Storylines of family medicine X: standing up for diversity, equity and inclusion.

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 'X: standing up for diversity, equity and inclusion', authors address the following themes: 'The power of diversity-why inclusivity is essential to equity in healthcare', 'Medical education for whom?', 'Growing a diverse and inclusive workforce', 'Therapeutic judo-an inclusive approach to patient care', 'Global family medicine-seeing the world "upside down"', 'The inverse care law', 'Social determinants of health as a lens for care', 'Why family physicians should care about human rights' and 'Toward health equity-the opportunome'. May the essays that follow inspire readers to promote change.

Extra/ordinary medicine: Toward an anthropology of primary care.

Primary care is at the forefront of healthcare delivery. It is the site of disease prevention and health management and serves as the bridge between communities and the health care system As ethnographers of primary care, in this article we discuss what is gained by situating anthropological inquiry within primary care. We articulate how anthropologists can contribute to a better understanding of the issues that emerge in primary care. We provide a review of anthropological work in primary care and offer empirical data from two ethnographic case studies based in the United States, one focused on social risk screening in primary care and the other examining the diagnosis and care of people with dementia in primary care. Through these cases, we demonstrate how research of and within primary care can open important avenues for the study of the multidimensionality of primary care. This multidimensionality is apparent in the ways the medical field addresses the social and structural experiences of patients, scope of practice and disciplinary boundaries, and the intersection of ordinary and extraordinary medicine that emerge in the care of patients in primary care.

Transportation Justice and Health.

Policy Points The health care sector is increasingly investing in social conditions, including availability of safe, reliable, and adequate transportation, that contribute to improving health. In this paper, we suggest ways to advance the impact of transportation interventions and highlight the limitations of how health services researchers and practitioners currently conceptualize and use transportation. Incorporating a transportation justice framework offers an opportunity to address transportation and mobility needs more comprehensively and equitably within health care research, delivery, and policy.

Primary Care Pracitioner Perspectives on the Role of Primary Care in Dementia Diagnosis and Care.

Importance: Although the barriers to dementia care in primary care are well characterized, primary care practitioner (PCP) perspectives could be used to support the design of values-aligned dementia care pathways that strengthen the role of primary care. Objective: To describe PCP perspectives on their role in dementia diagnosis and care. Design, Setting, and Participation: In this qualitative study, interviews were conducted with 39 PCPs (medical doctors, nurse practitioners, and doctors of osteopathic medicine) in California between March 2020 and November 2022. Results were analyzed using thematic analysis. Main Outcomes and Measures: Overarching themes associated with PCP roles in dementia care. Results: Interviews were conducted with 39 PCPs (25 [64.1%] were female; 16 [41%] were Asian). The majority (36 PCPs [92.3%]) reported that more than half of their patients were insured via MediCal, the California Medicaid program serving low-income individuals. Six themes were identified that convey PCPs' perspectives on their role in dementia care. These themes focused on (1) their role as first point of contact and in the diagnostic workup; (2) the importance of long-term, trusting relationships with patients; (3) the value of understanding patients' life contexts; (4) their work to involve and educate families; (5) their activities around coordinating dementia care; and (6) how the care they want to provide may be limited by systems-level constraints. Conclusions and Relevance: In this qualitative study of PCP perspectives on their role in dementia care, there was alignment between PCP perspectives about the core values of primary care and their work diagnosing and providing care for people living with dementia. The study also identified a mismatch between these values and the health systems infrastructure for dementia care in their practice environment.

"Wanting the Best for Our Folks"-A Mixed Methods Analysis of Community Health Center Social Risk Screening Initiatives.

