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.

Storylines of family medicine VI: ways of being-in the office with patients.

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 'VI: ways of being-in the office with patients', authors address the following themes: 'Patient-centred care-cultivating deep listening skills', 'Doctor as witness', 'Words matter', 'Understanding others-metaphor and its use in medicine', 'Communicating with patients-making good use of time', 'The patient-centred medical home-aspirations for the future', 'Routine, ceremony or drama?' and 'The life course'. May readers better appreciate the nuances of patient care through these essays.

Population health in primary care.

Population health in the United States continues to lag behind other wealthy nations. Primary care has the promise of enhancing population health; however, the implementation of a population health approach within primary care deserves further consideration. Clinicians and staff from a national sample of 10 innovative primary care practices participated in a working conference to reflect upon population health approaches in primary care. A series of small- and large-group discussions were recorded, transcribed, and coded through an immersion/crystallization approach. Two prominent themes emerged: (1) Transitioning to a population health focus generally develops through stages, with early implementation focusing on risk stratification and later, more advanced stages focusing on community health; and (2) Several inherent barriers confront implementation of a population health approach, including tensions with patient-centered care, and limitations of health information technology. A broader conceptualization of population health in terms of community health could more effectively allow partnerships among primary care, large health care systems, public health organizations, patients, and other partners in the community.

Leading primary care under the weight of COVID-19: how leadership was enacted in six australian general practices during 2020.

BACKGROUND: The COVID-19 pandemic challenged health care delivery globally, providing unique challenges to primary care. Australia's primary healthcare system (primarily general practices) was integral to the response. COVID-19 tested the ability of primary health care to respond to the greater urgency and magnitude than previous pandemics. Early reflections highlighted the critical role of leaders in helping organisations negotiate the pandemic's consequences. This study explores how general practice leadership was enacted during 2020, highlighting how leadership attributes were implemented to support practice teams. METHODOLOGY: We performed secondary analysis on data from a participatory prospective qualitative case study involving six general practices in Melbourne, Victoria, between April 2020 and February 2021. The initial coding template based on Miller et al.'s relationship-centred model informed a reflexive thematic approach to data re-analysis, focused on leadership. Our interpretation was informed by Crabtree et al.'s leadership model. RESULTS: All practices realigned clinical and organisational routines in the early months of the pandemic - hierarchical leadership styles often allowing rapid early responses. Yet power imbalances and exclusive communication channels at times left practice members feeling isolated. Positive team morale and interdisciplinary teamwork influenced practices' ability to foster emergent leaders. However, emergence of leaders generally represented an inherent 'need' for authoritative figures in the crisis, rather than deliberate fostering of leadership. CONCLUSION: This study demonstrates the importance of collaborative leadership during crises while highlighting areas for better preparedness. Promoting interdisciplinary communication and implementing formal leadership training in crisis management in the general practice setting is crucial for future pandemics.

A longitudinal multi-site evaluation of community-based partnerships: implications for researchers, funders, and communities.

BACKGROUND: Innovative Models Promoting Access to Care Transformation (IMPACT) was a five-year (2013-2018), Canadian-Australian research program that aimed to use a community-based partnership approach to transform primary health care (PHC) organizational structures to improve access to appropriate care for vulnerable populations. Local Innovation Partnerships (LIPs) were developed to support the IMPACT research program, and to be ongoing structures that would continue to drive local improvements to PHC. METHODS: A longitudinal development-focused evaluation explored the overall approach to governance, relationships and processes of the LIPs in the IMPACT program. Semi-structured interviews were conducted with purposively selected participants including researchers with implementation roles and non-researchers who were members of LIPs at four time points: early in the development of the LIPs in 2014; during intervention development in 2015/2016; at the intervention implementation phase in 2017; and nearing completion of the research program in 2018.  A hybrid deductive-inductive thematic analysis approach was used. A Guide developed to support the program was used as the framework for designing questions and analysing data using a qualitative descriptive method initially. A visual representation was developed and refined after each round of data collection to illustrate emerging themes around governance, processes and relationship building that were demonstrated by IMPACT LIPs. After all rounds of data collection, an overarching cross-case analysis of narrative summaries of each site was conducted. RESULTS: Common components of the LIPs identified across all rounds of data collection related to governance structures, stakeholder relationships, collaborative processes, and contextual barriers.  LIPs were seen primarily as a structure to support implementation of a research project rather than an ongoing multisectoral community-based partnership.  LIPs had relationships with many and varied stakeholders although not necessarily in ways that reflected the intended purpose. Collaboration was valued, but multiple barriers impeded the ability of LIPs to enact real collaboration in daily operations over time. We learned that experience, history, and time matter, especially with respect to community-oriented collaborative skills, structures, and relationships. CONCLUSIONS: This longitudinal multiple case study offers lessons and implications for researchers, funders, and potential stakeholders in community-based participatory research.

