Storylines of family medicine IX: people and places-diverse populations and locations of care.

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 'IX: people and places-diverse populations and locations of care', authors address the following themes: 'LGBTQIA+health in family medicine', 'A family medicine approach to substance use disorders', 'Shameless medicine for people experiencing homelessness', '''Difficult" encounters-finding the person behind the patient', 'Attending to patients with medically unexplained symptoms', 'Making house calls and home visits', 'Family physicians in the procedure room', 'Robust rural family medicine' and 'Full-spectrum family medicine'. May readers appreciate the breadth of family medicine in these essays.

Addressing and Dismantling the Legacy of Race and Racism in Academic Medicine: A Socioecological Framework.

Over the past several years, in both clinical and academic medicine, there seems to be a growing consensus that racial/ethnic health inequities result from social, economic and political determinants of health rather than from nonexistent biological markers of race. Simply put, racism is the root cause of inequity, not race. Yet, methods of teaching and practicing medicine have not kept pace with this truth, and many learners and practitioners continue to extrapolate a biological underpinning for race. To achieve systemic change that moves us toward racially/ethnically equitable health outcomes, it is imperative that medical academia implement policies that explicitly hold us accountable to maintain a clear understanding of race as a socio-political construct so that we can conduct research, disseminate scholarly work, teach, and practice clinically with more clarity about race and racism. This short commentary proposes the use of a socioecological framework to help individuals, leadership teams, and institutions consider the implementation of various strategies for interpersonal, community-level, and broad institutional policy changes. This proposed model includes examples of how to address race and racism in academic medicine across different spheres, but also draws attention to the complex interplay across these levels. The model is not intended to be prescriptive, but rather encourages adaptation according to existing institutional differences. This model can be used as a tool to refresh how academic medicine addresses race and, more importantly, normalizes conversations about racism and equity across all framework levels.

Evaluating the Uptake of Antiracism Training, Policies, and Practices in Departments of Family Medicine.

BACKGROUND: Recent attention and focus on, antiracism training in health care has potential to accelerate our path to social justice and achieve health equity on a national scale. However, theoretical frameworks and empirical data have yet to emerge that explain the uptake of antiracism trainings and their efficacy. OBJECTIVE: This goal of this study was to test hypotheses regarding uptake of antiracism training in Family Medicine departments using Diffusion of Innovation Theory. METHODS: In 2021, we incorporated 10 survey items in the Council of Academic Family Medicine Educational Research Alliance's national omnibus survey for Department of Family Medicine Chairs (n = 104). We used DOI (Diffusion of Innovation) attributes (ie, relative advantage, compatibility, complexity, trialability, and observability) as a guiding framework to assess perceived innovation of antiracism training. We also evaluated the mode of training (eg, didactic, experiential) and whether any subsequent policy or practice-level antiracist actions occurred. We used c2 tests to examine associations between DOI attributes and antiracist actions; and logistic regression to determine odds of association. RESULTS: Ninety-two percent of respondents indicated antiracism training was happening in their department. Relative advantage, compatibility and observability were positively associated with antiracist actions, P < .05. Perceived relative advantage was associated with implementation of antiracist action (OR 1.94, 1.27-2.99). Complexity and trialability were not statistically significantly associated with action. CONCLUSION: Our findings provide evidence of DOIs influence on antiracism uptake in Departments of Family Medicine. We believe our findings can facilitate the future implementation of antiracism training activities and actionable antiracist policies and practices.

Diversity and Facing Discrimination in Family Medicine Residencies: A CERA Survey of Program Directors.

