Three offered definitions of role modeling, and one compared and contrasted definitions of mentoring; 17 articles laid groundwork that indicated that role modeling and mentorship are important factors in career choice and specifically in primary care. Thirteen articles reported the effectiveness and impact of role modeling and mentoring in influencing intent to enter primary care or actual career choice. Primary care and non-primary care physicians influenced student interest, intent, and choice of primary care careers; this influence could be positive or negative. CONCLUSIONS: Role modeling and mentorship influence primary care career choice. Very few articles defined the studied relationships. More work on the impact of mentorship and role modeling on career choice is needed.

Curricular Recommendations for a National Family Medicine Subinternship: A Qualitative Analysis From Multiple Stakeholders.

BACKGROUND AND OBJECTIVES: The 2011 Alliance for Clinical Education panel recommended the development of a specialty-specific curriculum for all subinternships (sub-Is). A 2019 CERA survey found that 58% of family medicine clerkship directors agreed that a standardized curriculum would be helpful. The goal of this study was to explore attitudes and preferences regarding a national family medicine sub-I curriculum among a broad set of stakeholders. METHODS: Focus groups were conducted with medical students, residents, residency faculty, and undergraduate medical education faculty at the 2020 STFM Conference on Medical Student Education. Focus groups were transcribed, and a qualitative analysis was conducted with participants' responses about the benefits and characteristics of a family medicine sub-I, recommendations for core sub-I skills/objectives, likelihood of using a national curriculum, and preferred student and program evaluation methods. RESULTS: There were four focus groups with a total of 24 participants. The following main themes emerged: the family medicine sub-I has distinctive characteristics from other sub-Is and provides unique benefits for students and residency programs, a standardized curriculum should allow for adaptability and flexibility, and the sub-I evaluation for the students and program should be specific and experience-focused. These themes were classified into specific subthemes. CONCLUSIONS: The stakeholder emphasis on themes of uniqueness, adaptability, and specificity within evaluation will help educators structure a comprehensive framework for national recommendations for the sub-I curriculum. A well-designed family medicine sub-I may provide rigorous educational training for students and may also encourage career commitment to the discipline.

A Novel Curriculum for Medical Student Training in LGBTQ Healthcare: A Regional Pathway Experience.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals face considerable health disparities, often due to a lack of LGBTQ-competent care. Such disparities and lack of access to informed care are even more staggering in rural settings. As the state medical school for the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region, the University of Washington School of Medicine (UWSOM) is in a unique position to train future physicians to provide healthcare that meets the needs of LGBTQ patients both regionally and nationally. OBJECTIVE: To describe our methodology of developing a student-driven longitudinal, region-wide curriculum to train medical students to provide high-quality care to LGBTQ patients. METHODS: A 4-year LGBTQ Health Pathway was developed and implemented as a student-led initiative at the UWSOM. First- and second-year medical students at sites across the WWAMI region are eligible to apply. Accepted Pathway students complete a diverse set of pre-clinical and clinical components: online modules, didactic courses, longitudinal community service/advocacy work, a scholarly project, and a novel clinical clerkship in LGBTQ health developed specifically for this Pathway experience. Students who complete all requirements receive a certification of Pathway completion. This is incorporated into the Medical Student Performance Evaluation as part of residency applications. RESULTS: The LGBTQ Health Pathway is currently in its fourth year. A total of 43 total students have enrolled, of whom 37.3% are based in the WWAMI region outside of Seattle. Pathway students have completed a variety of scholarly projects on LGBTQ topics, and over 1000 hours of community service/advocacy. The first cohort of 8 students graduated with a certificate of Pathway completion in spring 2020. CONCLUSIONS: The LGBTQ Health Pathway at UWSOM is a novel education program for motivated medical students across the 5-state WWAMI region. The diverse milestones, longitudinal nature of the program, focus on rural communities, and opportunities for student leadership are all strengths and unique aspects of this program. The Pathway curriculum and methodology described here serve as a model for student involvement and leadership in medical education. This program enables medical students to enhance their training in the care of LGBTQ patients and provides a unique educational opportunity for future physicians who strive to better serve LGBTQ populations.