The Role of Primary Care in Improving Population Health.

Policy Points Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure. Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges. Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.

At the edge of chaos: a prospective multiple case study in Australian general practices adapting to COVID-19.

OBJECTIVES: The rapid onset and progressive course of the COVID-19 pandemic challenged primary care practices to generate rapid solutions to unique circumstances, creating a natural experiment of effectiveness, resilience, financial stability and governance across primary care models. We aimed to characterise how practices in Melbourne, Australia modified clinical and organisational routines in response to the pandemic in 2020-2021 and identify factors that influenced these changes. DESIGN: Prospective, qualitative, participatory case study design using constant comparative data analysis, conducted between April 2020 and February 2021. Participant general practitioner (GP) investigators were involved in study design, recruitment of other participants, data collection and analysis. Data analysis included investigator diaries, structured practice observation, documents and interviews. SETTING: The cases were six Melbourne practices of varying size and organisational model. PARTICIPANTS: GP investigators approached potential participants. Practice healthcare workers were interviewed by social scientists on three occasions, and provided feedback on presentations of preliminary findings. RESULTS: We conducted 58 interviews with 26 practice healthcare workers including practice owners, practice managers, GPs, receptionists and nurses; and six interviews with GP investigators. Data saturation was achieved within each practice and across the sample. The pandemic generated changes to triage, clinical care, infection control and organisational routines, particularly around telehealth. While collaboration and trust increased within several practices, others fragmented, leaving staff isolated and demoralised. Financial and organisational stability, collaborative problem solving, creative leadership and communication (internally and within the broader healthcare sector) were major influences on practice ability to negotiate the pandemic. CONCLUSIONS: This study demonstrates the complex influences on primary care practices, and reinforces the strengths of clinician participation in research design, conduct and analysis. Two implications are: telehealth, triage and infection management innovations are likely to continue; the existing payment system provides inadequate support to primary care in a global pandemic.

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

INTRODUCTION: To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. METHODS: Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. RESULTS: Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. DISCUSSION: Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

INTRODUCTION: To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. METHODS: Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. RESULTS: Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. DISCUSSION: Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

A Novel Mixed Methods Approach Combining Geospatial Mapping and Qualitative Inquiry to Identify Multilevel Policy Targets: The Focused Rapid Assessment Process (fRAP) Applied to Cancer Survivorship.

Multi-level perspectives across communities, medical systems and policy environments are needed, but few methods are available for health services researchers with limited resources. We developed a mixed method health policy approach, the focused Rapid Assessment Process (fRAP), that is designed to uncover multi-level modifiable barriers and facilitators contributing to public health issues. We illustrate with a study applying fRAP to the issue of cancer survivorship care. Through this multi-level investigation we identified two major modifiable areas impacting high-quality cancer survivorship care: 1) the importance of cancer survivorship guidelines/data, 2) the need for improved oncology-primary care relationships. This article contributes to the mixed methods literature by coupling geospatial mapping to qualitative rapid assessment to efficiently identify policy change targets.

The Time Is Now: A Plan to Redesign Family Medicine Residency Education.

