Chronic cough diagnosis, treatment, and referral practices among family physicians in the United States: a survey study.

BACKGROUND: Cough is one of the most common presenting problems for patients in primary care and is largely managed in primary care clinical settings. Family physicians' familiarity with chronic cough guidelines and the extent to which these guidelines translate into everyday practice have not been well described. The objective of this study was to characterize current diagnosis, treatment, and referral practices among family physicians and to identify potentially impactful strategies to optimize chronic cough management in primary care. METHODS: We conducted a cross-sectional survey of 5,000 family physicians to explore diagnosis, treatment, and referral practices related to chronic cough management in adults in primary care. Respondents completed the survey via paper or online. The outcome measures were self-reported numeric ratings and responses related to the survey elements. RESULTS: 588 surveys were completed (11.8% response rate). About half (49.6%) of respondents defined chronic cough in a manner consistent with the American College of Chest Physicians (ACCP) chronic cough guidelines, with the rest differing in opinion primarily regarding duration of symptom presentation. Respondents reported trying to rule out most common causes of chronic cough themselves before referring (mean 3.41 on a 4-point scale where 4 is "describes me completely") and indicated a desire for more resources to help them manage and treat chronic cough. Years in practice and rural/urban setting influenced diagnosis and referral practices. CONCLUSIONS: Family physicians see chronic cough as a complicated condition that can be and is often diagnosed and treated entirely in a primary care setting. They also value the ability to refer in complex cases. Our results support that family physicians provide evidence-based management of chronic cough.

Block Scheduling for LARC in a Family Medicine Residency Program.

BACKGROUND AND OBJECTIVES: Only 20% of family physicians report providing long-acting reversible contraception (LARC). Clinician-related barriers include confidence and comfort with LARC counseling and insertion/removal, and limited availability and uptake. Training during residency may address barriers and increase access/availability of LARC to support reproductive autonomy. We sought to determine the impact of block scheduling LARC clinics on resident comfort and confidence with LARC counseling and insertion/removal. METHODS: LARC block schedules were established in a Midwest family medicine residency's primary clinic (FMC) and in a federally qualified health center rotation clinic. Baseline and end-of-study surveys, compared by Mann-Whitney U and Wilcoxon signed-rank tests, were used to assess comfort and confidence with counseling and inserting LARC. The number of LARC devices placed at the FMC were collected for the intervention year and the year prior. RESULTS: Twenty of 30 residents completed the baseline survey; 13 completed the end-of-study survey. At the group and individual levels, comfort increased for counseling on Levonorgestrel (LNG) intrauterine devices (IUDs) and for inserting implants and LNG IUDs. Individual comfort increased for copper IUDs. Resident willingness to recommend LARC increased, and more devices were placed during the intervention year than the year prior in the FMC (all: P<.05). CONCLUSIONS: Block scheduling of LARC clinics was associated with increased residents' comfort and confidence with counseling and placement of implants (LNG IUDs) and with an increase in LARCs placed at one clinic. Changes to scheduling may be an effective educational strategy that may increase access/availability to LARC.

Integrated Behavioral Health Adaptations During the COVID-19 Pandemic.

INTRODUCTION: COVID-19 pandemic lockdowns threatened standard components of integrated behavioral health (IBH) such as in-person communication across care teams, screening, and assessment. Restrictions also exacerbated pre-existing challenges to behavioral health (BH) access. METHODS: Semistructured interviews were completed with clinicians from family medicine residency programs on the impact of the pandemic on IBH care delivery along with adaptations employed by care teams to ameliorate disruption. RESULTS: Participants (n = 41) from 14 family medicine residency programs described the rapid shift to virtual care, creating challenges for IBH delivery and increased demand for BH services. With patients and care team members at home, virtual warm handoffs and increased attention to communication were necessary. Screening and measurement were more difficult, and referrals to appropriate services were challenging due to higher demand. Tele-BH facilitated continued access to BH services but was associated with logistic challenges. Participants described adaptations to stay connected with patients and care teams and discussed the need to increase capacity for both in-person and virtual care. DISCUSSION: Most practices modified their workflows to use tele-BH as COVID-19 cases increased. Participants shared key learnings for successful implementation of tele-BH that could be applied in future health care crises. CONCLUSION: Practices adapted readily to challenges posed by pandemic restrictions and their ability to sustain key elements of IBH during the COVID-19 pandemic demonstrates innovation in maintaining access when in-person care is not possible, informing strategies applicable to other scenarios.

