Ten-Year Outcomes: Community Health Center/Academic Medicine Partnership for Rural Family Medicine Training.

BACKGROUND AND OBJECTIVES: The widening gap between urban and rural health outcomes is exacerbated by physician shortages that disproportionately affect rural communities. Rural residencies are an effective mechanism to increase physician placement in rural and medically underserved areas yet are limited in number due to funding. Community health center/academic medicine partnerships (CHAMPs) can serve as a collaborative framework for expansion of academic primary care residencies outside of traditional funding models. This report describes 10-year outcomes of a rural training pathway developed as part of a CHAMP collaboration. METHODS: Using data from internal registries and public sources, our retrospective study examined demographic and postgraduation practice characteristics for rural pathway graduates. We identified the rates of postgraduation placement in rural (Federal Office of Rural Health Policy grant-eligible) and federally designated Medically Underserved Areas/Populations (MUA/Ps). We assessed current placement for graduates >3 years from program completion. RESULTS: Over a 10-year period, 25 trainees graduated from the two residency expansion sites. Immediately postgraduation, 84% (21) were in primary care Health Professional Shortage Areas (HPSAs), 80% (20) in MUA/Ps, and 60% (15) in rural locations. Sixteen graduates were >3 years from program completion, including 69% (11) in primary care HPSAs, 69% (11) in MUA/Ps, and 50% (5) in rural locations. CONCLUSIONS: This CHAMP collaboration supported development of a rural pathway that embedded family medicine residents in community health centers and effectively increased placement in rural and MUA/Ps. This report adds to national research on rural workforce development, highlighting the role of academic-community partnerships in expanding rural residency training outside of traditional funding models.

In-Hospital Code Status Updates: Trends Over Time and the Impact of COVID-19.

OBJECTIVE: The primary objective was to evaluate if the percentage of patients with missing or inaccurate code status documentation at a Trauma Level 1 hospital could be reduced through daily updates. The secondary objective was to examine if patient preferences for DNR changed during the COVID-19 pandemic. METHODS: This retrospective study, spanning March 2019 to December 2022, compared the code status in ICU and ED patients drawn from two data sets. The first was based on historical electronic medical records (EHR), and the second involved daily updates of code status following patient admission. RESULTS: Implementing daily updates upon admission was more effective in ICUs than in the ED in reducing missing code status documentation. Around 20% of patients without a specific code status chose DNR under the new system. During COVID-19, a decrease in ICU patients choosing DNR and an increase in full code (FC) choices were observed. CONCLUSION: This study highlights the importance of regular updates and discussions regarding code status to enhance patient care and resource allocation in ICU and ED settings. The COVID-19 pandemic's influence on shifting patient preferences towards full code status underscores the need for adaptable documentation practices. Emphasizing patient education about DNR implications and benefits is key to supporting informed decisions that reflect individual health contexts and values. This approach will help balance the considerations for DNR and full code choices, especially during health care crises.

Postgraduate education to expand access to dental care: A roadmap to community dental program development.

Evidence indicates an increasing shortage of dentists in communities across the United States with potentially significant implications for oral health, as well as overall health and well-being. One strategy to increase access to dental care in rural and underserved communities is community-based postgraduate dental training. However, developing new dental programs requires navigating complex accreditation, financial and community governance, among other, barriers. The Roadmap for Teaching Health Center Dental Program Development presents a framework that guides institutions through the successive steps of developing new postgraduate training programs from identification of need to ultimate maintenance and sustainability. The tool assists programs in anticipating and understanding requirements, reducing time, expense, and uncertainty. While the framework was developed for community-based programs, the steps are applicable to postgraduate programs sponsored by academic institutions as well.

Reflections on Part-Time Residency Training, 15-25 Years Later: A Qualitative Study on Wellness and Career Impact.