BACKGROUND AND OBJECTIVES: Increasing the number of underrepresented minorities in medicine (URM) has the potential to improve access and quality of care and reduce health inequities for diverse populations. Having a diverse workforce in residency programs necessitates structures in place for support, training, and addressing racism and discrimination. This study examines reports of discrimination and training initiatives to increase diversity and address discrimination and unconscious bias in family medicine residency programs nationally. METHODS: This survey was part of the Council of Academic Family Medicine Educational Research Alliance (CERA) 2018 national survey of family medicine residency program directors. Questions addressed the presence of reported discrimination, residency program training about discrimination and bias, and admissions practices concerning physician workforce diversity. We performed univariate and bivariate analyses on CERA survey response data. RESULTS: We received 272 responses to the diversity survey items within the CERA program director survey from 522 possible residency director respondents, yielding a response rate of 52.1%. The majority of residency programs (78%) offer training for faculty and/or residents in unconscious/implicit bias and systemic/institutional racism. A minority of program directors report discrimination in the residency environment, most often reported by patients (13.2%) and staff (7.2%) and least often by faculty (3.3%), with most common reasons for discrimination noted as language or race/skin color. CONCLUSIONS: Most family medicine residency program directors report initiatives to address diversity in the workforce. Research is needed to develop best practices to ensure continued improvement in workforce diversity and racial climate that will enhance the quality of care and access for underserved populations.

Exploring the Face-to-Face: Revisiting Patient-Doctor Relationships in a Time of Expanding Telemedicine.

The patient-doctor relationship lies at the heart of medicine. Confronted with the challenges of COVID-19, we find ourselves unable to provide care and comfort in the same physical space as our patients. As we are forced to reckon with telemedicine visits and contemplate continuing them in a postpandemic future, it is important to understand the difference relationally between telemedicine and face-to-face encounters. I will argue that face-to-face visits remain essential in establishing the most fundamentally human components of relationships: responsibility and vulnerability. This established bond assures fidelity in subsequent encounters, whether by phone, video, or in person.

Dear White People.

We are living in unprecedented times. While the world is grappling with COVID-19, we find the horrors of racism looming equally large as we, yet again, confront lurid deaths in the center of the news cycle of Black and brown people from police bias and brutality. Those of us who have been championing antiracism and justice work and bearing the burden of the "minority tax" have been overwhelmed by sudden asks from our well-intentioned White colleagues of how to best respond. In the tone of the Netflix series, "Dear White People," we further emphasize that we are not alone in trying to reach out to you, our White colleagues and leaders. Please hear our story and heed our call to action.

Teaching About Racism in Medical Education: A Mixed-Method Analysis of a Train-the-Trainer Faculty Development Workshop.

BACKGROUND AND OBJECTIVES: Curriculum addressing racism as a driver of inequities is lacking at most health professional programs. We describe and evaluate a faculty development workshop on teaching about racism to facilitate curriculum development at home institutions. METHODS: Following development of a curricular toolkit, a train-the-trainer workshop was delivered at the 2017 Society of Teachers of Family Medicine Annual Spring Conference. Preconference evaluation and a needs assessment collected demographic data of participants, their learning communities, and experience in teaching about racism. Post-conference evaluations were completed at 2- and 6-month intervals querying participants' experiences with teaching about racism, including barriers; commitment to change expressed at the workshop; and development of the workshop-delivered curriculum. We analyzed quantitative data using Statistical Package for the Social Sciences (SPSS) software and qualitative data, through open thematic coding and content analysis. RESULTS: Forty-nine people consented to participate. The needs assessment revealed anxiety but also an interest in obtaining skills to teach about racism. The most reported barriers to developing curriculum were institutional and educator related. The majority of respondents at 2 months (61%, n=14/23) and 6 months (70%, n=14/20) had used the toolkit. Respondents ranked all 10 components as useful. The three highest-ranked components were (1) definitions and developing common language; (2) facilitation training, exploring implicit bias, privilege, intersectionality and microaggressions, and videos/podcasts; and (3) Theater of the Oppressed and articles/books. CONCLUSIONS: Faculty development training, such as this day-long workshop and accompanying toolkit, can advance skills and increase confidence in teaching about racism.

Teaching Racial Affinity Caucusing as a Tool to Learn About Racial Health Inequity Through an Experiential Workshop.