Moving Toward a Standardized National Family Medicine Subinternship Curriculum: Results From a CERA Clerkship Directors Survey.

BACKGROUND AND OBJECTIVES: Although the subinternship (sub-I) is considered integral in many medical schools' curricula, family medicine does not have standardized course recommendations. Given the variable nature of this clinical experience, this study investigated the potential role of a standardized sub-I curriculum in family medicine. METHODS: Questions about sub-Is were created and data were gathered and analyzed as part of the 2019 Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) survey of family medicine clerkship directors. The survey was distributed via email to 126 US and 16 Canadian recipients between June 19, 2019 and August 2, 2019 through the online program SurveyMonkey. RESULTS: A total of 101 (71.1%) of 142 clerkship directors responded to the survey. Most (84.2%) schools require sub-Is. There was a positive association between students matching into family medicine and having family medicine sub-Is at residency programs (P<.001). There was no relationship between higher family medicine match rates and the presence of family medicine sub-Is at nonresidency sites (P=.48) or having an advanced ambulatory rotation requirement (P=.16). CONCLUSIONS: A sub-I is a way to further expose students to family medicine, and increasing sub-I positions at residency programs may influence the number who pursue the specialty. Creation of a standardized sub-I curriculum presents an opportunity to enhance a critical educational experience in family medicine.

The Effect of Teaching Family Medicine Clerkship Students on Preceptor Productivity.

INTRODUCTION: High-quality, experiential learning in outpatient settings is indispensable for medical student education; however these settings are difficult to recruit and retain. The majority of primary care physicians are employed by organizations and are under pressure to increase their relative value unit (RVU) production. Although the common perception that teaching medical students decreases productivity is unproven, it is likely a barrier for primary care physicians pursuing clinical teaching. We sought to investigate whether medical student teaching affects clinical productivity. METHODS: We recruited 15 family medicine (FM) clerkship sites to participate in our study via email and at an in-person meeting. For each preceptor, we collected billing data in the form of current procedural terminology (CPT) codes for all patient encounters and the number of patients seen per half-day for when the preceptor had a student and when they did not. We converted CPT codes to RVU data. We compared differences in productivity for each individual preceptor, and we used a paired t test to examine collective data with and without a student. RESULTS: Ten preceptors at six FM clerkship sites provided reliable data. The average RVU per half-day without a student was 10.84, and it was slightly higher at 11.25 when a student was present (P=.74). The average number of patients seen per half-day without a student was 8.32 and it was slightly lower at 7.87 when a student was present (P=.58). CONCLUSION: This study shows promising data that teaching students in the outpatient setting does not decrease preceptor productivity. This pilot study can lead to a larger-scale exploration of family medicine preceptor productivity in different settings and institutions.

Association of Family Medicine Interest at Matriculation to Medical School and FMIG Participation With Eventual Practice as a Family Physician.

BACKGROUND AND OBJECTIVES: An adequate family medicine workforce is needed to improve health and health care outcomes in the United States, yet few medical students in the US become family physicians. Indicators of family medicine interest upon medical school matriculation exist. Family medicine interest groups (FMIGs) may influence student choice. This study examines the association of FMIG participation with various matriculation interest indicators to predict which students go on to become family physicians. METHODS: The American Medical Association Masterfile was used to identify the practice specialty of 601 graduates of the University of Washington School of Medicine who matriculated between 2003 and 2007. Graduates' scores on the Family Medicine Interest Survey (FMIS) and whether a student listed family medicine as their top choice upon matriculation along with FMIG participation and demographic characteristics were used in a binary logistic regression model to predict eventual practice. The model output was used to calculate odds ratios and predicted probabilities of family medicine practice given initial family medicine interest and FMIG participation. RESULTS: FMIG participation was associated with higher odds ratios and increased predicted probability of becoming a family physician regardless of initial interest although the magnitude of the difference varied. FMIG participants who listed family medicine as their top specialty had a 68% predicted probability of entering family medicine compared to 8% probability if they did not list family medicine first and did not participate in FMIG. FMIG participation was associated with odds ratios between 3.27-4.19 for entering family medicine regardless of FMIS score. CONCLUSIONS: Among University of Washington students with family medicine as their top specialty choice upon matriculation, FMIG participation was associated with higher odds of entering the specialty. The same was true, although to a lesser degree, for students who had a high score on the FMIS.

