Storylines of family medicine I: framing family medicine - history, values and perspectives.

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 'I: framing family medicine-history, values, and perspectives', the authors address the following themes: 'Notes on Storylines of Family Medicine', 'Family medicine-the generalist specialty', 'Family medicine's achievements-a glass half full assessment', 'Family medicine's next 50 years-toward filling our glasses', 'Four enduring truths of family medicine', 'Names matter', 'Family medicine at its core' and 'The ecology of medical care.' May readers find much food for thought in these essays.

Health systems science education: The new post-Flexner professionalism for the 21st century.

The foundations of medical education have drawn from the Flexner Report to prepare students for practice for over a century. These recommendations relied, however, upon a limited set of competencies and a relatively narrow view of the physician's role. There have been increasing calls and recommendations to expand those competencies and the professional identity of the physician to better meet the current and future needs of patients, health systems, and society. We propose a framework for the twenty-first century physician that includes an expectation of new competency in health systems science (HSS), creating 'system citizens' who are effective stewards of the health care system. Experiential educational strategies, in addition to knowledge-centered learning, are critically important for students to develop their professional identity as system citizens working alongside interprofessional colleagues. Challenges to HSS adoption range from competing priorities for learners, to the need for faculty development, to the necessity for buy-in by medical schools and their associated health care systems. Ultimately, success will depend on our ability to articulate, encourage, support, and evaluate system citizenship and its impact on health care and health care systems.

What matters in patient-centered medical home transformation: Whole system evaluation outcomes of the Brown Primary Care Transformation Initiative.

OBJECTIVES: Patient-centered medical home transformation initiatives for enhancing team-based, patient-centered primary care are widespread in the United States. However, there remain large gaps in our understanding of these efforts. This article reports findings from a contextual, whole system evaluation study of a transformation intervention at eight primary care teaching practice sites in Rhode Island. It provides a picture of system changes from the perspective of providers, staff, and patients in these practices. METHODS: Quantitative/qualitative evaluation methods include patient, provider, and staff surveys and qualitative interviews; practice observations; and focus groups with the intervention facilitation team. RESULTS: Patient satisfaction in the practices was high. Patients could describe observable elements of patient-centered medical home functioning, but they lacked explicit awareness of the patient-centered medical home model, and their activation decreased over time. Providers' and staff's emotional exhaustion and depersonalization increased slightly over the course of the intervention from baseline to follow-up, and personal accomplishment decreased slightly. Providers and staff expressed appreciation for the patient-centered medical home as an ideal model, variously implemented some important patient-centered medical home components, increased their understanding of patient-centered medical home as more than specific isolated parts, and recognized their evolving work roles in the medical home. However, frustration with implementation barriers and the added work burden they associated with patient-centered medical home persisted. CONCLUSION: Patient-centered medical home transformation is disruptive to practices, requiring enduring commitment of leadership and personnel at every level, yet the model continues to hold out promise for improved delivery of patient-centered primary care.

Curricular Transformation: The Case Against Global Change.

In this Commentary, the authors make the case for medical schools to pursue more circumscribed solutions to curricular redesign for undergraduate medical education rather than whole system changes-at least as first steps and perhaps as ultimate solutions. Although they focus primarily on the experience at the Warren Alpert Medical School of Brown University (AMS), they believe that the insights gleaned from their experiences are generalizable to other innovations and other medical schools. The authors describe the implementation of the Primary Care-Population Medicine track at AMS as a working example of implementing circumscribed rather than global change, and they discuss the advantages and disadvantages of such an approach to curriculum transformation.

Recommendations for a mixed methods approach to evaluating the patient-centered medical home.