Phenomenon: While part-time clinical work options are popular for physicians, part-time residency training is uncommon. Some residency training programs have offered trainees the option to complete their training on a modified schedule in the past. These part-time tracks often involved extending training in order to complete equivalent hours on a part-time basis. Having experience with trainees in such programs, we sought to explore the impact of completing residency training part-time on the professional and private lives of physicians. Approach: Between 2019 and 2020, we conducted interviews with physicians who completed portions of their residency training part-time between 1995 and 2005 in our institution's pediatrics, combined medicine-pediatrics, and family medicine programs. Findings: Seven female physicians who completed at least some portion of residency part-time were interviewed. To better characterize their experiences, we chose phenomenology as our analytic framework. Members of the research team independently coded each interview and met to resolve conflicts. Codes were then combined and discussed to determine four overarching themes as reasons and benefits of part-time training: The pursuit of extended-time training, logistics, effects on career trajectory, and wellness. These themes highlighted the utility of part-time training and the need for programmatic support to ensure their success. Insights: Based on our findings, adaptability for training and a sense of agency from their part-time experiences persisted throughout interviewees' careers. Each felt empowered to make career choices that fit their personal and professional needs. These findings suggest further investigation into the benefits of offering time-variable training in residency programs.

Bolstering the rural physician workforce in underserved communities: Are Rural Residency Planning and Development Programs finding the sweet spot?

PURPOSE: The purpose of this study is to describe the characteristics of Rural Residency Planning and Development (RRPD) Programs, compare the characteristics of counties with and without RRPD programs, and identify rural places where future RRPD programs could be developed. METHODS: The study sample comprised 67 rural sites training residents in 40 counties in 24 US states. Descriptive statistics were used to describe RRPD programs and logistic regression to predict the probability of a county being an RRPD site as a function of population, primary care physicians (PCP) per 10,000 population, and the social vulnerability index (SVI) compared to a control sample of nonmetro counties without RRPD sites. FINDINGS: Most RRPD grantees (78%) were family medicine programs affiliated with medical schools (97%). RRPD counties were more populous (P<.01), had a higher population density (P<.05), and a higher percent of the non-White or Hispanic population (P = .05) compared to non-RRPD counties. Both higher population (P<.001) and PCP ratio (P = .046) were strong predictors, while SVI (P = .07) was a weak predictor of being an RRPD county. CONCLUSIONS: RRPD sites appear to represent a "sweet spot" of rural counties that have the population and physician supply to support a training program but also are relatively more socially vulnerable with high-need populations. Additional counties fitting this "sweet spot" could be targeted for funding to address health disparities and health workforce maldistribution.

Responding to One Rural Community's Primary Care Needs: Investing in Workforce and Broad Community Stakeholder Engagement.

Lack of access to high-quality primary care has been shown to contribute to urban-rural health disparities. We describe a model in which an academic health system made targeted primary care investments to address rural health disparities while building the health workforce to ensure sustainability.

New Opportunities for Expanding Rural Graduate Medical Education to Improve Rural Health Outcomes: Implications of the Consolidated Appropriations Act of 2021.

Evidence shows that those living in rural communities experience consistently worse health outcomes than their urban and suburban counterparts. One proven strategy to address this disparity is to increase the physician supply in rural areas through graduate medical education (GME) training. However, rural hospitals have faced challenges developing training programs in these underserved areas, largely due to inadequate federal funding for rural GME. The Consolidated Appropriations Act of 2021 (CAA) contains multiple provisions that seek to address disparities in Medicare funding for rural GME, including funding for an increase in rural GME positions or "slots" (Section 126), expansion of rural training opportunities (Section 127), and relief for hospitals that have very low resident payments and/or caps (Section 131). In this Invited Commentary, the authors describe historical factors that have impeded the growth of training programs in rural areas, summarize the implications of each CAA provision for rural GME, and provide guidance for institutions seeking to avail themselves of the opportunities presented by the CAA. These policy changes create new opportunities for rural hospitals and partnering urban medical centers to bolster rural GME training, and consequently the physician workforce in underserved communities.

Using a Delphi Technique to Define a Feedback Culture in Graduate Medical Education.

BACKGROUND AND OBJECTIVES: Experts in medical education hypothesize that programs with a robust culture of feedback foster learning and growth for learners and educators, yet the literature shows no consensus for what defines a feedback culture in graduate medical education. METHODS: Using a two-round, modified Delphi technique in summer and fall of 2019, the authors asked a panel of experts to identify essential elements to a feedback culture. The research team compiled a list of experts and a list of 29 descriptors of a highly functioning feedback culture. Experts rated the items as an essential, compatible, or not important aspect of a highly functioning culture of feedback. Researchers set a minimum threshold of 80% agreement and used comments from panelists to revise elements that did not meet agreement during round one. Experts then rerated the elements using information on their initial ratings, aggregate panelist ratings, and comments from all panelists. RESULTS: The response rates from our panel of experts were 68% (17/25) for round one and 88% (15/17) for round two. Seventeen elements were rated as essential to a feedback culture. CONCLUSIONS: An expert panel endorsed essential elements that can be used to assess feedback culture in graduate medical education programs.