A new graduate medical education program in family medicine is urgently needed now. We propose an innovative plan to develop community-based, community-owned family medicine residency programs. The plan is founded on five guiding principles in which residencies will (1) transition to independent, community-owned organizations; (2) sustain comprehensiveness and generalism; (3) emphasize collaborative learning and interprofessional education; (4) develop local educators with national guidance; and (5) share resources, responsibilities, and learning. We describe actionable steps to begin the process of transforming residencies and strengthening primary care. As community-based and locally-run organizations, residencies will gain self-determination in how time is allocated, budgets are spent, and teams function. Building on the momentum of the National Academy of Medicine's 2021 primary care implementation plan and recommendations by family medicine organization leaders, we propose a Decade of Family Medicine Residency Transformation. We encourage individuals and organizations spanning disciplines, health care systems, and communities, to join forces to reimagine and recreate the preparation of outstanding personal physicians dedicated to individual and community health and well-being.

The Craft of Generalism clinical skills and attitudes for whole person care.

RATIONALE, AIMS AND OBJECTIVES: Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism. METHODS: The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research. RESULTS: The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent. CONCLUSIONS: Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.

How do general practices respond to a pandemic? Protocol for a prospective qualitative study of six Australian practices.

INTRODUCTION: The COVID-19 pandemic has transformed healthcare systems worldwide. Primary care providers have been at the forefront of the pandemic response and have needed to rapidly adjust processes and routines around service delivery. The pandemic provides a unique opportunity to understand how general practices prepare for and respond to public health emergencies. We will follow a range of general practices to characterise the changes to, and factors influencing, modifications to clinical and organisational routines within Australian general practices amidst the COVID-19 pandemic. METHODS AND ANALYSIS: This is a prospective case study of multiple general practices using a participatory approach for design, data collection and analysis. The study is informed by the sociological concept of routines and will be set in six general practices in Melbourne, Australia during the 2020-2021 COVID-19 pandemic. General practitioners associated with the Monash University Department of General Practice will act as investigators who will shape the project and contribute to the data collection and analysis. The data will include investigator diaries, an observation template and interviews with practice staff and investigators. Data will first be analysed by two external researchers using a constant comparative approach and then later refined at regular investigator meetings. Cross-case analysis will explain the implementation, uptake and sustainability of routine changes that followed the commencement of the pandemic. ETHICS AND DISSEMINATION: Ethics approval was granted by Monash University (23950) Human Research Ethics Committees. Practice reports will be made available to all participating practices both during the data analysis process and at the end of the study. Further dissemination will occur via publications and presentations to practice staff and medical practitioners.

Simple Rules That Guide Generalist and Specialist Care.

The sometimes-paradoxical emergent behavior of complex systems may be explained by the interaction of simple rules. The paradox of primary care-that systems based on primary care have healthier populations, fewer health inequities, lower health care expenditures, and better system-level evidence-based disease care, despite less evidence-based care for individual diseases-may be explained by the iterative interaction among three simple rules that describe the generalist approach: (1) Recognize a broad range of problems/opportunities; (2) Prioritize attention and action with the intent of promoting health, healing, and connection; and (3) Personalize care based on the particulars of the individual or family in their local context. These are complemented by three simple rules for specialist care that represent current approaches to quality and health care system improvement: (1) Identify and classify disease for management; (2) Interpret through specialized knowledge; (3) Generate and carry out a management plan. Health care systems that support the enactment of the simple rules of the generalist approach are likely to have more effective primary and specialty care, and greater population health, equity, quality, and sustainable cost.

Indicator species characterization and removal in a detention pond in the Plaster Creek watershed.

Microbial pathogen contamination is a leading cause of impairment for urban rivers and streams in Michigan. Reports on the ability of green infrastructure best management practices to remove microbial pathogens have been highly variable. This study evaluated the influence of a detention basin (Kreiser Pond) on microbial dynamics in the Plaster Creek watershed in West Michigan. High levels of fecal indicator bacteria and coliphage were documented in influent and effluent water, with significant increases in indicator microbe concentrations during storm events. In dry conditions, Kreiser Pond efficiently reduced the number of indicator microbes flowing through the basin. Rainfall volume had a greater influence on the diversity of bacteria than sampling location. Antibiotic resistance was prevalent in culturable E. coli from Kreiser Pond, demonstrating a potential public health risk and highlighting the need for identifying the ultimate sources of microbial pollution.

Improving Smoking and Blood Pressure Outcomes: The Interplay Between Operational Changes and Local Context.