PURPOSE: There is a strong push in the United States to evaluate whether the patient-centered medical home (PCMH) model produces desired results. The explanatory and contextually based questions of how and why PCMH succeeds in different practice settings are often neglected. We report the development of a comprehensive, mixed qualitative-quantitative evaluation set for researchers, policy makers, and clinician groups. METHODS: To develop an evaluation set, the Brown Primary Care Transformation Initiative convened a multidisciplinary group of PCMH experts, reviewed the PCMH literature and evaluation strategies, developed key domains for evaluation, and selected or created methods and measures for inclusion. RESULTS: The measures and methods in the evaluation set (survey instruments, PCMH meta-measures, patient outcomes, quality measures, qualitative interviews, participant observation, and process evaluation) are meant to be used together. PCMH evaluation must be sufficiently comprehensive to assess and explain both the context of transformation in different primary care practices and the experiences of diverse stakeholders. In addition to commonly assessed patient outcomes, quality, and cost, it is critical to include PCMH components integral to practice culture transformation: patient and family centeredness, authentic patient activation, mutual trust among practice employees and patients, and transparency, joy, and collaboration in delivering and receiving care in a changing environment. CONCLUSIONS: This evaluation set offers a comprehensive methodology to enable understanding of how PCMH transformation occurs in different practice settings. This approach can foster insights about how transformation affects critical outcomes to achieve meaningful, patient-centered, high-quality, and cost-effective sustainable change among diverse primary care practices.

Health is primary: Family medicine for America's health.

PURPOSE: More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to "renew the specialty to meet the needs of people and society," some of which bore important fruit. Family Medicine for America's Health was launched in 2013 to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim). METHODS: Family Medicine for America's Health was preceded and guided by the development of a family physician role definition. A consulting group facilitated systematic strategic plan development over 9 months that included key informant interviews, formal stakeholder surveys, future scenario testing, a retreat for family medicine organizations and stakeholder representatives to review strategy options, further strategy refinement, and finally a formal strategic plan with draft tactics and design for an implementation plan. A second communications consulting group surveyed diverse stakeholders in coordination with strategic planning to develop a communication plan. The American College of Osteopathic Family Physicians joined the effort, and students, residents, and young physicians were included. RESULTS: The core strategies identified include working to ensure broad access to sustained, primary care relationships; accountability for increasing primary care value in terms of cost and quality; a commitment to helping reduce health care disparities; moving to comprehensive payment and away from fee-for-service; transformation of training; technology to support effective care; improving research underpinning primary care; and actively engaging patients, policy makers, and payers to develop an understanding of the value of primary care. The communications plan, called Health is Primary, will complement these strategies. Eight family medicine organizations have pledged nearly $20 million and committed representatives to a multiyear implementation team that will coordinate these plans in a much more systematic way than occurred with FFM. CONCLUSIONS: Family Medicine for America's Health is a new commitment by 8 family medicine organizations to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim. It is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.

The future role of the family physician in the United States: a rigorous exercise in definition.

As the U.S. health care delivery system undergoes rapid transformation, there is an urgent need to define a comprehensive, evidence-based role for the family physician. A Role Definition Group made up of members of seven family medicine organizations developed a statement defining the family physician's role in meeting the needs of individuals, the health care system, and the country. The Role Definition Group surveyed more than 50 years of foundational manuscripts including published works from the Future of Family Medicine project and Keystone III conference, external reviews, and a recent Accreditation Council on Graduate Medical Education Family Medicine Milestones definition. They developed candidate definitions and a "foil" definition of what family medicine could become without change. The following definition was selected: "Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health." This definition will guide the second Future of Family Medicine project and provide direction as family physicians, academicians, clinical networks, and policy-makers negotiate roles in the evolving health system.

Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing.

