Underfunding for Research Training and Career Development: The Impact on Family Medicine Research.

BACKGROUND AND OBJECTIVES: The National Institutes of Health and related federal awards for research training (RT) and research career development (RCD) are designed to prepare applicants for research careers. We compared funding rates for RT and RCD for anesthesiology, dermatology, emergency medicine, family medicine, internal medicine, neurology, obstetrics-gynecology, pathology, pediatrics, and psychiatry. METHODS: We estimated the denominator using the number of residency graduates from different specialties from 2001 to 2010 from the Association of American Medical Colleges data. For the numerator, we used published data on federally funded awards by specialty from 2011 to 2020. We also examined the correlation between RCD funding and overall research funding. RESULTS: Family medicine had the lowest rate per graduating resident for RT (0.01%) and RCD (0.77%) awards among 10 specialties and was lower than the mean/median for the other nine specialties, ranging from 2.15%/1.19% and 9.83%/8.74%. We found a strong correlation between rates of RCD awards and mean federal funding per active physician, which was statistically significant (ρ=0.77, P=.0098). CONCLUSIONS: Comparatively low rates for family medicine awards for RT and RCD plausibly contribute to poor federal funding for family medicine research, underscoring the need to bolster the research career pathway in family medicine.

Team-based home blood pressure monitoring for blood pressure equity a protocol for a stepped wedge cluster randomized trial.

BACKGROUND: Home Blood Pressure Monitoring (HBPM) that includes a team with a clinical pharmacist is an evidence-based intervention that improves blood pressure (BP). Yet, strategies for promoting its adoption in primary care are lacking. We developed potentially feasible and sustainable implementation strategies to improve hypertension control and BP equity. METHODS: We assessed barriers and facilitators to HBPM and iteratively adapted implementation strategies through key informative interviews and guidance from a multistakeholder stakeholder team involving investigators, clinicians, and practice administration. RESULTS: Strategies include: 1) pro-active outreach to patients; 2) provision of BP devices; 3) deployment of automated bidirectional texting to support patients through education messages for patients to transmit their readings to the clinical team; 3) a hypertension visit note template; 4) monthly audit and feedback reports on progress to the team; and 5) training to the patients and teams. We will use a stepped wedge randomized trial to assess RE-AIM outcomes. These are defined as follows Reach: the proportion of eligible patients who agree to participate in the BP texting; Effectiveness: the proportion of eligible patients with their last BP reading <140/90 (six months); Adoption: the proportion of patients invited to the BP texting; Implementation: patients who text their BP reading ≥10 of days per month; and Maintenance: sustained BP control post-intervention (twelve months). We will also examine RE-AIM metrics stratified by race and ethnicity. CONCLUSIONS: Findings will inform the impact of strategies for the adoption of team-based HPBM and the impact of the intervention on hypertension control and equity. REGISTRATION DETAILS: www. CLINICALTRIALS: gov Identifier: NCT05488795.

Physical and psychosocial impact on peers with HIV co-leading an HIV intervention: A pilot theory-guided case-study.

Objective: To examine longitudinal changes in activation, HIV health outcomes, and social and psychological determinants of adherence to antiretroviral therapy (ART) among peer trainers with HIV. Methods: A multi-method case study. The study population included peers (n = 4) from a randomized controlled trial about peers training patients with HIV (n = 359) to better manage their health. Each peer completed a semi-structured interview that we analyzed using Social Learning Theory (SLT) as a guiding framework. The peers also completed longitudinal surveys about their health after each training cohort (n = 5) over 3-years. Results: Peers reported personal benefits from training others with HIV in self-management. Their self-reported activation, self-efficacy and some health outcomes increased overtime. The peers mentioned SLT principles during their interviews. Generally, the peers enjoyed and benefited from training others with HIV in a group-based learning environment. Conclusion: Our findings suggest peer leadership can serve as a means for empowerment that is effective at both supporting improvements in health outcomes for patients and for themselves, which may be both scalable and sustainable. Innovation: To our knowledge, this is the first mixed-methods study to show reciprocal long-term improvement in health behaviors in a diverse group of peers training others with HIV to self-manage their care.

Addressing Sexual Harassment and Gender Bias: Mandatory Modules Are Not Enough.