Fully Integrated Readiness for Service Training (FIRST): An Accelerated Medical Training Program for Rural and Underserved North Carolina.

PROBLEM: The U.S. primary care workforce remains inadequate to meet the health needs of the U.S. population. Effective programs are needed to provide workforce development for rural and other underserved areas. APPROACH: At the University of North Carolina (UNC) School of Medicine (SOM), between November 2014 and July 2015, the authors developed and implemented the Fully Integrated Readiness for Service Training (FIRST) Program, an accelerated curriculum focused on rural and underserved care that links 3 years of medical school with a conditional acceptance into UNC's 3-year family medicine residency, followed by 3 years of practice support post-graduation. Students are recruited to the FIRST Program during the fall of their first year of medical school. The FIRST Program promotes close faculty mentorship and familiarity with the health care system, includes a longitudinal quality improvement project with an assigned patient panel, includes early integration into the clinic, and fosters a close cohort of fellow students. OUTCOMES: As of March 2020, the FIRST Program had successfully recruited 5 classes of medical students, and 3 of those classes had matched into residency. In total, as of March 2020, 18 students had participated in the FIRST Program. NEXT STEPS: The FIRST Program will be expanded to additional clinical sites across North Carolina and to specialties beyond family medicine, including pediatrics, general surgery, and psychiatry.

Improved Breastfeeding Outcomes Following an On-site Support Intervention in an Academic Family Medicine Center.

BACKGROUND AND OBJECTIVES: Despite the importance of breastfeeding, most US women do not meet recommendations for length of any or exclusive breastfeeding. Support in primary care settings is recommended (US Preventive Services Task Force, 2016), but optimal implementation strategies are not established. We evaluated the effect on breastfeeding rates of on-site breastfeeding support within an academic family medicine center with a diverse patient population. METHODS: We conducted a retrospective chart review 10 months before and 10 months following the implementation of integrated breastfeeding support provided by an International Board Certified Lactation Consultant (IBCLC) or MD-IBCLC. Two hundred eighty-one infants were identified, 140 before implementation and 141 after. A research assistant extracted data from the electronic medical record. We performed bivariate and multiple logistic regression analyses using STATA. RESULTS: There were no significant demographic differences before and after the intervention. The proportion of infants with any breastfeeding at 2, 4, and 6 months was greater in the postimplementation group (71.7% vs 86.7% at 2 months, P=.05; 61.5% vs 77.1% at 4 months, P=.08; and 50.7% vs 64.4%, P=.09 at 6 months). The proportion of infants exclusively breastfed was also greater in the postimplementation group (58.7% vs 77.8% at 2 months, P=.04; 50.5% vs. 54.2% at 4 months, P=.06; and 44.0% vs 49.3% at 6 months, P=.12). CONCLUSIONS: Providing on-site IBCLC breastfeeding support services within an academic family medicine clinic is associated with significant increases in breastfeeding, supporting the provision of lactation services on-site where mothers and children receive primary care.

Residency Faculty Teaching Evaluation: What Do Faculty, Residents, and Program Directors Want?

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education Common Residency Program Requirements stipulate that each faculty member's performance be evaluated annually. Feedback is essential to this process, yet the culture of medicine poses challenges to developing effective feedback systems. The current study explores existing and ideal characteristics of faculty teaching evaluation systems from the perspectives of key stakeholders: faculty, residents, and residency program directors (PDs). METHODS: We utilized two qualitative approaches: (1) confidential semistructured telephone interviews with PDs from a convenience sample of eight family medicine residency programs, (2) qualitative responses from an anonymous online survey of faculty and residents in the same eight programs. We used inductive thematic analysis to analyze the interviews and survey responses. Data collection occurred in the fall of 2017. RESULTS: All eight (100%) of the PDs completed interviews. Survey response rates for faculty and residents were 79% (99/126) and 70% (152/216), respectively. Both PD and faculty responses identified a desire for actionable, real-time, frequent feedback used to foster continued professional development. Themes unique to faculty included easy accessibility and feedback from peers. Residents expressed an interest in in-person feedback and a process minimizing potential retribution. Residents indicated that feedback should be based on shared understanding of what skill(s) the faculty member is trying to address. CONCLUSIONS: PDs, faculty, and residents share a desire to provide faculty with meaningful, specific, and real-time feedback. Programs should strive to provide a culture in which feedback is an integral part of the learning process for both residents and faculty.