Validation and Comparison of a Brief Instrument vs a Single-Item Screen to Predict Entry to Family Medicine at Matriculation to Medical School.

BACKGROUND AND OBJECTIVES: A strong US primary care workforce is necessary to meet health care needs, yet fewer than 9% of allopathic medical students choose family medicine each year. No validated instrument exists to identify students likely to enter family medicine upon medical school matriculation. METHODS: A subset of a larger survey at the University of Washington School of Medicine (UWSOM) was used to create the Family Medicine Interest Survey (FMIS), a 15-item instrument to predict eventual practice in family medicine for a 2003-2007 matriculating cohort. A single-item screen asking about top specialty choice was administered at UWSOM for the same cohort and for a 2006-2012 matriculating cohort of students at Oregon Health & Science University (OHSU). Test performance measures including D (discrimination) and Cronbach α were calculated. Logistic regression determined whether FMIS score or reporting family medicine as the top specialty choice predicted family medicine practice for 601 UWSOM graduates or family medicine residency match for 744 OHSU graduates. RESULTS: The FMIS is reliable (Cronbach α=0.76). Both tests significantly predicted the probability of entering family medicine. Listing family medicine as the preferred specialty choice yielded a 47% predicted probability for UWSOM graduates entering family medicine. OHSU graduates listing family medicine first had an eightfold odds of matching to family medicine residencies. Combining the two instruments for UWSOM graduates showed a dose-response curve for predicted probability of entering family medicine with increasing levels of interest. CONCLUSION: Each screening tool can predict students more likely to enter family medicine upon matriculation.

Overview and Assessment of a Full-time Family Medicine Faculty Development Fellowship.

BACKGROUND AND OBJECTIVES: Part-time faculty development (FD) fellowships help faculty become successful and effective teachers in medicine. Fulltime FD fellowships provide a unique and promising model to train and retain high-quality faculty. This article presents an overview of a well-established, fulltime FD fellowship at the University of Pittsburgh and the results from a survey of its graduates regarding fellowship experiences and their career trajectories. METHODS: A 29-item questionnaire was sent to all graduates who completed the University of Pittsburgh St Margaret Faculty Development Fellowship from 1982 and 2014. Questions covered motivation for pursuing the fellowship, explored fellowship experiences, and examined its impact on career and professional development. We present descriptive frequencies and common themes identified from qualitative data from physician respondents. RESULTS: Fifty-two of the 69 physicians surveyed responded (75.2% response rate). Many completed a 2-year fellowship (n=32, 61.5%). Nearly two-thirds of graduates had an educator position as their first (n=34, 65.4%) and current (n=30, 62.5%) job. Graduates reported a mean fellowship satisfaction score of 8.83 (SD 1.74) on a 10-point scale. Research-related activities and professional development skills were identified as being the most useful/valuable aspects of the fellowship. CONCLUSIONS: Fellowship graduates were highly satisfied with their training and had a high retention rate in academic positions. Our findings can guide FD fellowship program design and address the needs of future and current educators in medicine.

Maternal prolactin during late pregnancy is important in generating nurturing behavior in the offspring.

Although maternal nurturing behavior is extremely important for the preservation of a species, our knowledge of the biological underpinnings of these behaviors is insufficient. Here we show that the degree of a mother's nurturing behavior is regulated by factors present during her own fetal development. We found that Cin85-deficient (Cin85-/-) mother mice had reduced pituitary hormone prolactin (PRL) secretion as a result of excessive dopamine signaling in the brain. Their offspring matured normally and produced their own pups; however, nurturing behaviors such as pup retrieval and nursing were strongly inhibited. Surprisingly, when WT embryos were transplanted into the fallopian tubes of Cin85-/- mice, they also exhibited inhibited nurturing behavior as adults. Conversely, when Cin85-/- embryos were transplanted into the fallopian tubes of WT mice, the resultant pups exhibited normal nurturing behaviors as adults. When PRL was administered to Cin85-/- mice during late pregnancy, a higher proportion of the resultant pups exhibited nurturing behaviors as adults. This correlates with our findings that neural circuitry associated with nurturing behaviors was less active in pups born to Cin85-/- mothers, but PRL administration to mothers restored neural activity to normal levels. These results suggest that the prenatal period is extremely important in determining the expression of nurturing behaviors in the subsequent generation, and that maternal PRL is one of the critical factors for expression. In conclusion, perinatally secreted maternal PRL affects the expression of nurturing behaviors not only in a mother, but also in her pups when they have reached adulthood.