PURPOSE: Reflective writing (RW) curriculum initiatives to promote reflective capacity are proliferating within medical education. The authors developed a new evaluative tool that can be effectively applied to assess students' reflective levels and assist with the process of providing individualized written feedback to guide reflective capacity promotion. METHOD: Following a comprehensive search and analysis of the literature, the authors developed an analytic rubric through repeated iterative cycles of development, including empiric testing and determination of interrater reliability, reevaluation and refinement, and redesign. Rubric iterations were applied in successive development phases to Warren Alpert Medical School of Brown University students' 2009 and 2010 RW narratives with determination of intraclass correlations (ICCs). RESULTS: The final rubric, the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT), consisted of four reflective capacity levels ranging from habitual action to critical reflection, with focused criteria for each level. The rubric also evaluated RW for transformative reflection and learning and confirmatory learning. ICC ranged from 0.376 to 0.748 for datasets and rater combinations and was 0.632 for the final REFLECT iteration analysis. CONCLUSIONS: The REFLECT is a rigorously developed, theory-informed analytic rubric, demonstrating adequate interrater reliability, face validity, feasibility, and acceptability. The REFLECT rubric is a reflective analysis innovation supporting development of a reflective clinician via formative assessment and enhanced crafting of faculty feedback to reflective narratives.

Are we making progress?: the tenth international forum for primary care research on low back pain.

STUDY DESIGN: Synthesis and analysis of presentation and discussion highlights, with a focus on emerging trends and promising new directions in primary care research on low back pain (LBP). OBJECTIVE: To present a summary of findings, themes, and insights from the Tenth International Forum on Primary Care Research on Low Back Pain, a meeting of researchers designed to share the latest concepts, methods, and results of research on LBP diagnosis, treatment, and disability prevention. SUMMARY OF BACKGROUND DATA: Earlier Forum meetings have developed several common themes and general conclusions. These are contrasted with the presentations and discussions at the 10th International Forum. RESULTS: Major themes included concerns about the epidemic of chronic, disabling LBP, associated treatments, iatrogenesis, and the "LBP medical industrial complex"; the variability and complexity of outcomes and how their importance differed across patients in defining recovery and recurrence; the power of nonspecific effects, expectations, and therapeutic alliance; and the challenges of identifying important therapeutic subgroups. New research addressed early risk factor screening and linked intervention, nonmedical approaches to reframe the LBP problem and avoid unnecessary care, cognitive and behavioral aspects of LBP, and ways to train clinicians to implement these innovations. More appropriate use of longitudinal designs and a greater focus on implementation research was called for. CONCLUSION: Although the field of primary care LBP research often seems to progress slowly, the Forum highlighted several important, promising developments that could substantially improve LBP research and primary care practice.

'The Loss of My Elderly Patient:' Interactive reflective writing to support medical students' rites of passage.

BACKGROUND: The fostering of reflective capacity within medical education helps develop critical thinking and clinical reasoning skills and enhances professionalism. Use of reflective narratives to augment reflective practice instruction is well documented. AIM: At Warren Alpert Medical School of Brown University (Alpert Med), a narrative medicine curriculum innovation of students' reflective writing (field notes) with individualized feedback from an interdisciplinary faculty team (in pre-clinical years) has been implemented in a Doctoring course to cultivate reflective capacity, empathy, and humanism. Interactive reflective writing (student writer/faculty feedback provider dyad), we propose, can additionally support students with rites of passage at critical educational junctures. METHOD: At Alpert Med, we have devised a tool to guide faculty in crafting quality feedback, i.e. the Brown Educational Guide to Analysis of Narrative (BEGAN) which includes identifying students' salient quotes, utilizing reflection-inviting questions and close reading, highlighting derived lessons/key concepts, extracting clinical patterns, and providing concrete recommendations as relevant. RESULTS: We provide an example of a student's narrative describing an emotionally powerful and meaningful event - the loss of his first patient - and faculty responses using BEGAN. CONCLUSION: The provision of quality feedback to students' reflective writing - supported by BEGAN - can facilitate the transformation of student to professional through reflection within medical education.

Encouraging scholarship: medical school programs to promote student inquiry beyond the traditional medical curriculum.