BACKGROUND: Many community health centers (CHC) are scaling social risk screening in response to growing awareness of the influence of social adversity on health outcomes and concurrent incentives for social risk data collection. We studied the implementation of social risk screening in Texas CHCs to inform best practices and understand equity implications. METHODS: Convergent mixed methods of 3 data sources. Using interviews and surveys with CHC providers and staff, we explored social risk screening practices to identify barriers and facilitators; we used electronic health record (EHR) data to assess screening reach and disparities in screening. RESULTS: Across 4 urban/suburban Texas CHCs, we conducted 27 interviews (15 providers/12 staff) and collected 97 provider surveys; 2 CHCs provided EHR data on 18,672 patients screened during the study period. Data revealed 2 cross-cutting themes: 1) there was broad support for social risk screening/care integration that was rooted in CHCs' mission and positionalities, and 2) barriers to social risk screening efforts were largely a result of limited time and staffing. Though EHR data showed screens per month and screens/encounters increased peri-pandemic (4.1% of encounters in 8/2019 to 46.1% in 2/2021), there were significant differences in screening rates by patient race/ethnicity and preferred language (P < .001). In surveys, 90.0% of surveyed providers reported incorporating social risk screening into patient conversations; 28.6% were unaware their clinic had an embedded screening tool. CONCLUSIONS: Study CHCs were in the early stages of standardizing social risk screening. Differences in screening reach by patient demographics raise concerns that social screening initiatives, which often serve as a path to resource/service connection, might exacerbate disparities. Overcoming barriers to reach, sustainability, and equity requires supports targeted to program design/development, workforce capacity, and quality improvement.

Essential not Supplemental: Medicare Advantage Members' Use of Non-Emergency Medical Transportation (NEMT).

BACKGROUND: Over five million people in the USA miss or delay medical care because of a lack of transportation. Transportation barriers are especially relevant to Medicare Advantage (MA) health plan enrollees, who are more likely to live with multiple chronic conditions and experience mobility challenges. Non-Emergency Medical Transportation (NEMT) helps to address transportation gaps by providing rides to and from routine medical care (for example, medical appointments, laboratory tests, and pharmacy visits) and has been added as a supplemental benefit to some MA health plans. OBJECTIVE: We aimed to characterize MA enrollees' experiences with supplemental NEMT benefits. DESIGN: Qualitative interviews focused on participants' experiences with existing NEMT benefits, transportation, and mobility. PARTICIPANTS: Twenty-one MA enrollees who used their MA NEMT benefit in 2019 and who remained eligible for ongoing transportation benefits through 2021. APPROACH: Using purposive sampling from a list of eligible participants, we recruited individuals who used their MA NEMT benefit in 2019 and who remained eligible for benefit-covered transportation services through 2021. KEY RESULTS: Participants considered NEMT an essential service, particularly because these services helped them decrease social isolation, reduce financial insecurity, and manage their own medical needs. Navigating logistical challenges associated with arranging NEMT services required participants to commit considerable time and energy and limited the effectiveness and reliability of NEMT. CONCLUSION: Participants described NEMT as a valued service essential to their ability to access health care. They suggested ways to increase service flexibility and reliability that could inform future NEMT policy and practice. As health systems and payers learn how to best address social risks, particularly as the US population ages, our findings underscore the importance of NEMT services and highlight opportunities to advance comprehensive transportation solutions for MA participants.

"They Go Hand in Hand": Perspectives on the Relationship Between the Core Values of Family Medicine and Abortion Provision Among Family Physicians Who Do Not Oppose Abortion.

INTRODUCTION: Most family physicians do not provide abortion care, despite an apparent alignment between the defined values of family medicine and provision of abortion in primary care. This study seeks to understand how family physicians themselves perceive the relationship between their specialty's values and abortion provision. METHODS: We conducted in-depth interviews in 2019 with 56 family physicians who do not oppose abortion in the United States. We employed a deductive-inductive content analysis approach with memos to identify key themes. This analysis focuses on participants' beliefs in the core values of family medicine and how those values relate to abortion in family medicine. RESULTS: Participants identified and described six values of the specialty they prioritized, which included relationships, care across the lifespan, whole-person care, nonjudgmental care, meeting community needs, and social justice. Family physicians in the study overwhelmingly believed that abortion aligned with family medicine values, regardless of whether they themselves provided abortion care. CONCLUSIONS: Providing abortion care in primary care settings gives family physicians an opportunity to provide comprehensive care while improving access to meet community needs. As abortion care becomes increasingly restricted in the United States, family physicians can manifest the values of family medicine through integrating abortion care into their practices in states where abortion remains legal.

Social Care Recommendations in National Diabetes Treatment Guidelines.