An Update on Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) includes 2 chronic idiopathic inflammatory diseases: ulcerative colitis and Crohn disease. The incidence and prevalence of IBD is increasing worldwide. It can affect people of all ages, including children and geriatric populations, and can impact all aspects of life. In this article, diagnosis and treatment of IBD in adults, pediatric, pregnant, and elderly populations are explored from the perspective of a primary care physician.

Fellowship or Further Training for Family Medicine Residents?

BACKGROUND AND OBJECTIVES: The breadth of family medicine (FM) generates debate about the length of residency training. One argument used by proponents for lengthening training is that residents feel unprepared for practice. The objectives of our study were to (1) identify the proportion of FM residency graduates intending to pursue fellowship training and those who would have done an additional year of core residency training had it been available, and (2) determine whether an association exists between these two variables. METHODS: We used data collected by the American Board of Family Medicine (ABFM) as part of resident certification examination application in 2014 and 2015. Data included fellowship intention, and interest in pursuing another year of residency training if it were available. We used descriptive and bivariate statistics. RESULTS: The questionnaire was completed by 6,235 residents, of which 17.0% (n=1,063) intended to enroll in a fellowship. Overall 54.2% of residents were "not at all likely" to extend residency training, with 19.9% "extremely/moderately likely". Forty-six percent of those intending a fellowship were "not at all likely" to extend training and only 29% of those "extremely/moderately likely" to extend residency training intended to enroll in a fellowship. CONCLUSIONS: We found a disconnect between fellowship intention and desire for another year of residency training. Desire for fellowship may be more about obtaining specific skills and expertise or additional certifications, and less about being prepared for general practice in family medicine.

Training Family Medicine Residents to Perform Home Visits: A CERA Survey.

BACKGROUND: Home visits have been shown to improve quality of care, save money, and improve outcomes. Primary care physicians are in an ideal position to provide these visits; of note, the Accreditation Council for Graduate Medical Education no longer requires home visits as a component of family medicine residency training. OBJECTIVE: To investigate changes in home visit numbers and expectations, attitudes, and approaches to training among family medicine residency program directors. METHODS: This research used the Council of Academic Family Medicine Educational Research Alliance (CERA) national survey of family medicine program directors in 2015. Questions addressed home visit practices, teaching and evaluation methods, common types of patient and visit categories, and barriers. RESULTS: There were 252 responses from 455 possible respondents, representing a response rate of 55%. At most programs, residents performed 2 to 5 home visits by graduation in both 2014 (69% of programs, 174 of 252) and 2015 (68%, 172 of 252). The vast majority (68%, 172 of 252) of program directors expect less than one-third of their graduates to provide home visits after graduation. Scheduling difficulties, lack of faculty time, and lack of resident time were the top 3 barriers to residents performing home visits. CONCLUSIONS: There appeared to be no decline in resident-performed home visits in family medicine residencies 1 year after they were no longer required. Family medicine program directors may recognize the value of home visits despite a lack of few formal curricula.

An innovative, residency-based, interprofessional faculty development program.

