Storylines of family medicine XII: family medicine and the healthcare system.

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 'XII: Family medicine and the future of the healthcare system', authors address the following themes: 'Leadership in family medicine', 'Becoming an academic family physician', 'Advocare-our call to act', 'The paradox of primary care and three simple rules', 'The quadruple aim-melding the patient and the health system', 'Fit-for-purpose medical workforce', 'Universal healthcare-coverage for all', 'The futures of family medicine' and 'The 100th essay.' May readers of these essays feel empowered to be part of family medicine's exciting future.

Rethinking Health and Health Care: How Clinicians and Practice Groups Can Better Promote Whole Health and Well-Being for People and Communities.

A new National Academies of Sciences, Engineering, and Medicine report, "Achieving Whole Health: A New Approach for Veterans and the Nation," redefines what it means to be healthy and creates a roadmap for health systems, including the Veterans Health Administration and the nation, to scale and spread a whole health approach to care. The report identifies 5 foundational elements for whole health care and sets 6 national, state, and local policy goals for change. This article summarizes the report, emphasizes the importance of preventive medicine, and identifies concrete actions clinicians and practices can take now to deliver whole health care.

Achieving Whole Health for Veterans and the Nation: A National Academies of Sciences, Engineering, and Medicine Report.

This Viewpoint discusses the Whole Health System of care led by the US Department of Veterans Affairs.

How to Sponsor, Coach, and Mentor: A Qualitative Study With Family Medicine Department Chairs.

BACKGROUND AND OBJECTIVES: The goal of this study was to explore how to use sponsoring, coaching, and mentoring (SCM) for faculty development by clarifying the functions embedded in SCM. The study aims to ensure that department chairs can be intentional in providing those functions and/or playing those roles for the benefit of all their faculty. METHODS: We used qualitative, semistructured interviews in this study. We followed a purposeful sampling strategy to recruit a diverse sample of family medicine department chairs across the United States. Participants were asked about their experiences receiving and providing sponsoring, coaching, and mentoring. We iteratively coded audio recorded and transcribed interviews for content and themes. RESULTS: We interviewed 20 participants between December 2020 and May 2021 to identify actions associated with sponsoring, coaching, and mentoring. Participants identified six main actions sponsors perform. These actions are identifying opportunities, recognizing an individual's strengths, encouraging opportunity-seeking, offering tangible support, optimizing candidacy, nominating as a candidate, and promising support. In contrast, they identified seven main actions a coach performs. These are clarifying, advising, giving resources, performing critical appraisals, giving feedback, reflecting, and scaffolding (ie, providing support while learning). Finally, participants identified six main actions the mentors perform. The list includes checking in, listening, sharing wisdom, directing, supporting, and collaborating. CONCLUSIONS: We present SCM as an identifiable series of actions that need to be thought of and performed intentionally. Our clarification will help leaders purposefully select their actions and allows opportunity for evaluating their effectiveness. Future research will explore developing and evaluating programs that support learning how to provide SCM in order to enhance the process of faculty development and provide it equitably.

Mentoring as a Buffer for the Syndemic Impact of Racism and COVID-19 among Diverse Faculty within Academic Medicine.

Within this article, we explore the dual impact of two pandemics, racism and COVID-19, on the career and psychological well-being of diverse faculty within academic medicine. First, we present a discussion of the history of racism in academic medicine and the intensification of racial disparities due to the COVID-19 pandemic. As a result of the syndemic of racism and COVID-19, the outlook for the recruitment, retention, and advancement of diverse faculty and leaders within academic medicine is at risk. While mentoring is known to have benefits for career and personal development, we focus on the unique and often unacknowledged role that mentoring can play as a buffer for women and people of color, especially when working in institutions that lack diversity and are now struggling with the syndemic of racism and COVID-19. We also discuss the implications of acknowledging mentoring as a buffer for future leadership development, research, and programs within academic medicine and health professions.

Racial Diversity Among American Cardiologists: Implications for the Past, Present, and Future.

In the United States, race-based disparities in cardiovascular disease care have proven to be pervasive, deadly, and expensive. African American/Black, Hispanic/Latinx, and Native/Indigenous American individuals are at an increased risk of cardiovascular disease and are less likely to receive high-quality, evidence-based medical care as compared with their White American counterparts. Although the United States population is diverse, the cardiovascular workforce that provides its much-needed care lacks diversity. The available data show that care provided by physicians from racially diverse backgrounds is associated with better quality, both for minoritized patients and for majority patients. Not only is cardiovascular workforce diversity associated with improvements in health care quality, but racial diversity among academic teams and research scientists is linked with research quality. We outline documented barriers to achieving workforce diversity and suggest evidence-based strategies to overcome these barriers. Key strategies to enhance racial diversity in cardiology include improving recruitment and retention of racially diverse members of the cardiology workforce and focusing on cardiovascular health equity for patients. This review draws attention to academic institutions, but the implications should be considered relevant for nonacademic and community settings as well.