Variation in Triple Aim Measures: Implications of Clinical Signatures in Family Medicine Residency Programs.

BACKGROUND: Evidence from several specialties suggests that practice patterns developed in residency influence the quality and cost of care long after completion of training. Improving the quality, cost, and patient experience of care (the "Triple Aim") is foundational to future health systems change. OBJECTIVE: We measured variation in Triple Aim measures among family medicine residency programs in a regional quality improvement collaborative (I3 Population Health Collaborative). METHODS: We calculated medians and interquartile ranges for each of 11 Triple Aim measures and compared them with median splits of population and practice characteristics, including payer mix, patient race and age, electronic health record used, registry use, and National Committee for Quality Assurance patient-centered medical home recognition. RESULTS: All 22 participating family medicine residency programs provided baseline data. The number of practices reporting data on individual measures ranged from 9 to 17 (41%-77%). We found variation averaging 51% across all measures, from a low of 12% for readmission rates to 94% for emergency department visit rates. Variations were stable over time. We found no significant relationships between practice or population characteristics and measures, nor between practice characteristics and outcomes variation. CONCLUSIONS: The 22 family medicine residency programs in our study showed substantial variation in quality, cost, and patient experience of care. These variations did not appear to result from differences in practice characteristics, payer mix, or patient demographics.

Latent autoimmune diabetes of adulthood: case report.

BACKGROUND: Primary care clinicians will see a higher incidence of type 2 diabetes in adult patients, and the diagnosis and management of an initial presentation of type 1 diabetes can pose challenges to clinicians who see it less frequently. Symptoms of hyperglycemia and risk of ketoacidosis may be missed. Further, endocrine autoimmune disease can run together in patients and families. CASE PRESENTATION: A 49-year-old Caucasian female with history of pituitary adenoma and Graves' disease with history of thyroid ablation presented in the outpatient setting due to hand tingling of her right middle finger that was worse in the mornings and improved throughout the day. She also complained of excessive thirst, finding herself drinking more water than usual and waking up in the night to urinate. There was no dysuria or haematuria, and no other neurologic symptoms. She did report feeling hungry. She had no family history of diabetes, normal body mass index of 21.7, and reported taking her thyroid replacement medication every day. The differential diagnosis for her thirst included dehydration, psychogenic polydipsia, diabetes mellitus, diabetes insipidus, and anxiety. The patient had normal vital signs and was well appearing; labs were ordered for her on her way home from clinic with no medications. Labs revealed a random blood glucose level of 249 mg/dL, normal renal function, a normal B12 of 996 pg/mL, and an elevated thyroid stimulating hormone level of 25.67 u[iU]/mL. On follow up with her primary care provider 5 days later, additional labs were drawn showing A1C of 11.5%, 1+ ketonuria, a negative Acetest, and a normal basic metabolic panel, except for a fasting glucose of 248 mg/dL, and Free T3 of 2.42 pg/mL, and Free T4 of 1.7 ng/dL. Islet cell antibodies and glutamic acid decarboxylase antibodies were both positive, consistent with type 1 diabetes. She was started on insulin and improved. CONCLUSION: Given the patient's age, this is a less common presentation of type 1 diabetes mellitus, as a part of polyglandular autoimmune syndrome type IIIa. It serves as a reminder that clinicians should remember that patients with one autoimmune disease (in this case, h/o Graves' disease) are at higher risk for diabetes and other endocrine autoimmune diseases and should be screened appropriately. Clinicians should keep latent type 1 diabetes in the differential in adulthood to ensure proper and timely treatment.

Cost of Incremental Expansion of an Existing Family Medicine Residency Program.