BACKGROUND AND OBJECTIVES: In its landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine concluded that unconscious or implicit negative racial attitudes and stereotypes contribute to poorer health outcomes for patients of color. We describe and report on the outcome of teaching a workshop on the tool of racial affinity caucusing to address these issues. METHODS: Applying the framework described by Crossroads Antiracism Organizing and Training, we developed a 90-minute workshop teaching racial affinity caucusing to family medicine educators interested in racial health disparities. The workshop included didactic and experiential components as well as a panel discussion. We administered pre- and posttests. RESULTS: Participants' (n=53) impression of and confidence in implementing racial affinity caucusing significantly increased following the workshop from a mean pretest score of 5.40 to a mean posttest score of 7.12 (P<.01) on a scale of 1 to 9. Ninety-two percent of participants indicated that the workshop made them more likely to think about implementing this tool at their home institutions (P<.01). CONCLUSIONS: This study demonstrated the first exploration in medical education of racial affinity caucusing and illustrated that it can be easily implemented in residency programs as an effort to address racial health inequities. Though the participating educators were mostly unfamiliar with it, the workshop was an effective introduction to this tool and by the end, educators reported increased comfort and enthusiasm for racial affinity caucusing, regardless of their preexisting levels of knowledge of or comfort with the tool. In addition, the overwhelming majority of the participants felt they could implement it at their respective institutions.

A Qualitative Study of Undergraduate Racial and Ethnic Minority Experiences and Perspectives on Striving to Enter Careers in the Health Professions.

BACKGROUND: Diversification of the health care workforce by race and ethnicity offers a strategy for addressing health care disparities. This study explored the experiences with pathways programming and mentoring of minority undergraduates aspiring to health professions careers. METHODS: We interviewed 21 minority undergraduates in 4 focus groups. The interviews explored participants' backgrounds; perceptions of racial climate; exposure to health professions careers, mentors, and pathways programs; barriers to success; and desired support. RESULTS: Many participants described diminished confidence and feelings of isolation due to stereotyping and discrimination; some were empowered to pursue health care careers because of adversity. Common themes included desire for mentorship, earlier career exposure, and college readiness support. DISCUSSION: Minority students desire health career exposure, mentoring, pre-college advising, and a positive racial climate; unfortunately, these desires often go unmet.

Addressing Family Medicine's Capacity to Improve Health Equity Through Collaboration, Accountability and Coalition-Building.

Achieving health equity requires an evaluation of social, economic, environmental, and other factors that impede optimal health for all. Family medicine has long valued an ecological perspective of health, partnering with families and communities. However, both the quantity and degree of continued health disparities requires that family medicine intentionally work toward improvement in health equity. In recognition of this, Family Medicine for America's Health (FMAHealth) formed a Health Equity Tactic Team (HETT). The team's charge was to address primary care's capacity to improve health equity by developing action-oriented approaches accessible to all family physicians. The HETT has produced a number of projects. These include the Starfield II Summit, the focus of which was "Primary Care's Role in Achieving Health Equity." Multidisciplinary thought leaders shared their work around health equity, and actionable interventions were developed. These formed the basis of subsequent work by the HETT. This includes the Health Equity Toolkit, designed for a broad interdisciplinary audience of learners to learn to improve care systems, reduce disparities, and improve patient outcomes. The HETT is also building a business case for health equity. This has focused efforts on demonstrating to the private sector an economic argument for health equity. The HETT has formed a close partnership with the American Academy of Family Physicians' (AAFP's) Center for Diversity and Health Equity (CDHE), collaborating on numerous efforts to increase awareness of health equity. The team has also focused on engaging leadership in all eight US national family medicine organizations to participate in its activities and to ensure that health equity remains a top priority in its leadership. Looking ahead, family medicine will be required to continuously engage with government and nongovernment agencies, academic centers, and the private sector to create partnerships to systematically tackle health inequities.

Transforming a Family Medicine Residency Into a Community-Oriented Learning Environment.

BACKGROUND AND OBJECTIVES: Improvement in population health has become a key goal of health systems and payers in the United States. Because 80% of health outcomes are driven by social determinants of health beyond medical care and health care access, such improvements require attention to factors outside of the conventional areas of expertise for clinicians. Yet primary care physicians often graduate from training programs with few skills in population and community health. METHODS: In 2011, the University of Wisconsin Department of Family Medicine began transformative work to become a Department of Family Medicine and Community Health (DFMCH). As part of this effort, educators in the department addressed deficiencies in its residency's community and population health curriculum by implementing curricular change and faculty development. A set of guiding principles, "Three Community Health Responsibilities for Family Doctors," was developed to provide background and structure to current and future work. RESULTS: An annual program evaluation survey was administered to faculty and residents between 2012 and 2016. Respondents reported a significant increase in their understanding of population and community health over the prior year in each year this was assessed (P<0.001). CONCLUSIONS: Community and population health principles have become part of the fabric of the entire residency curriculum in the DFMCH. Faculty development was a key part of this work and will be integral to sustaining improvements.