PURPOSE: We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care. METHODS: We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW-a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes. RESULTS: In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes. CONCLUSIONS: There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation.

Comparison of sample types from white-tailed deer (Odocoileus virginianus) for DNA extraction and analyses.

Collection of biological samples for DNA is necessary in a variety of disciplines including disease epidemiology, landscape genetics, and forensics. Quantity and quality of DNA varies depending on the method of collection or media available for collection (e.g., blood, tissue, fecal). Blood is the most common sample collected in vials or on Whatman Flinders Technology Associates (FTA) cards with short- and long-term storage providing adequate DNA for study objectives. The focus of this study was to determine if biological samples stored on Whatman FTA Elute cards were a reasonable alternative to traditional DNA sample collection, storage, and extraction. Tissue, nasal swabs, and ocular fluid were collected from white-tailed deer (Odocoileus virginianus). Tissue samples and nasal swabs acted as a control to compare extraction and DNA suitability for microsatellite analysis for nasal swabs and ocular fluid extracted from FTA Elute cards. We determined that FTA Elute cards improved the extraction time and storage of samples and that nasal swabs and ocular fluid containing pigmented fluid were reasonable alternatives to traditional tissue DNA extractions.

Simple Method to Determine the Apparent Quantum Yield Matrix of CDOM Photobleaching in Natural Waters.

The photobleaching of chromophoric dissolved organic matter (CDOM) is considered an important loss process for CDOM absorption in sunlit natural waters, where it can regulate the biota's exposure to sunlight, surface solar heating, and dissolved organic matter dynamics. Despite its importance, this sink remains poorly quantified, primarily because of the difficulty of determining photobleaching apparent quantum yields (AQYs) that capture the dual spectral dependency of this process and are applicable to polychromatic sunlight. Here, we present a simple method to determine a CDOM photobleaching AQY matrix (AQY-M) for natural water samples that does not require any a priori assumptions about the spectral dependency of photobleaching. It combines controlled irradiation experiments, a partial least-square regression, and an optimization procedure to produce AQY-Ms that are spectrally coherent and optimized for modeling accurate photobleaching rates in natural waters. Water temperature and the solar exposure history of CDOM had a major influence on the magnitude and spectral characteristics of the AQY-M. These factors should be considered when determining the AQY-M of samples and provide constraints when modeling photobleaching rates in natural waters. We expect that this effective method will provide future studies with a robust means to characterize and understand the variability of AQY-M in natural waters.

Assessment of spatial genetic structure to identify populations at risk for infection of an emerging epizootic disease.

Understanding the geographic extent and connectivity of wildlife populations can provide important insights into the management of disease outbreaks but defining patterns of population structure is difficult for widely distributed species. Landscape genetic analyses are powerful methods for identifying cryptic structure and movement patterns that may be associated with spatial epizootic patterns in such cases.We characterized patterns of population substructure and connectivity using microsatellite genotypes from 2,222 white-tailed deer (Odocoileus virginianus) in the Mid-Atlantic region of the United States, a region where chronic wasting disease was first detected in 2009. The goal of this study was to evaluate the juxtaposition between population structure, landscape features that influence gene flow, and current disease management units.Clustering analyses identified four to five subpopulations in this region, the edges of which corresponded to ecophysiographic provinces. Subpopulations were further partitioned into 11 clusters with subtle (F ST ≤ 0.041), but significant genetic differentiation. Genetic differentiation was lower and migration rates were higher among neighboring genetic clusters, indicating an underlying genetic cline. Genetic discontinuities were associated with topographic barriers, however.Resistance surface modeling indicated that gene flow was diffuse in homogenous landscapes, but the direction and extent of gene flow were influenced by forest cover, traffic volume, and elevational relief in subregions heterogeneous for these landscape features. Chronic wasting disease primarily occurred among genetic clusters within a single subpopulation and along corridors of high landscape connectivity.These results may suggest a possible correlation between population substructure, landscape connectivity, and the occurrence of diseases for widespread species. Considering these factors may be useful in delineating effective management units, although only the largest features produced appreciable differences in subpopulation structure. Disease mitigation strategies implemented at the scale of ecophysiographic provinces are likely to be more effective than those implemented at finer scales.