Many medical curricula now include programs that provide students with opportunities for scholarship beyond that provided by their traditional, core curricula. These scholarly concentration (SC) programs vary greatly in focus and structure, but they share the goal of producing physicians with improved analytic, creative, and critical-thinking skills. In this article, the authors explore models of both required and elective SC programs. They gathered information through a review of medical school Web sites and direct contact with representatives of individual programs. Additionally, they discuss in-depth the SC programs of the Warren Alpert Medical School of Brown University; the University of South Florida College of Medicine; the University of California, San Francisco; and Stanford University School of Medicine. The authors describe each program's focus, participation, duration, centralization, capstone requirement, faculty involvement, and areas of concentration. Established to address a variety of challenges in the U.S. medical education system, these four programs provide an array of possible models for schools that are considering the establishment of an SC program. Although data on the impact of SC programs are lacking, the authors believe that this type of program has the potential to significantly impact the education of medical students through scholarly, in-depth inquiry and longitudinal faculty mentorship.

Begin the BEGAN (The Brown Educational Guide to the Analysis of Narrative) - a framework for enhancing educational impact of faculty feedback to students' reflective writing.

OBJECTIVE: The study aim was the development of a method to further enhance the educational benefit of medical students' reflective writing. The setting is a Doctoring course at the Warren Alpert Medical School of Brown University, which includes reflective writing assignments, termed "field notes", combining students' reflective writing with ongoing individualized feedback from small group faculty. METHODS: Three-year (2005-2008) iterative process with three stages of immersion, analysis, and revision that resulted in the analysis framework. An interdisciplinary team composed of the four authors with backgrounds in narrative medicine, qualitative research, psychology, and medical education analyzed 12 first and second year students' selected field notes in iterative cycles. In each cycle, consultations with small group faculty and content experts were conducted to further validate the emergent framework. RESULTS: This process culminated in the creation of the Brown Educational Guide to Analysis of Narrative (BEGAN) framework, a guide for crafting feedback to students' reflective writing, and the integration of the BEGAN framework into the faculty and student manuals for the Doctoring Course in 2008-2009. CONCLUSIONS: We propose the BEGAN framework as a useful innovative tool that can be incorporated in reflective writing curricula in the field of health professions education. It is tailored to support the educational impact of the course through additional scaffolding of student writing, and the robust process it delineates for crafting of faculty feedback. Providing systematic feedback to enhance reflective writing may represent the path forward in fostering professional development through reflection in health professions education. PRACTICE IMPLICATIONS: The BEGAN can be incorporated in reflective writing curricula in the field of health professions education. It is a springboard for the necessary next steps of development and research into the acquisition of reflective and narrative competence in the emerging professional.

An anatomy of conflicts in primary care encounters: a multi-method study.

BACKGROUND: Medical consultations are replete with conflicts, particularly in the current era of explicit and implicit rationing practices in health care organizations. Although such conflicts may challenge the doctor-patient relationship, little is known about them or their consequences. AIMS: To systematically describe the nature of doctor-patient conflicts in medical encounters and the strategies physicians use when faced with conflicts. METHODS: Analysis of 291 videotaped routine encounters with 28 general practitioners, using a novel adaptation of the Roter interaction analysis system software, provided quantitative empirical data on the conflicts and on the communication process. Seven focus groups (56 GPs) provided qualitative insights and guided the analysis. RESULTS: Conflicts were identified in 40% of consultations; 21% of these were related to the rationing of health care resources. In conflictual encounters, both the opening and closing phases of the encounter were shorter than in non-conflictual encounters. In coping with resource rationing, the commonest strategy was to accept the dictates of the system without telling the patients about other options. When conflict of this type occurred, doctors showed more opposition to the patients rather than empathy. CONCLUSIONS: Doctors often face conflicts in their routine work, but resource-related conflicts are especially difficult and expose the dual loyalties of the doctor to the patient and to the system. Insights derived from this research can be used to design training interventions that improve doctors' efficacy in coping with conflicts and ultimately allow them to provide better patient care.