BACKGROUND AND OBJECTIVES: Despite decades of new policy guidelines and mandatory training modules, sexual harassment (SH) and gender bias (GB) continue in academic medicine. The hierarchical structure of medical training makes it challenging to act when one experiences or witnesses SH or GB. Most trainings designed to address SH and GB are driven by external mandates and do not utilize current educational techniques. Our goal was to design training that is in-person, active, and directed toward skills development. METHODS: Our academic family medicine (FM) department began by surveying our faculty and residents about their lived experiences of SH and GB. We used these data, incorporating principles of adult learning, to deliver voluntary, experiential, interactive workshops throughout 2019. The workshops took place during faculty development meetings and an annual retreat. We used interactive techniques that included case-based and Theater of the Oppressed formats. OUTCOMES: Eighty percent of faculty and residents participated in at least one of our voluntary training sessions. In April of 2020, we administered a retrospective, pre/postsurvey on confidence in recognizing, responding to, and reporting SH and GB. We found significant improvements in all domains surveyed; many participants reported using the skills in the 6 months prior to completing the surveys. CONCLUSION: We demonstrated that voluntary, interactive training sessions using the recommendations of the National Academies of Science Engineering and Medicine Report on the Sexual Harassment of Women improve participants' reported confidence in recognizing, responding to, and reporting SH and GB in one academic FM department. This training intervention is practical and can be disseminated and implemented in many settings.

Accessibility of State and Territory Public Health Department Website Information on COVID-19 Outpatient Treatments in the US.

This cross-sectional study assesses the reading level and accessibility of information on COVID-19 treatments posted on US public health websites for states, territories, and Washington, DC.

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.

Training Family Medicine Residents to Address the COVID-19 Pandemic: A National Survey of Program Directors.

BACKGROUND AND OBJECTIVES: Public health training became particularly important for family medicine (FM) residency training programs amid the COVID-19 pandemic; the Accreditation Council for Graduate Medical Education (ACGME IV.C.19) requires a structured curriculum in which residents address population health. Our primary goal was to understand if, and to what extent, public health interventions trainings were incorporated into FM residency training programs amid the COVID-19 pandemic. We hypothesized programs with more resources (eg, university affiliates) would be better able to incorporate the training compared to those without such resources (ie, nonuniversity affiliates). METHODS: In 2021, we incorporated items addressing COVID-19 public health training competencies into the 2021 Council of Academic Family Medicine Educational Research Alliance national survey of FM residency program directors. The items addressed the type of training provided, mode of delivery, barriers to providing training, perceived importance of training, and support in delivering training. RESULTS: The overall survey response rate was 46.4% (n=287/619). All programs offered at least some training to residents. There were no statistically significant differences in training intensity between university and nonuniversity affiliates. The length of time an FM residency director spent in their position was positively associated with training intensity (r=0.1430, P=.0252). The biggest barrier to providing the trainings was the need to devote time to other curriculum requirements. CONCLUSIONS: FM residency programs were able to provide some public health interventions training during the pandemic. With increased support and resources, FM resident training curricula may better prepare FM residents now in anticipation of a future pandemic.

Sexual Harassment and Gender Bias in Family Medicine: Divergent Experiences of Men and Women.

BACKGROUND AND OBJECTIVES: Awareness of sexual harassment (SH), gender bias (GB), and gender discrimination (GD) has spread throughout popular culture and has been highlighted at universities across the United States. More nuanced data is needed to inform policies that address these issues. However, there are currently limited qualitative studies examining the nature of SH, GB, and GD in academic medicine, particularly family medicine. METHODS: In 2018, we conducted a series of gender-specific focus groups with faculty and residents in a department of family medicine (DFM) to understand their experiences with and responses to SH, GB, and GD. The focus groups were transcribed verbatim. We used immersion-crystallization and an adapted SH Experiences model to review the transcripts and identify patterns or themes during the immersion process. RESULTS: Participants identified the potential for patients, colleagues, faculty, and themselves as perpetrators and victims of SH, GB, and GD. Results suggested that GB was often implicit. SH was experienced verbally and physically. Women participants, especially, reported that both SH and GB occurred frequently and had lasting psychological effects. Gender, age, and position (faculty vs trainee) moderated SH and GB experiences. The effects seemed to be mediated by moral distress. CONCLUSIONS: This study emphasizes the importance of recognizing differences in experiences across gender, age, and position of SH, GB, and GD in academic family medicine. Our findings can be leveraged to develop antiharassment policies and set cultural expectations.