Integrated Behavioral Health Implementation and Training in Primary Care: A Practice-Based Research Network Study.

INTRODUCTION: Integrating behavioral health services into primary care has a strong evidence base, but how primary care training programs incorporate integrated behavioral health (IBH) into care delivery and training has not been well described. The goal of this study was to evaluate factors related to successful IBH implementation in family medicine (FM) residency programs and assess perspectives and attitudes on IBH among program leaders. METHODS: FM residency programs, all which are required to provide IBH training, were recruited from the American Academy of Family Physicians National Research Network. After completing eligibility screening that included the Integrated Practice Assessment Tool (IPAT) questionnaire, 14 training programs were included. Selected practices identified 3 staff in key roles to be interviewed: medical director or similar, behavioral health professional (BHP), and chief medical officer or similar. RESULTS: Forty-one individuals from 14 FM training programs were interviewed. IPAT scores ranged from 4 (Close Collaboration Onsite) to 6 (Full Collaboration). Screening, outcome tracking, and treatment differed among and within practices. Use of curricula and trainee experience also varied with little standardization. Most participants described similar approaches to communication and collaboration between primary care clinicians and BHPs and believed that IBH should be standard practice. Participants reported space, staff, and billing support as critical for sustainability. CONCLUSIONS: Delivery and training experiences in IBH varied widely despite recognition of the value and benefits to patients and care delivery processes. Standardizing resources and training and simplifying and assuring reimbursement for services may promote sustainable and high quality IBH implementation.

Research interests of family physicians applying for research training.

BACKGROUND: There is an ongoing need for research to support the practice of high quality family medicine. The Family Medicine Discovers Rapid Cycle Scientific Discovery and Innovation (FMD RapSDI) program is designed to build capacity for family medicine scientific discovery and innovation in the United States. Our objective was to describe the applicants and research questions submitted to the RapSDI program in 2019 and 2020. METHODS: Descriptive analysis for applicant characteristics and rapid qualitative analysis using principles of grounded theory and content analysis to examine the research questions and associated themes. We examined differences by year of application submission and the applicant's career stage. RESULTS: Sixty-five family physicians submitted 70 applications to the RapSDI program; 45 in 2019 and 25 in 2020. 41% of applicants were in practice for five years or less (n = 27), 18% (n = 12) were in in practice 6-10 years, and 40% (n = 26) were ≥ 11 years in practice. With significant diversity in questions, the most common themes were studies of new innovations (n = 20, 28%), interventions to reduce cost (n = 20, 28%), improving screening or diagnosis (n = 19, 27%), ways to address mental or behavioral health (n = 18, 26%), and improving care for vulnerable populations (n = 18, 26%). CONCLUSION: Applicants proposed a range of research questions and described why family medicine is optimally suited to address the questions. Applicants had a desire to develop knowledge to help other family physicians, their patients, and their communities. Findings from this study can help inform other family medicine research capacity building initiatives.

"We've Really Built Something": Why Family Medicine Program Directors Stay in Their Positions-A Qualitative Study.

Background: Program directors (PDs) are essential to more than 12 000 residency and fellowship programs accredited in the United States. Short PD tenure may affect overall program quality. Reasons why PDs leave the position are multifactorial, and little is known about the reasons why PDs stay in the position. Objective: The authors explored factors related to retention and why family medicine PDs have stayed in their positions long term. Methods: This was a qualitative study of PDs in their roles for 12 or more years drawn from a national sample of family medicine residency PDs. Interviews with semi-structured and structured questions about long-term PD experience were conducted in October and November 2020. Multiple cycles of comparative coding and code network analysis produced constructs describing reasons why some PDs stay in the position long term. Results: Among 17 respondents with a mean tenure of 17.4 years, 3 interrelated constructs consistently emerged that supported PDs: developing the program, support systems, and job rewards. Program development reinforces internal and external support systems and enhances experiencing rewards of the job. Strong support systems enable further program development and job rewards. Conclusions: Family medicine residency PDs who have been in the role 12 or more years continuously work to develop the program, benefit from strong internal and external support systems, and describe many important rewards of the position that help sustain them in the role.