Awareness and Use of Contraceptive Methods and Perceptions of Long-Acting Reversible Contraception Among White and Non-White Women.

Background: Unintended pregnancies continue to account for half of all pregnancies in the United States, primarily due to incorrect or inconsistent use of contraception methods. Long-acting reversible contraception (LARC) methods are safe and highly effective, yet underutilized. Low uptake of LARC may be due to inadequate education, misconceptions, and cultural factors such as race, ethnicity, or religion. This study examined racial differences in contraceptive awareness and use among women seeking care at family health centers. Materials and Methods: Focus groups were used to identify recurrent themes in contraceptive choice of participants and develop a survey, completed by nonpregnant female patients 18-45 years of age from seven family health centers. Results: Among a total of 465 participants, 210 (46.2%) of whom were non-white, awareness of most types of birth control was generally high. Awareness of all types of contraceptives was significantly higher among white than non-white women (p < 0.001). Across most types of contraceptives, use was significantly higher among white women than non-white women with the exception of injectable hormones which were used significantly more often by non-white women (46.0% vs. 28.5%; p < 0.001). Reasons for using LARC did not vary by type nor by race but reasons for not using LARC varied by race and by specific method. Conclusions: Differing patterns of awareness, use, and perceptions of contraceptive methods between white and non-white women were revealed. By understanding factors that influence contraceptive awareness, use, and perceptions, clinicians can better address the contraceptive needs and concerns of their female patients. Clinical Trial # NCT03486743.

Combating the Hidden Health Disparity of Kernicterus in Black Infants: A Review.

Importance: Kernicterus is a devastating, permanently disabling neurologic condition resulting from bilirubin neurotoxicity. Black neonates account for more than 25% of kernicterus cases in the US, despite making up only approximately 14% of all births. This is a largely overlooked health disparity. Observations: The black kernicterus health disparity exists despite a lower overall incidence of clinically significant hyperbilirubinemia among black neonates, a paradox recently explained by a previously unrecognized risk for hazardous hyperbilirubinemia. Aligned with national and global health initiatives to reduce or eliminate health disparities, this review highlights the multiple biologic and nonbiologic factors contributing to kernicterus risk in black infants and approaches to reduce this health disparity. This includes both parent-level and clinician-level kernicterus prevention strategies, with an emphasis on improving parental health literacy on neonatal jaundice and acute bilirubin encephalopathy and clinician awareness of the key factors that contribute to hazardous hyperbilirubinemia risk in this vulnerable group. Parent-level prevention strategies include efforts to improve their health literacy on neonatal jaundice and acute bilirubin encephalopathy and empower care seeking for jaundice. Clinician-level prevention strategies include efforts to eliminate community and institutional barriers that impede access to care, heighten clinician awareness of the factors that contribute to kernicterus risk in this vulnerable patient group, and strengthen newborn hyperbilirubinemia management and bilirubin surveillance. Conclusions and Relevance: There are multiple opportunities for intervention to reduce black kernicterus risk. Although kernicterus is a rare disorder, the incidence among black infants is not a trivial matter nor are efforts to prevent kernicterus. While the multiple interacting biologic and nonbiologic contributors to increased kernicterus risk among black infants pose a considerable challenge to clinicians, there are opportunities for intervention to reduce this risk and health disparity. Continued study is imperative to understand the current scope of kernicterus and its occurrence in black neonates.

Leadership Pathways in Academic Family Medicine: Focus on Underrepresented Minorities and Women.

BACKGROUND AND OBJECTIVES: Leadership positions in academic medicine lack racial and gender diversity. In 2016, the Council of Academic Family Medicine (CAFM) established a Leadership Development Task Force to specifically address the lack of diversity among leadership in academic family medicine, particularly for underrepresented minorities and women. APPROACH: The task force was formed in August 2016 with members from each of the CAFM organizations representing diversity of race, gender, and academic position. The group met from August 2016 to December 2017. The task force reviewed available leadership development programming, and through consensus identified common pathways toward key leadership positions in academic family medicine-department chairs, program directors, medical student education directors, and research directors. consensus development: The task force developed a model that describes possible pathways to several leadership positions within academic family medicine. Additionally, we identified the intentional use of a multidimensional mentoring team as critically important for successfully navigating the path to leadership. CONCLUSIONS: There are ample opportunities available for leadership development both within family medicine organizations and outside. That said, individuals may require assistance in identifying and accessing appropriate opportunities. The path to leadership is not linear and leaders will likely hold more than one position in each of the domains of family medicine. Development as a leader is greatly enhanced by forming a multidimensional team of mentors.