PURPOSE OF REVIEW: An expanding body of research documents associations between socioeconomic circumstances and health outcomes, which has led health care institutions to invest in new activities to identify and address patients' social circumstances in the context of care delivery. Despite growing national investment in these "social care" initiatives, the extent to which social care activities are routinely incorporated into care for patients with type II diabetes mellitus (T2D), specifically, is unknown. We conducted a scoping review of existing T2D treatment and management guidelines to explore whether and how these guidelines incorporate recommendations that reflect social care practice categories. RECENT FINDINGS: We applied search terms to locate all T2D treatment and management guidelines for adults published in the US from 1977 to 2021. The search captured 158 national guidelines. We subsequently applied the National Academies of Science, Engineering, and Medicine framework to search each guideline for recommendations related to five social care activities: Awareness, Adjustment, Assistance, Advocacy, and Alignment. The majority of guidelines (122; 77%) did not recommend any social care activities. The remainder (36; 23%) referred to one or more social care activities. In the guidelines that referred to at least one type of social care activity, adjustments to medical treatment based on social risk were most common [34/36 (94%)]. Recommended adjustments included decreasing medication costs to accommodate financial strain, changing literacy level or language of handouts, and providing virtual visits to accommodate transportation insecurity. Ensuring that practice guidelines more consistently reflect social care best practices may improve outcomes for patients living with T2D.

Adjusting for Patient Economic/Access Issues in a Hypertension Quality Measure.

INTRODUCTION: The American Heart Association and American College of Cardiology have proposed adjusting hypertension-related care quality measures by excluding patients with economic/access issues from the denominator of rate calculations. No research to date has explored the methods to operationalize this recommendation or how to measure economic/access issues. This study applied and compared different approaches to populating these denominator exceptions. METHODS: Electronic health record data from 2019 were used in 2021 to calculate hypertension control rates in 84 community health centers. A total of 10 different indicators of patient economic/access barriers to care were used as denominator exclusions to calculate and then compare adjusted quality measure performance. Data came from a nonprofit health center‒controlled network that hosts a shared electronic health record for community health centers located in 22 states. RESULTS: A total of 5 of 10 measures yielded an increase in adjusted hypertension control rates in ≥50% of clinics (average rate increases of 0.7-3.71 percentage points). A total of 3 of 10 measures yielded a decrease in adjusted hypertension control rates in >50% of clinics (average rate decreases of 1.33-13.82 percentage points). A total of 5 measures resulted in excluding >50% of the clinic's patient population from quality measure assessments. CONCLUSIONS: Changes in clinic-level hypertension control rates after adjustment differed depending on the measure of economic/access issue. Regardless of the exclusion method, changes between baseline and adjusted rates were small. Removing community health center patients experiencing economic/access barriers from a hypertension control quality measure resulted in excluding a large proportion of patients, raising concerns about whether this calculation can be a meaningful measure of clinical performance.

Family Physicians' Barriers and Facilitators in Incorporating Medication Abortion.

PURPOSE: Medication abortion (MAB) provision by family physicians has the potential to expand abortion access. However, there are documented individual and structural barriers to provision. This study investigates how family physicians in the United States (US) navigate the barriers impeding abortion provision in primary care. METHODS: We conducted a qualitative study on the experiences of US family physicians with MAB in primary care. We recruited participants at national conferences and via professional networks. This analysis focuses on the experiences of the subset of participants who expressed interest in providing MAB. RESULTS: Forty-eight participants met inclusion criteria, with representation from all 4 regions of the US. Participants had diverse experiences related to abortion provision, training, and the environment in which they practice, with a third of participants working in states with hostile abortion policies. We categorized participants into 3 groups: (1) doctors who did not receive training and do not provide abortions (n = 11), (2) doctors who received training but do not provide abortions (n = 20), and (3) doctors who received training and currently provide abortions (n = 17). We found that training, administrative and community support, and internal motivation to overcome barriers help family physicians integrate MAB in primary care practices. Federal and state laws, absence of training, stigma around abortion provision, inaccurate or limited knowledge of institutional barriers, and administrative resistance all contributed to doctors excluding abortion provision from their scope of practice. CONCLUSION: Improving medication abortion provision by family physicians requires addressing the individual and system barriers family physicians encounter so they receive the education, training, and support to successfully integrate abortion care into clinical practice.

"More than just giving them a piece of paper": Interviews with Primary Care on Social Needs Referrals to Community-Based Organizations.