COVID-19's Financial Impact on Primary Care Clinicians and Practices.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) disrupted and undermined primary care delivery. The goal of this study was to examine the financial impacts the pandemic has had on primary care clinicians and practices. METHODS: The American Academy of Family Physicians National Research Network and the Robert Graham Center distributed weekly surveys from March 27, 2020, through June 15, 2020, to a network of more than 1960 physicians. Responses to the question, "Could you please tell us about any financial impact the COVID-19 pandemic has had on your practice, if any?" were analyzed using a grounded theory approach of qualitative analysis. The number of unique respondents who answered the financial impact question totaled 461 over the 12 weeks. RESULTS: Severe declines in patient visits, causing drastic revenue reductions, greatly impacted the ability to serve patients. Primary care clinicians and practices experienced significant changes in several areas about financial implications: patient visits, financial strain, staffing and telehealth. DISCUSSION: Preliminary findings revealed that even with Coronavirus Aid, Relief, and Economic Security Act, also known as CARES Act, funding, business viability remains questionable for some primary care practices. CONCLUSIONS: Low patient visits directly resulted in decreased revenues, which in turn, impacted staffing decisions and fueled telehealth implementation. It is difficult to predict whether patient visits will increase after June. Alternate payment models could provide some financial stability and address business viability.

Loneliness, Burnout, and Other Types of Emotional Distress Among Family Medicine Physicians: Results From a National Survey.

PURPOSE: This study assessed the prevalence of loneliness, burnout, and depressive symptoms from a national sample of family medicine physicians. DISCUSSION: We conducted a cross-sectional survey of 401 physicians who were members of the American Academy of Family Physicians (AAFP) and AAFP National Research Network between December 7, 2019, and January 20, 2020. The study participants completed an anonymous, 30-item survey measuring loneliness, burnout, symptoms of depression, fatigue, in addition to providing demographic information. RESULTS: The response rates were 16.3% (401 of 2456) for all the physicians, 7.0% (113 of 1606) for the AAFP NRN member physicians, and 33.9% (288 of 850) for the AAFP member insight physicians. The prevalence of loneliness, burnout, and depressive symptoms was 44.9% (165 of 367), 45.1% (181 of 401), and 44.3% (163 of 368) respectively. The physicians who experienced a greater feeling of loneliness compared with those who experienced a lesser feeling of loneliness were more likely to report at least 1 manifestation of burnout (69.1% vs 27.4%, P < .01), screen positive for depression (66.0% vs 27.6%, P < .01), and experience a higher degree of fatigue (59.5% vs 32.4%, P < .01). Depressive symptoms (odds ratio [OR] = 5.08; 95% confidence interval [CI], 4.64-7.94; P < .001), overwhelming exhaustion (OR = 7.19; 95% CI, 4.03 to 12.02; P < .001), and burnout (OR = 4.61; 95% CI, 2.96-7.19; P < .001) were associated with loneliness status. CONCLUSION: Our findings demonstrate that loneliness is common in practicing family medicine physicians and is significantly associated with burnout and depression. Future work is needed to understand the various interactions and relationships among loneliness, burnout, and depression to help inform effective interventions.

Why Family Medicine Program Directors Leave Their Position.

BACKGROUND AND OBJECTIVES: Family medicine residency program directors (PD) oversee the training of every new family physician in the United States. The median tenure of family medicine PDs is 4.5 years, and factors relating to length of tenure and reasons for departure are not well known. This exploratory study examined why family medicine PDs leave their position. METHODS: We conducted in-depth interviews with family medicine PDs who recently left their director position. Semistructured and structured questions asked about their PD experience and factors contributing to stepping away from the PD role. We analyzed answers quantitatively and qualitatively. RESULTS: When comparing cases with longer (>6 years) and shorter tenures (≤6 years), 25 PDs described differing pathways but few major differences in why they left the position. The two groups were distinguished more by their similarities than their differences. The majority left voluntarily due to a combination of factors, not a single factor. Most PDs left the position because of their desire and opportunities to move up, move over, or move on, and not because of dissatisfaction with the job. Succession plans helped with PD decisions to leave the position, knowing that the program was in good hands. CONCLUSIONS: Family medicine PDs left the position due to multiple factors primarily related to career pathway choices and not solely due to demands of the job. Additional research with PDs of very short tenures and long tenures may yield further details about sustaining PDs in residency education to successfully train the next generation of family physicians.