Addressing Racism in Medical Education An Interactive Training Module.

BACKGROUND AND OBJECTIVES: Education of health care clinicians on racial and ethnic disparities has primarily focused on emphasizing statistics and cultural competency, with minimal attention to racism. Learning about racism and unconscious processes provides skills that reduce bias when interacting with minority patients. This paper describes the responses to a relationship-based workshop and toolkit highlighting issues that medical educators should address when teaching about racism in the context of pernicious health disparities. METHODS: A multiracial, interdisciplinary team identified essential elements of teaching about racism. A 1.5-hour faculty development workshop consisted of a didactic presentation, a 3-minute video vignette depicting racial and gender microaggression within a hospital setting, small group discussion, large group debrief, and presentation of a toolkit. RESULTS: One hundred twenty diverse participants attended the workshop at the 2016 Society of Teachers of Family Medicine Annual Spring Conference. Qualitative information from small group facilitators and large group discussions identified some participants' emotional reactions to the video including dismay, anger, fear, and shame. A pre/postsurvey (N=72) revealed significant changes in attitude and knowledge regarding issues of racism and in participants' personal commitment to address them. DISCUSSION: Results suggest that this workshop changed knowledge and attitudes about racism and health inequities. Findings also suggest this workshop improved confidence in teaching learners to reduce racism in patient care. The authors recommend that curricula continue to be developed and disseminated nationally to equip faculty with the skills and teaching resources to effectively incorporate the discussion of racism into the education of health professionals.

TEACH Cards: Teaching Evidence-Based Medicine and Clinical Topics in the Hospital.

INTRODUCTION: Inpatient training and evidence-based medicine (EBM) curricula are fundamental components of medical education. Teaching EBM And Clinical topics in the Hospital (TEACH) Cards is an inpatient curricular tool developed to help guide efficient, discussion-based teaching sessions. TEACH Cards aims to increase frequency of inpatient teaching, improve exposure to the breadth of inpatient topics, advance EBM skills, and improve efficiency in answering clinical questions. METHODS: TEACH Cards is a set of 25 topic-based cards, each addressing an adult inpatient medicine topic by asking background questions and encouraging learners to write and answer foreground questions. Residents and faculty from a family medicine residency rotating on an adult inpatient medicine service during the 6-month study period were invited to complete a prerotation survey, use the TEACH Cards, and then complete a postrotation survey. RESULTS: Out of 54 potential participants, 35% completed both the pre- and postrotation surveys. Respondents used TEACH Cards on average three times per week, reporting significantly stronger agreement that they were both learning (P=0.034) and teaching (P=0.006) core inpatient topics. Respondents reported greater confidence in using EBM resources ( P=0.006) and significantly shorter time to find an evidence-based answer to a clinical question (pretest median=6-10 minutes vs posttest median=2-5 minutes, P=0.002). CONCLUSION: Use of TEACH Cards increased self-reported exposure to the breadth of core inpatient topics, confidence with EBM skills, and efficiency in finding answers to clinical questions.

A commitment to health equity: Reflections on why; One journey toward how.

Many health care practitioners and educators feel stymied as to how to address the pervasive and persistent problem of health care disparities between racial and ethnic groups. The closing plenary for the 37th Forum for Behavioral Science in Family Medicine held in September 2016 reminded participants of the urgent need to attend to health inequities and provided both a theoretical framework as well as some sample resources for where to begin.

Finding Hope in the Face-to-Face.

What does it mean to look into the face of a patient who looks back? Face-to-face encounters are at the heart of the patient-clinician relationship but their singular significance is often lost amid the demands of today's high-tech, metric-driven health care systems. Using the framework provided by the philosopher and Holocaust survivor Emmanuel Levinas, the authors explore the unique responsibility and potential for hope found only in face-to-face encounters. Revisiting this most fundamental attribute of medicine is likely our greatest chance to reclaim who we are as clinicians and why we do what we do.