BACKGROUND: Primary care practices are responding to calls to incorporate patients' social risk factors, such as housing, food, and economic insecurity, into clinical care. Healthcare likely relies on the expertise and resources of community-based organizations to improve patients' social conditions, yet little is known about the referral process. OBJECTIVE: To characterize referrals to community-based organizations by primary care practices. DESIGN: Qualitative study using semi-structured interviews with healthcare administrators responsible for social care efforts in their organization. PARTICIPANTS: Administrators at 50 diverse US healthcare organizations with efforts to address patients' social risks. MAIN MEASURES: Approaches used in primary care to implement social needs referral to community-based organizations. RESULTS: Interviewed administrators reported that social needs referrals were an essential element in their social care activities. Administrators described the ideal referral programs as placing limited burden on care teams, providing patients with customized referrals, and facilitating closed-loop referrals. We identified three key challenges organizations experience when trying to implement the ideal referrals program: (1) developing and maintaining resources lists; (2) aligning referrals with patient needs; and (3) measuring the efficacy of referrals. Collectively, these challenges led to organizations relying on staff to manually develop and update resource lists and, in most cases, provide patients with generic referrals. Administrators not only hoped that referral platforms may help overcome some of these barriers, but also reported implementation challenges with platforms including inconsistent buy-in and use across staff; integration with electronic health records; management and prioritization of resources; and alignment with other organizations in their market. CONCLUSION AND RELEVANCE: Referrals to community-based organizations were used in primary care to improve patients' social conditions, but despite strong motivations, interviewees reported challenges providing tailored and up-to-date information to patients.

Content Analysis of Transportation Screening Questions in Social Risk Assessment Tools: Are We Capturing Transportation Insecurity?

PURPOSE: To analyze transportation screening and assessment questions used in social risk screening tools to understand how these tools assess patients' mobility and transportation needs. METHODS: We conducted content analysis of transportation screening and assessment tools used in adult health care delivery settings. RESULTS: We identified 23 unique social risk screening tools; 14 included at least 1 transportation question. Transportation screeners differed in terms of content domain, structure, and response options. Existing transportation screening and assessment tools do not uniformly or comprehensively assess transportation needs. Questions typically fail to surface relevant information on financial constraints, disability, local transportation options, and social isolation that should influence related interventions. CONCLUSIONS: Development of a brief screening question that broadly captures transportation insecurity followed by a more comprehensive assessment triggered by positive response could enable policy makers and health systems to better identify individuals facing transportation insecurity and to develop transportation solutions that address patients' transportation needs.

Exploring the impact of mifepristone's risk evaluation and mitigation strategy (REMS) on the integration of medication abortion into US family medicine primary care clinics✰,✰✰.

OBJECTIVES: In 2000, the United States' Food and Drug Administration (FDA) approved mifepristone for medication abortion. In this article, we explore how the Risk Evaluation and Mitigation Strategy (REMS) criteria for mifepristone specifically impede family physicians' ability to provide medication abortion in primary care settings. STUDY DESIGN: We conducted 56 qualitative interviews with a national sample of family physicians across the US who were not opposed to abortion. We examined how the REMS criteria for mifepristone impact family physicians' ability to provide medication abortion. RESULTS: Of the 56 interviews conducted, 23 participants (41%) raised the REMS criteria as a barrier to providing medication abortion in primary care. These participants reported the REMS added a layer of bureaucratic complexity that made it difficult for family physicians to navigate, even when trained, to provide abortion care. These family physicians described 2 predominant ways the REMS impede their ability to provide medication abortion: (1) The REMS require substantial involvement of clinic administration, who can be unsupportive; (2) The complexity of navigating the REMS results in physicians and clinic administration in primary care viewing medication abortion as not worth the effort, since it is only a small component of services offered in primary care. CONCLUSION: Removing the REMS could simplify integration of medication abortion into primary care, which could meet patient preferences, improve access, and reduce abortion stigma. The FDA's revised REMS criteria may ease administrative burden but will likely maintain key barriers to integrating medication abortion into family physicians' practice. IMPLICATIONS: Our study highlights that the REMS criteria are barriers to family physicians' ability to integrate medication abortion into their primary care practices. The FDA's removal of in person dispensing criteria may provide some impetus for trained family physicians to integrate medication abortion into their scope of practice but the revised REMS criteria maintain key barriers to broader adoption.

The work of reform: a critical examination of health policy.