Informing the American Academy of family Physician's Health Equity strategy - an environmental scan using the Delphi technique.

BACKGROUND: Many organizations have prioritized health equity and the social determinants of health (SDoH). These organizations need information to inform their planning, but, relatively few quantifiable measures exist. This study was conducted as an environmental scan to inform the American Academy of Family Physician's (AAFP's) health equity strategy. The objectives of the study were to identify and prioritize a comprehensive list of strategies in four focus areas: health equity leadership, policy, research, and diversity. METHODS: A Delphi study was used to identify and prioritize the most important strategies for reducing health inequities among the four aforementioned focus areas. Health equity experts were purposefully sampled. Data were collected in three rounds for each focus area separately. A comprehensive list of strategy statements was identified for each focus area in round one. The strategy statements were prioritized in round two and reprioritized in a final third round. Quantitative and qualitative data were integrated for the final analysis. RESULTS: Fifty strategies were identified across the four focus areas. Commitment to health equity, knowledge of health inequities, and knowledge of effective strategies to address the drivers of health inequities were ranked the highest for leadership. Universal access to health care and health in all policies were ranked highest for policy. Multi-level interventions, the effect of policy, governance, and politics, and translating and disseminating health equity interventions into practice were ranked the highest for research. Providing financial support to students from minority or low-socioeconomic backgrounds, commitment from undergraduate and medical school leadership for educational equity, providing opportunities for students from minority or low-socioeconomic backgrounds to prepare for standardized tests, and equitable primary and secondary school funding were ranked highest for diversity. CONCLUSIONS: The AAFP and other medical specialty societies have an important opportunity to advance health equity. They should develop a health equity policy agenda, equip physicians and other stakeholders, use their connections with practice-based research networks to identify and translate practical solutions to address the SDoH, and advocate for a more diverse medical workforce. TRIAL REGISTRATION: Not applicable.

Supporting Family Medicine Research Capacity: The Critical Role and Current Contributions of US Family Medicine Organizations.

BACKGROUND AND OBJECTIVES: Family medicine is continuously advanced by a reinforcing research enterprise. In the United States, each national family medicine organization contributes to the discipline's research foundations. We sought to map the unique and interorganizational roles of the eight US family medicine professional organizations participating in Family Medicine for America's Health (FMAHealth) in supporting family medicine research. METHODS: We interviewed leaders and reviewed supporting materials from organizations participating in FMAHealth. We explored existing activities, capacity, and collaboration. We identified areas of strength and opportunities for growth and synergy with respect to how the family of family medicine nurtures family medicine research. RESULTS: The FMAHealth organizations support certain aspects of the family medicine research infrastructure. Six domains were identified through this work: showcasing scholarship, communication and dissemination, workforce development, data-driven initiatives, performing primary research, and advocacy for family medicine research. Each organization's areas of emphasis differ, but we found substantial collaboration on initiatives across organizations, possibly attributable to the fact that many members belong to more than one organization. CONCLUSIONS: Deliberate contributions to each of the six domains identified herein will be important for the future success of family medicine research. Key opportunity areas described here include coordinated and strategic advocacy for increased funding for family medicine research, dedicated investment in training opportunities, protected effort to grow the next generation of family medicine researchers, pilot funding to build a research base for future high-impact research, and infrastructure to facilitate cross-institutional collaboration and data sharing.

Fast food consumption is associated with higher education in women, but not men, among older adults in urban safety-net clinics: A cross-sectional survey.