The current state of basic medical education in Israel: implications for a new medical school.

The recent government decision to establish a new medical school, the fifth in Israel, is an opportune moment to reflect on the state of Basic Medical Education (BME) in the country and globally. It provides a rare opportunity for planning an educational agenda tailored to local needs. This article moves from a description of the context of Israeli health care and the medical education system to a short overview of two existing Israeli medical schools where reforms have recently taken place. This is followed by an assessment of Israeli BME and an effort to use the insights from this assessment to inform the fifth medical school blueprint. The fifth medical school presents an opportunity for further curricular reforms and educational innovations. Reforms and innovations include: fostering self-directed professional development methods; emphasis on teaching in the community; use of appropriate educational technology; an emphasis on patient safety and simulation training; promoting the humanities in medicine; and finally the accountability to the community that the graduates will serve.

Reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback.

The promotion of reflective capacity within the teaching of clinical skills and professionalism is posited as fostering the development of competent health practitioners. An innovative approach combines structured reflective writing by medical students and individualized faculty feedback to those students to augment instruction on reflective practice. A course for preclinical students at the Warren Alpert Medical School of Brown University, entitled "Doctoring," combined reflective writing assignments (field notes) with instruction in clinical skills and professionalism and early clinical exposure in a small-group format. Students generated multiple e-mail field notes in response to structured questions on course topics. Individualized feedback from a physician-behavioral scientist dyad supported the students' reflective process by fostering critical-thinking skills, highlighting appreciation of the affective domain, and providing concrete recommendations. The development and implementation of this innovation are presented, as is an analysis of the written evaluative comments of students taking the Doctoring course. Theoretical and clinical rationales for features of the innovation and supporting evidence of their effectiveness are presented. Qualitative analyses of students' evaluations yielded four themes of beneficial contributions to their learning experience: promoting deeper and more purposeful reflection, the value of (interdisciplinary) feedback, the enhancement of group process, and personal and professional development. Evaluation of the innovation was the fifth theme; some limitations are described, and suggestions for improvement are provided. Issues of the quality of the educational paradigm, generalizability, and sustainability are addressed.

Towards cultural humility in healthcare for culturally diverse Rhode Island.

This article presents a framework for quality care that attends to culture and ethnicity. Tools and approaches for achieving cultural competency and humility are provided that may help improve the care of the patients, irrespective of their backgrounds or beliefs.

Secrets in primary care: a qualitative exploration and conceptual model.

OBJECTIVE: Secrets and issues of confidentiality are critical concerns in doctor-patient communication and fundamental aspects of every medical encounter. Nevertheless, the nature, content, prevalence, impact, and consequences of secrets in medicine have largely been unexplored. This study investigates the role of secrets in primary care. It describes the intuitive strategies used by primary care physicians to cope with secrets, provides a categorization system, and suggests a conceptual model. DESIGN: Focus groups of primary care physicians were the principal data collection method employed. Transcripts from 8 focus groups were analyzed using an "immersion-crystallization" framework involving cycles of concentrated textual review of data. Insights from this iterative process and from the literature were employed in the construction of contextual types, content categories, processes, and models. PARTICIPANTS: Sixty-one family physicians and general practitioners in Israel with a wide variety of seniority, ethnic, religious, and immigration backgrounds. SETTING: Locations in the north, south, and center of Israel. RESULTS: Analysis revealed insights about definitions, prevalence, process, and content of secrets in primary care. The main content findings centered on categories of secrets such as propensity to secrecy, toxicity of secrets, and the special nature of secrets in family medicine. The main process findings regarded the life cycle of secrets and doctors' coping strategies. Based on our findings and a review of the literature, a conceptual model of secrets in primary care is proposed. CONCLUSIONS: The importance and impact of secrets are significant part of daily medical practice. Further research is needed to enhance physicians' effective and ethical handling of secrets and secrecy in practice.