Prioritized Research for the Prevention, Treatment, and Reversal of Chronic Disease: Recommendations From the Lifestyle Medicine Research Summit.

Declining life expectancy and increasing all-cause mortality in the United States have been associated with unhealthy behaviors, socioecological factors, and preventable disease. A growing body of basic science, clinical research, and population health evidence points to the benefits of healthy behaviors, environments and policies to maintain health and prevent, treat, and reverse the root causes of common chronic diseases. Similarly, innovations in research methodologies, standards of evidence, emergence of unique study cohorts, and breakthroughs in data analytics and modeling create new possibilities for producing biomedical knowledge and clinical translation. To understand these advances and inform future directions research, The Lifestyle Medicine Research Summit was convened at the University of Pittsburgh on December 4-5, 2019. The Summit's goal was to review current status and define research priorities in the six core areas of lifestyle medicine: plant-predominant nutrition, physical activity, sleep, stress, addictive behaviors, and positive psychology/social connection. Forty invited subject matter experts (1) reviewed existing knowledge and gaps relating lifestyle behaviors to common chronic diseases, such as cardiovascular disease, diabetes, many cancers, inflammatory- and immune-related disorders and other conditions; and (2) discussed the potential for applying cutting-edge molecular, cellular, epigenetic and emerging science knowledge and computational methodologies, research designs, and study cohorts to accelerate clinical applications across all six domains of lifestyle medicine. Notably, federal health agencies, such as the Department of Defense and Veterans Administration have begun to adopt "whole-person health and performance" models that address these lifestyle and environmental root causes of chronic disease and associated morbidity, mortality, and cost. Recommendations strongly support leveraging emerging research methodologies, systems biology, and computational modeling in order to accelerate effective clinical and population solutions to improve health and reduce societal costs. New and alternative hierarchies of evidence are also be needed in order to assess the quality of evidence and develop evidence-based guidelines on lifestyle medicine. Children and underserved populations were identified as prioritized groups to study. The COVID-19 pandemic, which disproportionately impacts people with chronic diseases that are amenable to effective lifestyle medicine interventions, makes the Summit's findings and recommendations for future research particularly timely and relevant.

Long-term Outcomes for Teen Mothers Who Participated in a Mentoring Program to Prevent Repeat Teen Pregnancy.

BACKGROUND: Each year in the United States (US), one million adolescents are pregnant, of which approximately 20% are repeat pregnancies. Adolescent motherhood is associated with lower educational attainment, socioeconomic status and poorer health outcomes. A mentoring program called the Maikuru Program conducted from 2011 to 2015, was designed to teach young mothers under 20 years old how to face daily life challenges, to support them by pairing them with an adult mentor, and prevent a subsequent pregnancy during their teens. The goal of the present study was to examine educational attainment, employment and pregnancies of these adolescent mothers 1-5 years post program. METHODS: Former participants of the Maikuru Program were contacted by telephone and/or Facebook in 2016 to conduct a survey about education attainment, employment status, number of subsequent children delivered, and satisfaction with the program. RESULTS: Nineteen of 51 participants (37%) were reached to complete the survey. Of those who responded, all were in high school or had graduated, nearly half were pursuing some form of higher education and 12 (63%) were currently employed. Nine mothers had given birth to another child; only two (10.5%) were known to be less than 20 years old at the time. All participants reported positive perceptions of the program and would recommend it to other adolescent mothers. CONCLUSION: Educational achievement and employment were high among a modest proportion of adolescent mothers who had participated in a culturally tailored, teen mother-adult mentoring program. Repeat teen pregnancy was infrequent and the mentoring program was perceived as contributing to the success of those who responded to the follow-up. A future randomized trial based on this model may confirm these findings.

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.

Using the 4 pillars™ practice transformation program to increase adult influenza vaccination and reduce missed opportunities in a randomized cluster trial.