Fast food consumption is linked to poor health, yet many older adults regularly consume fast food. Understanding factors contributing to fast food consumption is useful in the development of targeted interventions. The aim of this study was to characterize how fast food consumption relates to socio-demographic characteristics in a low-income sample of older adults. This study used cross-sectional survey data of 50 to79-year-olds (N-236) in urban safety-net clinics in 2010 in Kansas City, KS. Self-reported frequency of fast food consumption was modeled using ordinal logistic regression with socio-demographics as predictor variables. Participants were 56.8 ±â€¯6.0 (mean ±â€¯SD) years old, 64% female, 45% non-Hispanic African American, and 26% Hispanic. Thirty-nine percent denied eating fast food in the past week, 36% ate once, and 25% ate fast food at least twice. Age was negatively correlated with fast food intake (r = -0.20, P = 0.003). After adjusting for age, race-ethnicity, employment, and marital status, the association between education and fast food consumption differed by sex (Pinteraction = 0.017). Among women, higher education was associated with greater fast food intake (Spearman's correlation; r = 0.28, P = 0.0005); the association was not significant in men (r = -0.14, P = 0.21). In this diverse, low-income population, high educational attainment (college graduate or higher) related to greater fast food intake among women but not men. Exploration of the factors contributing to this difference could inform interventions to curb fast food consumption or encourage healthy fast food choices among low-income, older adults.

Relating Stool Microbial Metabolite Levels, Inflammatory Markers and Dietary Behaviors to Screening Colonoscopy Findings in a Racially/Ethnically Diverse Patient Population.

Colorectal cancer (CRC) is the third leading cause of cancer death for both men and women in the United States, yet it is treatable and preventable. African Americans have higher incidence of CRC than other racial/ethnic groups, however, it is unclear whether this disparity is primarily due to environmental or biological factors. Short chain fatty acids (SCFAs) are metabolites produced by bacteria in the colon and are known to be inversely related to CRC progression. The aim of this study is to investigate how stool SCFA levels, markers of inflammation in stool and dietary intake relate to colonoscopy findings in a diverse patient population. Stool samples from forty-eight participants were analyzed for SCFA levels and inflammatory markers (lysozyme, secretory IgA, lactoferrin). Additionally, participants completed the National Cancer Institute's Diet History Questionnaire II (DHQ II) to report dietary intake over the past year. Subsequently, the majority of participants underwent screening colonoscopy. Our results showed that African Americans had higher total levels of SCFAs in stool than other racial/ethnic groups, significantly lower intake of non-starchy vegetables and similar inflammatory marker expression and colonoscopy outcomes, compared to others. This work is an initial exploration into the biological and clinical factors that may ultimately inform personalized screening approaches and clinical decision-making to improve colorectal cancer disparities for African Americans.

Fecal microbes, short chain fatty acids, and colorectal cancer across racial/ethnic groups.

AIM: To investigate differences in microbes and short chain fatty acid (SCFA) levels in stool samples from Hispanic and non-Hispanic African American, American Indian, and White participants. METHODS: Stool samples from twenty participants were subjected to analysis for relative levels of viable bacteria and for SCFA levels. Additionally, the samples were subjected to 16S rRNA gene pyrosequencing for identification of bacteria present in the stool. We used a metagenome functional prediction technique to analyze genome copy numbers and estimate the abundance of butyrate kinase in all samples. RESULTS: We found that African Americans had significantly lower levels of acetate, butyrate, and total SCFAs than all other racial/ethnic groups. We also found that participant microbial profiles differed by racial/ethnic group. African Americans had significantly more Firmicutes than Whites, with enriched Ruminococcaceae. The Firmicutes/Bacteroidetes ratio was also significantly higher for African Americans than for Whites (P = 0.049). We found Clostridium levels to be significantly and inversely related to total SCFA levels (P = 0.019) and we found Bacteroides to be positively associated (P = 0.027) and Clostridium to be negatively associated (P = 0.012) with levels of butyrate. We also identified a correlation between copy number for a butyrate kinase predicted from 16S rRNA gene abundance and levels of butyrate in stool. CONCLUSION: The identified differences in gut flora and SCFA levels may relate to colorectal cancer mortality differentials and may be useful as targets for future clinical and behavioral interventions.

Implementation intentions and colorectal screening: a randomized trial in safety-net clinics.