Effect of an Intensive Mindful Practice Workshop on Patient-Centered Compassionate Care, Clinician Well-Being, Work Engagement, and Teamwork.

INTRODUCTION: Mindfulness-based interventions for health professionals have been linked to improvements in burnout, well-being, empathy, communication, patient-centered care, and patient safety, but the optimal formats and intensity of training have been difficult to determine because of the paucity of studies and the heterogeneity of programs. A 4-days residential "Mindful Practice" workshop for physicians and medical educators featuring contemplative practices, personal narratives, and appreciative dialogs about challenging experiences may hold promise in improving participants' well-being while also improving compassionate care, job satisfaction, work engagement, and teamwork. METHODS: We collected baseline and 2-month follow-up data during four workshops conducted in 2018 to 2019 at conference centers in the United States and Europe. Primary outcomes were burnout, work-related distress, job satisfaction, work engagement, patient-centered compassionate care, and teamwork. RESULTS: Eighty-five of 120 participants (71%) completed both surveys (mean age was 49.3 and 68.2% female). There were improvements (P < .01) in two of three burnout components (emotional exhaustion and depersonalization), work-related distress, job satisfaction, patient-centered compassionate care, work engagement and meaning, teamwork, well-being, positive emotion, mindfulness, somatic symptoms, and spirituality. Effect sizes (standardized mean difference of change) ranged from 0.25 to 0.61. With Bonferroni adjustments (P < .0031), teamwork, general well-being, and mindfulness became nonsignificant. DISCUSSION: An intensive, multiday, mindfulness-based workshop for physicians had clinically significant positive effects on clinician well-being, quality of interpersonal care and work satisfaction, and meaning and engagement, all important indicators of improved health and sustainability of the health care workforce. Future iterations of the program should increase the focus on teamwork.

Blood Pressure Visit Intensification in Treatment (BP-Visit) Findings: a Pragmatic Stepped Wedge Cluster Randomized Trial.

BACKGROUND: Shortening time between office visits for patients with uncontrolled hypertension represents a potential strategy for improving blood pressure (BP). OBJECTIVE: We evaluated the impact of multimodal strategies on time between visits and on improvement in systolic BP (SBP) among patients with uncontrolled hypertension. DESIGN: We used a stepped-wedge cluster randomized controlled trial with three wedges involving 12 federally qualified health centers with three study periods: pre-intervention, intervention, and post-intervention. PARTICIPANTS: Adult patients with diagnosed hypertension and two BPs ≥ 140/90 pre-randomization and at least one visit during post-randomization control period (N = 4277). INTERVENTION: The core intervention included three, clinician hypertension group-based trainings, monthly clinician feedback reports, and monthly meetings with practice champions to facilitate implementation. MAIN MEASURES: The main measures were change in time between visits when BP was not controlled and change in SBP. A secondary planned outcome was changed in BP control among all hypertension patients in the practices. KEY RESULTS: Median follow-up times were 34, 32, and 32 days and the mean SBPs were 142.0, 139.5, and 139.8 mmHg, respectively. In adjusted analyses, the intervention did not improve time to the next visit compared with control periods, HR = 1.01 (95% CI: 0.98, 1.04). SBP was reduced by 1.13 mmHg (95% CI: -2.10, -0.16), but was not maintained during follow-up. Hypertension control (< 140/90) in the practices improved by 5% during intervention (95% CI: 2.6%, 7.3%) and was sustained post-intervention 5.4% (95% CI: 2.6%, 8.2%). CONCLUSIONS: The intervention failed to shorten follow-up time for patients with uncontrolled BP and showed very small, statistically significant improvements in SBP that were not sustained. However, the intervention showed statistically and clinically relevant improvement in hypertension control suggesting that the intervention affected clinician decision-making regarding BP control apart from visit frequency. Future practice initiatives should consider hypertension control as a primary outcome. CLINICAL TRIAL: www.ClinicalTrials.gov Identifier: NCT02164331.