PURPOSE: The impact of an interprofessional faculty development fellowship (FDF) on pharmacy graduates' careers is described. SUMMARY: The FDF instructional approach is a longitudinal acquisition and application of knowledge, skills, and attitudes fostered by clinical care delivery, teaching experiences, structured reflection, the giving and receiving of feedback, research and scholarly projects, and leadership development and exercises. Interprofessional FDF fellows teach, learn, and provide care together in both inpatient and outpatient clinical settings as a part of the evidence-based medicine curriculum, providing educational sessions for medical students, pharmacy students, medical residents, attending family medicine physicians, and clinical pharmacy faculty throughout the year. Twenty-seven of the 30 pharmacist graduates of the fellowship (90% response rate) responded to an electronic survey about the influence of the FDF on their careers. Overall, pharmacy graduates were very satisfied with the fellowship. The fellowship fostered a clear pattern of continued, collaborative learning. While additional training beyond a pharmacy residency program is not necessary for a successful clinical career, 41% of graduates pursued additional training after completing the fellowship. Open-ended responses for motivations for completing the FDF and influences the FDF had on their careers fell unforced into the FDF curriculum domains, which reinforced the belief that these are the right areas to target for development. CONCLUSION: Pharmacy residents participated in a broad, interprofessional faculty development curriculum, which fostered teaching, scholarship, leadership, professional development, and clinical skills. Pharmacist graduates indicated that the experience significantly influenced their careers and professional development.

Cost of physician-led home visit care (Zaitaku care) compared with hospital care at the end of life in Japan.

BACKGROUND: Physician-led home visit care with medical teams (Zaitaku care) has been developed on a national scale to support those who wish to stay at home at the end of life, and promote a system of community-based integrated care in Japan. Medical care at the end of life can be expensive, and is an urgent socioeconomic issue for aging societies. However medical costs of physician-led home visits care have not been well studied. We compared the medical costs of Zaitaku care and hospital care at the end of life in a rapidly aging community in a rural area in Japan. METHODS: A cross-sectional study was performed to compare the total medical costs during patients' final days of life (30 days or less) between Zaitaku care and hospital care from September 2012 to August 2013 in Fukuoka Prefecture, Japan. RESULTS: Thirty four patients died at home under Zaitaku care, and 72 patients died in the hospital during this period. The average daily cost of care during the last 30 days did not differ significantly between the two groups. Although Zaitaku care costs were higher than hospital care costs in the short-term (≦10 days, Zaitaku care $371.2 vs. Hospital care $202.0, p = 0.492), medical costs for Zaitaku care in the long-term care (≧30 days) were less than that of hospital care ($155.8 vs. $187.4, p = 0.055). CONCLUSIONS: Medical costs of Zaitaku care were less compared with hospital care if incorporated early for long term care, but it was high if incorporated late for short term care. For long term care, medical costs for Zaitaku care was 16.7% less than for hospitalization at the end of life. This physician-led home visit care model should be an available option for patients who wish to die at home, and may be beneficial financially over time.

Shifting Patterns of Physician Home Visits.

OBJECTIVES: Home visits have been shown to improve quality of care and lower medical costs for complex elderly patients. We investigated trends in physician home visits and domiciliary care visits as well as physician characteristics associated with providing these services. DESIGN: Longitudinal analysis of Medicare Part B claims data for a national sample of direct patient care physicians in 2006 and 2011. Descriptive statistics were used to characterize the physician sample and to determine numbers of home visits and domiciliary visits in total and by physician specialty. SETTING: Patient homes, nursing homes, and domiciliary care facilities. PARTICIPANTS: Direct patient care physicians (n = 22,186). MEASUREMENTS: Physician demographics, specialty, practice characteristics (practice type, geographic location), number of home visits, and domiciliary visits in 2006 and 2011. RESULTS: We found a small increase (n = 63,501) in total number of home visits made to Medicare beneficiaries between 2006 and 2011 performed by a decreasing percentage of physicians (5.1%, n = 18,165 in 2006; 4.5%, n = 15,296 in 2011). There was substantial growth in domiciliary care visit numbers (n = 218,514) and a small increase in percentage of physicians delivering these services (2.0% in 2006, 2.3% in 2011). Physicians who performed home visits were more likely to be older, in rural locations, specialists in primary care, and more likely to provide nursing home and domiciliary care compared with physicians who did not make any home visits (P < .05). CONCLUSION: Home visits and domiciliary visits to Medicare beneficiaries are increasing. General internal medicine physicians provided the highest number of home and domiciliary care visits in 2006, and family physicians did so in 2011. Such delivery models show promise in lowering medical costs while providing high-quality patient care.