BACKGROUND: An evidence-based, step-by-step guide, the 4 Pillars™ Practice Transformation Program, was the foundation of an intervention to increase adult immunizations in primary care and was tested in a randomized controlled cluster trial. The purpose of this study is to report changes in influenza immunization rates and on factors related to receipt of influenza vaccine. METHODS: Twenty five primary care practices were recruited in 2013, stratified by city (Houston, Pittsburgh), location (rural, urban, suburban) and type (family medicine, internal medicine), and randomized to the intervention (n = 13) or control (n = 12) in Year 1 (2013-14). A follow-up intervention occurred in Year 2 (2014-15). Demographic and vaccination data were derived from de-identified electronic medical record extractions. RESULTS: A cohort of 70,549 adults seen in their respective practices (n = 24 with 1 drop out) at least once each year was followed. Baseline mean age was 55.1 years, 35 % were men, 21 % were non-white and 35 % were Hispanic. After one year, both intervention and control arms significantly (P < 0.001) increased influenza vaccination, with average increases of 2.7 to 6.5 percentage points. In regression analyses, likelihood of influenza vaccination was significantly higher in sites with lower percentages of patients with missed opportunities (P < 0.001) and, after adjusting for missed opportunities, the intervention further improved vaccination rates in Houston (lower baseline rates) but not Pittsburgh (higher baseline rates). In the follow-up intervention, the likelihood of vaccination increased for both intervention sites and those that reduced missed opportunities (P < 0.005). CONCLUSIONS: Reducing missed opportunities across the practice increases likelihood of influenza vaccination of adults. The 4 Pillars™ Practice Transformation Program provides strategies for reducing missed opportunities to vaccinate adults. TRIAL REGISTRATION: This study was registered as a clinical trial on 03/20/2013 at ClinicalTrials.gov, Clinical Trial Registry Number: NCT01868334 , with a date of enrollment of the first participant to the trial of April 1, 2013.

Using the 4 Pillars™ Practice Transformation Program to increase adult Tdap immunization in a randomized controlled cluster trial.

INTRODUCTION: National adult Tdap vaccination rates are low, reinforcing the need to increase vaccination efforts in primary care offices. The 4 Pillars™ Practice Transformation Program is an evidence-based, step-by-step guide to improving primary care adult vaccination with an online implementation tracking dashboard. This study tested the effectiveness of an intervention to increase adult Tdap vaccination that included the 4 Pillars™ Program, provider education, and one-on-one coaching of practice-based immunization champions. METHODS: 25 primary care practices participated in a randomized controlled cluster trial (RCCT) in Year 1 (6/1/2013-5/31/2014) and a pre-post study in Year 2 (6/1/2014-1/31/2015). Baseline year was 6/1/2012-5/31/2013, with data analyzed in 2016. Demographic and vaccination data were derived from de-identified electronic medical record (EMR) extractions. The primary outcomes were vaccination rates and percentage point (PP) changes/year. RESULTS: The cohort consisted of 70,549 patients ⩾18years who were seen in the practices ⩾1 time each year, with a baseline mean age=55years; 35% were men; 56% were non-white; 35% were Hispanic and 20% were on Medicare. Baseline vaccination rate averaged 35%. In the Year 1 RCCT, cumulative Tdap vaccination increased significantly in both intervention and control groups; in both cities, the percentage point increases in the intervention groups (7.7 PP in Pittsburgh and 9.9 PP in Houston) were significantly higher (P<0.001) than in the control groups (6.4 PP in Pittsburgh and 7.6 PP in Houston). In the Year 2 pre-post study, in both cities, active intervention groups increased rates significantly more (6.2 PP for both) than maintenance groups (2.2 PP in Pittsburgh and 4.1 PP in Houston; P<0.001). CONCLUSIONS: An intervention that includes the 4 Pillars™ Practice Transformation Program, staff education and coaching is effective for increasing adult Tdap immunization rates within primary care practices. Clinical Trial Registry Name/Number: NCT01868334.

Building diversity in a complex academic health center.

For 30 years, the many diversity-related health sciences programs targeting the University of Pittsburgh undergraduate campus, school of medicine, schools of the health sciences, clinical practice plan, and medical center were run independently and remained separate within the academic health center (AHC). This lack of coordination hampered their overall effectiveness in promoting diversity and inclusion. In 2007, a group of faculty and administrators from the university and the medical center recognized the need to improve institutional diversity and to better address local health disparities. In this article, the authors describe the process of linking the efforts of these institutions in a way that would be successful locally and applicable to other academic environments. First, they engaged an independent consultant to conduct a study of the AHC's diversity climate, interviewing current and former faculty and trainees to define the problem and identify areas for improvement. Next, they created the Physician Inclusion Council to address the findings of this study and to coordinate future efforts with institutional leaders. Finally, they formed four working committees to address (1) communications and outreach, (2) cultural competency, (3) recruitment, and (4) mentoring and retention. These committees oversaw the strategic development and implementation of all diversity and inclusion efforts. Together these steps led to structural changes within the AHC and the improved allocation of resources that have positioned the University of Pittsburgh to achieve not only diversity but also inclusion and to continue to address the health disparities in the Pittsburgh community.