BACKGROUND AND OBJECTIVES: Expanding residency training programs to address shortages in the primary care workforce is challenged by the present graduate medical education (GME) environment. The Medicare funding cap on new GME positions and reductions in the Health Resources and Services Administration (HRSA) Teaching Health Center (THC) GME program require innovative solutions to support primary care residency expansion. Sparse literature exists to assist in predicting the actual cost of incremental expansion of a family medicine residency program without federal or state GME support. METHODS: In 2011 a collaboration to develop a community health center (CHC) academic medical partnership (CHAMP), was formed and created a THC as a training site for expansion of an existing family medicine residency program. The cost of expansion was a critical factor as no Federal GME funding or HRSA THC GME program support was available. Initial start-up costs were supported by a federal grant and local foundations. Careful financial analysis of the expansion has provided actual costs per resident of the incremental expansion of the residencyRESULTS: The CHAMP created a new THC and expanded the residency from eight to ten residents per year. The cost of expansion was approximately $72,000 per resident per year. CONCLUSIONS: The cost of incremental expansion of our residency program in the CHAMP model was more than 50% less than that of the recently reported cost of training in the HRSA THC GME program.

Learnings From the Pilot Implementation of Mobile Medical Milestones Application.

BACKGROUND: Implementation of the educational milestones benefits from mobile technology that facilitates ready assessments in the clinical environment. We developed a point-of-care resident evaluation tool, the Mobile Medical Milestones Application (M3App), and piloted it in 8 North Carolina family medicine residency programs. OBJECTIVE: We sought to examine variations we found in the use of the tool across programs and explored the experiences of program directors, faculty, and residents to better understand the perceived benefits and challenges of implementing the new tool. METHODS: Residents and faculty completed presurveys and postsurveys about the tool and the evaluation process in their program. Program directors were interviewed individually. Interviews and open-ended survey responses were analyzed and coded using the constant comparative method, and responses were tabulated under themes. RESULTS: Common perceptions included increased data collection, enhanced efficiency, and increased perceived quality of the information gathered with the M3App. Residents appreciated the timely, high-quality feedback they received. Faculty reported becoming more comfortable with the tool over time, and a more favorable evaluation of the tool was associated with higher utilization. Program directors reported improvements in faculty knowledge of the milestones and resident satisfaction with feedback. CONCLUSIONS: Faculty and residents credited the M3App with improving the quality and efficiency of resident feedback. Residents appreciated the frequency, proximity, and specificity of feedback, and faculty reported the app improved their familiarity with the milestones. Implementation challenges included lack of a physician champion and competing demands on faculty time.

Exploring outcomes associated with acupuncture.

OBJECTIVE: The objective was to explore various methods of assessing clinically meaningful change associated with a course of acupuncture treatments. DESIGN: The design was a prospective cohort study. SETTING: The setting was an acupuncture clinic staffed by two physician acupuncturists in a university-affiliated family practice center. SUBJECTS: Subjects consisted of consecutive new patients to an acupuncture clinic. OUTCOME MEASURES: Outcomes were measured using the Medical Outcomes Study Short-Form 36 (SF-36) and Measure Your Own Medical Outcomes Profile (MYMOP). Outcomes measured were global clinical change and patient satisfaction. RESULTS: Out of 112 eligible patients, 110 consented to the study and contributed baseline data. Of these, 80 (71%) completed the 2-month follow-up questionnaire. Mean age of study subjects was 54.5 (standard deviation, SD 17.6) years; 85 (77%) were female, and 75 (68%) were married. Mean number of acupuncture treatments during the 2-month follow-up period was 5.8 (SD, 3.5, range, 1 to 16). Statistically significant improvement from baseline to follow-up was observed with the bodily pain subscale of the SF-36 and with the MYMOP. Among those who completed the study, 52 (67%) felt that the main symptom for which they sought acupuncture had improved over the course of the study and 72 (90%) were satisfied with their treatment in the acupuncture clinic. CONCLUSIONS: The MYMOP instrument appears to be the most useful of the four measures used to evaluate clinical outcomes associated with a course of acupuncture treatments (SF-36, MYMOP, global clinical change, and patient satisfaction). This easy-to-administer instrument appears to be sensitive to clinical change over a 2-month period among patients who sought acupuncture for a wide variety of clinical conditions.