CONTEXT: Low-income and racial/ethnic minority populations experience disproportionate colorectal cancer (CRC) burden and poorer survival. Novel behavioral strategies are needed to improve screening rates in these groups. BACKGROUND: The study aimed to test a theoretically based "implementation intentions" intervention for improving CRC screening among unscreened adults in urban safety-net clinics. DESIGN: Randomized controlled trial. SETTING/PARTICIPANTS: Adults (N=470) aged ≥50 years, due for CRC screening, from urban safety-net clinics were recruited. INTERVENTION: The intervention (conducted in 2009-2011) was delivered via touchscreen computers that tailored informational messages to decisional stage and screening barriers. The computer then randomized participants to generic health information on diet and exercise (Comparison group) or "implementation intentions" questions and planning (Experimental group) specific to the CRC screening test chosen (fecal immunochemical test or colonoscopy). MAIN OUTCOME MEASURES: The primary study outcome was completion of CRC screening at 26 weeks based on test reports (analysis conducted in 2012-2013). RESULTS: The study population had a mean age of 57 years and was 42% non-Hispanic African American, 28% non-Hispanic white, and 27% Hispanic. Those receiving the implementation intentions-based intervention had higher odds (AOR=1.83, 95% CI=1.23, 2.73) of completing CRC screening than the Comparison group. Those with higher self-efficacy for screening (AOR=1.57, 95% CI=1.03, 2.39), history of asthma (AOR=2.20, 95% CI=1.26, 3.84), no history of diabetes (AOR=1.86, 95% CI=1.21, 2.86), and reporting they had never heard that "cutting on cancer" makes it spread (AOR=1.78, 95% CI=1.16, 2.72) were more likely to complete CRC screening. CONCLUSIONS: The results of this study suggest that programs incorporating an implementation intentions approach can contribute to successful completion of CRC screening even among very low-income and diverse primary care populations. Future initiatives to reduce CRC incidence and mortality disparities may be able to employ implementation intentions in large-scale efforts to encourage screening and prevention behaviors.

Self-reported barriers to colorectal cancer screening in a racially diverse, low-income study population.

Colorectal cancer (CRC) screening is underutilized, especially in low income, high minority populations. We examined the effect test-specific barriers have on colonoscopy and fecal immunochemical test (FIT) completion, what rationales are given for non-completion, and what "switch" patterns exist when participants are allowed to switch from one test to another. Low income adults who were not up-to-date with CRC screening guidelines were recruited from safety-net clinics and offered colonoscopy or FIT (n = 418). Follow up telephone surveys assessed test-specific barriers. Test completion was determined from patient medical records. For subjects who desired colonoscopy at baseline, finding a time to come in and transportation applied more to non-completers than completers (p = 0.001 and p < 0.001, respectively). For participants who initially wanted FIT, keeping track of cards, never putting stool on cards, and not remembering to mail cards back applied more to non-completers than completers (p = 0.003, p = 0.006, and p < 0.001, respectively). The most common rationale given for not completing screening was a desire for the other screening modality: 7 % of patients who initially preferred screening by FIT completed colonoscopy, while 8 % of patients who initially preferred screening by colonoscopy completed FIT. We conclude that test-specific barriers apply more to subjects who did not complete CRC screening. As a common rationale for test non-completion is a desire to receive a different screening modality, our findings suggest screening rates could be increased by giving patients the opportunity to switch tests after an initial choice is made.

Soj (ParA) DNA binding is mediated by conserved arginines and is essential for plasmid segregation.

Soj is a member of the ParA family of ATPases involved in plasmid and chromosomal segregation. It binds nonspecifically and cooperatively to DNA although the function of this binding is unknown. Here, we show that mutation of conserved arginine residues that map to the surface of Bacillus subtilis Soj caused only minimal effects on nucleotide-dependent dimerization but had dramatic effects on DNA binding. Using a model plasmid partitioning system in Escherichia coli, we find that Soj DNA-binding mutants are deficient in plasmid segregation. The location of the arginines on the Soj structure explains why DNA binding depends on dimerization and was used to orient the Soj dimer on the DNA, revealing the axis of Soj polymerization. The arginine residues are conserved among other chromosomal homologues, including the ParAs from Caulobacter crescentus, Pseudomonas aeruginosa, Pseudomonas putida, Streptomyces coelicolor, and chromosome I of Vibrio cholerae indicating that DNA binding is a common feature of members of this family.