Increasing Access to Medications for Opioid Use Disorder in Primary Care: Removing the Training Requirement May Not Be Enough.

BACKGROUND: Substance use disorders, including opioid use disorder (OUD), are understood as chronic diseases with a relapsing and remitting course and no known cure. Medications for OUD (MOUD) are well established with decades of evidence supporting their safety and efficacy; however, treatment access remains poor and inequitable. Buprenorphine is an MOUD that can be prescribed in a primary care outpatient setting, although regulatory and administrative challenges are a barrier to prescribing it. Recent regulatory changes offer an opportunity to expand the number of family doctors who treat OUD. METHODS: We offered free, easily accessible buprenorphine "x-waiver training" led by a team of primary care clinicians. In addition, we provided wrap-around support for MOUD clinical questions and administrative needs with experienced family medicine mentors. RESULTS: More than 400 clinicians attended our trainings, including medical students, residents, and attending physicians. Of the 101 attending physicians who completed our trainings, only 30 went on to apply for an x-wavier, and of those only 7 were currently prescribing when contacted 12 months later. CONCLUSION: Our experience indicates that removing the training requirement is a necessary first step but is unlikely to result in major changes to rates of prescribing without other significant cultural changes.

Anti-racism Training Using the Biopsychosocial Model: Frederick Douglas' Earthquake, Whirlwind, Storm and Fire.

Rochester, New York is home to George Engel and the Biopsychosocial (BPS) model. Rochester was also home to Fredrick Douglas and a stop on the Underground Railroad. More recently, Rochester, New York is also where Daniel Prude died at the hands of the police. In this article, we discuss how our department of family medicine has incorporated race and racism into the BPS model and how we have used it to help primary care trainees become more effective in their work with Black Indigenous and people of color (BIPOC) patients.

Motivation to move fast, motivation to wait and see: The association of prevention and promotion focus with clinicians' implementation of the JNC-7 hypertension treatment guidelines.

Roughly half of the adults in the United States are diagnosed with hypertension (HTN). Unfortunately, less than one-third have their condition under control. Clinicians generally have positive regard for the use of HTN guidelines to achieve HTN treatment goals; however, actual uptake remains low. Factors underpinning clinician variation in practice are poorly understood. To understand the relationship between clinicians' personal motivation to complete goals and their uptake of the Joint National Commission's HTN guidelines. The authors used Regulatory Focus Theory (RFT, ie, prevention and promotion focus), an empirically supported motivational theory, as a guiding framework to examine the relationship. The authors hypothesized that clinicians with high prevention focus would report following guidelines more often and have shorter follow-up visit intervals for patients with uncontrolled blood pressure. Clinicians (n  = 27) caring for adult patients diagnosed with HTN (n = 8605) in Federally Qualified Health Centers (n = 8). Clinicians' prevention and promotion focus scores and the number of days between visits for their patients with uncontrolled systolic blood pressure (SBP) (≥ 140 mm Hg). Consistent with RFT, 60% of prevention focused clinicians reported they always followed the monthly visit guideline for the patients with uncontrolled blood pressure, compared with 38% of promotion focused clinicians (p = .254). The unadjusted probability of returning for a follow-up visit within 30 days was greater among patients whose clinician was higher in prevention focus (p = .009), but there was no evidence at the 0.05 significance level in our adjusted model. These findings provide some limited evidence that RFT is a useful framework to understand clinician adherence to HTN treatment guidelines.

Attending a Biopsychosocially Focused Buprenorphine Training Improves Clinician Attitudes.