Pain and depression in a cohort of underserved, community-dwelling primary care patients.

PURPOSE: Almost 17% of the US population exhibits a major depressive disorder in their lifetimes. Prevalence data show that whites experience depression earlier than African Americans, and women have a higher prevalence than men. Less is known regarding depression among underserved minority populations. The goal of our study was to examine the relationship of depression and associated self-reported conditions in participants enrolled in a community-based research registry, a substantial number of whom were underrepresented minorities. METHODS: This study used a research registry of community members who had expressed interest in participating in health education projects conducted by the Center for Primary Care Community-Based Research. The patients received care at 10 family health centers. Participants were surveyed regarding family history of depression/anxiety and associated symptoms. Descriptive analyses, univariate analyses, and logistic regressions were used. RESULTS: The population (N = 2421) included women (72.2%), African Americans (54.9%), and reported good or very good general health (68.9%). Comorbid pain was found, with headache as the predominant complaint. Compared with nonwhites, whites had a significantly higher prevalence of current depression (26.3% vs. 23.8%; P = .01), current anxiety (25.5% vs. 16.6%), and current headache (14.2% vs. 11.2%). Whites also had a higher prevalence of a family history of depression (38.4% vs. 32.1%) and anxiety (8.9% vs. 7.7%) and of taking depression (22.4% vs. 14.8%) and anxiety (15.8% vs. 7.8%) medications. However, nonwhites had a higher prevalence of leg pain (18.8% vs. 14.9%) but a lower prevalence of headache (11.2% vs. 14.2%). CONCLUSIONS: Pain was common in patients with comorbid behavioral conditions. Headache was more common in whites, whereas leg pain was more common in nonwhites. Physicians should screen for depression and anxiety in patients with headache and other pain symptoms.

Effects of diet and physical activity interventions on weight loss and cardiometabolic risk factors in severely obese adults: a randomized trial.

CONTEXT: The prevalence of severe obesity is increasing markedly, as is prevalence of comorbid conditions such as hypertension and type 2 diabetes mellitus; however, apart from bariatric surgery and pharmacotherapy, few clinical trials have evaluated the treatment of severe obesity. OBJECTIVE: To determine the efficacy of a weight loss and physical activity intervention on the adverse health risks of severe obesity. DESIGN, SETTING, AND PARTICIPANTS: Single-blind randomized trial conducted from February 2007 through April 2010 at the University of Pittsburgh. Participants were 130 (37% African American) severely obese (class II or III) adult participants without diabetes recruited from the community. INTERVENTIONS: One-year intensive lifestyle intervention consisting of diet and physical activity. One group (initial physical activity) was randomized to diet and physical activity for the entire 12 months; the other group (delayed physical activity) had the identical dietary intervention but with physical activity delayed for 6 months. MAIN OUTCOME MEASURES: Changes in weight. Secondary outcomes were additional components comprising cardiometabolic risk, including waist circumference, abdominal adipose tissue, and hepatic fat content. RESULTS: Of 130 participants randomized, 101 (78%) completed the 12-month follow-up assessments. Although both intervention groups lost a significant amount of weight at 6 months, the initial-activity group lost significantly more weight in the first 6 months compared with the delayed-activity group (10.9 kg [95% confidence interval {CI}, 9.1-12.7] vs 8.2 kg [95% CI, 6.4-9.9], P = .02 for group × time interaction). Weight loss at 12 months, however, was similar in the 2 groups (12.1 kg [95% CI, 10.0-14.2] vs 9.9 kg [95% CI, 8.0-11.7], P = .25 for group × time interaction). Waist circumference, visceral abdominal fat, hepatic fat content, blood pressure, and insulin resistance were all reduced in both groups. The addition of physical activity promoted greater reductions in waist circumference and hepatic fat content. CONCLUSION: Among patients with severe obesity, a lifestyle intervention involving diet combined with initial or delayed initiation of physical activity resulted in clinically significant weight loss and favorable changes in cardiometabolic risk factors. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00712127.