Anthropologists have critically examined a range of reforms from education and land to finance and health. Yet the predominant way of looking at reforms has been through a lens focused on neoliberal governance. For example, prior studies of health reforms focus on insurance, financing, and access to care. Yet, seeing reform in this way fails to attend to other types of cultural work at play when calling a policy or law a reform. In this paper, we draw on ethnographic research on health policy reforms in Israel and Bolivia to examine the concept of reform and the work it does within national movements. We argue that while the language of reform often signals change or novelty, reforms also carry forward historical continuities and reifications of the past. By delving into the past and its relationship with ongoing health reforms, we attend to how reforms can reinforce and maintain health inequities in some cases, while creating a national language for new possibilities in others. Reform, as we will discuss in this paper, is not only about political ideology, neoliberal governance, or on-the-ground policy implementation, but centrally it is about representations of aspirations, and about crafting relationships between past, present, and future.

How Hypertension Guidelines Address Social Determinants of Health: A Systematic Scoping Review.

BACKGROUND: Patient-level and community-level social and economic conditions impact hypertension risk and control. We examined adult hypertension management guidelines to explore whether and how existing guidelines refer to social care activities. OBJECTIVE: The objective of this study was to explore how hypertension guidelines reference social care activities. RESEARCH DESIGN: A systematic scoping review of clinical guidelines for adult hypertension management. We employed a PubMed search strategy to identify all hypertension guidelines published in the United States between 1977 and 2019. We reviewed all titles to identify the most updated versions focused on nonpregnant adults with hypertension. We extracted instances where guidelines referred to social determinants of health (SDH) or social care activities. The primary outcome was how guidelines covered social care activities, defined using a framework adapted from the National Academies of Sciences, Engineering, and Medicine (NASEM). RESULTS: Search terms yielded 126 guidelines. Thirty-six guidelines met the inclusion criteria. Of those, 72% (26/36) recommended social care activities as part of hypertension management; 58% recommended clinicians change clinical practice based on social risk information. These recommendations often lacked specific guidance around how to directly address social risk factors or reduce the impact of these risks on hypertension management. When guidelines referred to specific social factors, patient financial security was the most common. Over time, hypertension guidelines have included more references to SDH. CONCLUSION: Information about SDH is included in many hypertension guidelines, but few guidelines provide clear guidance for clinicians or health systems on how to identify and address social risk factors in the context of care delivery.

"Far More than Just a Prescription": Focus Groups With U.S. Family Planning Providers and Staff About Integrating PrEP for HIV Prevention Into Their Work.

BACKGROUND: Cisgender women in the United States use pre-exposure prophylaxis (PrEP) for HIV prevention at lower rates relative to other groups. Advocacy groups and patients identify family planning clinics as the preferred sites to lead PrEP implementation for women in the United States. However, limited qualitative exploration exists of U.S. family planning practitioners' attitudes toward integrating PrEP into their work. METHODS: We conducted qualitative focus groups with a convenience sample of family planning clinicians, counselors, and clinic managers to explore barriers and facilitators to PrEP provision in U.S. family planning clinics. RESULTS: We conducted six focus groups (total participants = 37) with respondents who worked in family planning clinics in San Francisco, California; Kansas City, Missouri; and Philadelphia, Pennsylvania. Key themes emerged highlighting how PrEP at times runs contrary to other family planning agendas, including efficient clinic visits, condom promotion, and long-acting reversible contraception counseling. Throughout these discussions, participants expressed discomfort with HIV vulnerabilities rooted in social and structural determinants of health. CONCLUSIONS: Findings suggest that those seeking to implement PrEP for U.S. cisgender women may benefit from exploring 1) how to integrate patient/provider conversations about the structural determinants of health and their relationship to HIV and other sexual and reproductive health outcomes and 2) how to foster person-centered prevention conversations in the context of busy family planning visits.

Entangled Bodies: Jews, Bedouins, and the Making of the Secular Israeli.

Taking Israel's National Health Insurance Law as a point of entry, in this article I probe how notions of equality and citizenship, secularism, and religion become entangled in the experience of Negev/Naqab Bedouins, who are Palestinian citizens of Israel. Drawing on ethnographic and archival research, I show how Jewish citizens have come to represent the secular and modern citizens in the region, while Bedouins, although mandated and claimed by policy and providers to be the 'same' and 'equal,' are always already imagined and characterized as other. Universal health care and the daily manner in which biomedicine is practiced in southern Israel provides an avenue for examining the Jewish valences medicine carries in southern Israel, Israel's boundaries of inclusion, and the connection between biomedicine and secularism.