Objective: Substance use disorders remain highly stigmatized. Access to medications for opioid use disorder is poor. There are many barriers to expanding access including stigma and lack of medical education about substance use disorders. We enriched the existing, federally required, training for clinicians to prescribe buprenorphine with a biopsychosocial focus in order to decrease stigma and expand access to medications for opioid use disorder. Methods: We trained a family medicine team to deliver an enriched version of the existing buprenorphine waiver curriculum. The waiver training was integrated into the curriculum for all University of Rochester physician and nurse practitioner family medicine residents and also offered to University of Rochester residents and faculty in other disciplines and regionally. We used the Brief Substance Abuse Attitudes Survey to collect baseline and post-training data. Outcomes: 140 training participants completed attitude surveys. The overall attitude score increased significantly from pre to post-training. Additionally, significant changes were observed in non-moralism from pre-training (M = 20.07) to post-training (M = 20.98, p < 0.001); treatment optimism from pre-training (M = 21.56) to post-training (M = 22.33, p < 0.001); and treatment interventions from pre-training (M = 31.03) to post-training (M = 32.10, p < 0.001). Conclusion: Increasing medical education around Opioid Use Disorder using a Family Medicine trained team with a biopsychosocial focus can improve provider attitudes around substance use disorders. Enriching training with cases may improve treatment optimism and may help overcome the documented barriers to prescribing medications for opioid use disorder and increase access for patients to lifesaving treatments.

Can a brief peer-led group training intervention improve health literacy in persons living with HIV? Results from a randomized controlled trial.

OBJECTIVE: The goal of this study was to determine if a 6-week, peer-led intervention improves health literacy and numeracy among people living with HIV (PLWH). METHODS: We used a randomized controlled trial with repeated measurements, which included six, 90-minute, group-based training sessions. We recruited PLWH participants (n = 359) from safety-net practices in the New York City Metropolitan area and Rochester, NY. Participants were randomly assigned (1:1) to an intervention group (n = 180) or a control group (n = 179). Outcome measures were collected at baseline, eight weeks post-baseline, and at six months using the Brief Estimate of Health Knowledge and Action-HIV (BEHKA-HIV), the Electronic Health Literacy Scale (eHEALS), the Rapid Estimate of Adult Literacy (REALM), and the Newest Vital Sign (NVS). RESULTS: The intervention group had statistically significant improvements in eHealth literacy and BEHKA-HIV compared to the control group. There were no statistically significant changes in general health literacy or numeracy in either group. The intervention had the greatest impact on participants with the lowest levels of eHealth literacy at baseline. CONCLUSION: The intervention had a positive impact on participants' HIV health literacy and eHealth literacy. PRACTICE IMPLICATIONS: Our findings have implications for broadening the function of peer-workers in the health care continuum.

Interprofessional collaboration and smartphone use as promising strategies to improve prenatal oral health care utilization among US underserved women: results from a qualitative study.

BACKGROUND: Data on barriers and facilitators to prenatal oral health care among low-income US women are lacking. The objective of this study was to understand barriers/facilitators and patient-centered mitigation strategies related to the use of prenatal oral health care among underserved US women. METHODS: We used community-based participatory research to conduct two focus groups with eight pregnant/parenting women; ten individual in-depth interviews with medical providers, dental providers and community/social workers; and one community engagement studio with five representative community stakeholders in 2018-2019. Using an interpretive description research design, we conducted semi-structured interviews and focus groups which were audio-recorded, transcribed, and analyzed for thematic content. RESULTS: We identified individual and systemic barriers/facilitators to the utilization of prenatal oral health care by underserved US women. Strategies reported to improve utilization included healthcare system-wide changes to promote inter-professional collaborations, innovative educational programs to improve dissemination and implementation of prenatal oral health care guidelines, and specialized dental facilities providing prenatal oral health care to underserved women. Moreover, smartphones have the potential to be an innovative entry point to promote utilization of prenatal oral care at the individual level. CONCLUSIONS: Low-income women face multiple, addressable barriers to obtaining oral health care during pregnancy. Inter-professional collaboration holds strong promise for improving prenatal oral health care utilization.

Implementation Science to Address Health Disparities During the Coronavirus Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic is disproportionally affecting racial and ethnic minorities. In the United States, data show African American, Hispanic, and Native American populations are overrepresented among COVID-19 cases and deaths. As we speed through the discovery and translation of approaches to fight COVID-19, these disparities are likely to increase. Implementation science can help address disparities by guiding the equitable development and deployment of preventive interventions, testing, and, eventually, treatment and vaccines. In this study, we discuss three ways in which implementation science can inform these efforts: (1) quantify and understand disparities; (2) design equitable interventions; and (3) test, refine, and retest interventions.