A Pragmatic Approach to Identifying and Profiling Primary Care Clinicians and Primary Care Practices in the USA.

BACKGROUND: There are no consistent data on US primary care clinicians and primary care practices owing to the lack of standard methods to identify them, hampering efforts in primary care improvement. METHODS: We develop a pragmatic framework that identifies primary care clinicians and practices in the context of the US healthcare system, and applied the framework to the IQVIA OneKey Healthcare Professional database to identify and profile primary care clinicians and practices in the USA. RESULTS: Our framework prescribes sequential steps to identify primary care clinicians by cross-examining clinician specialties and organizational affiliations, and then identify primary care practices based on organization types and presence of primary care clinicians. Applying this framework to the 2021 IQVIA data, we identified 365,751 physicians with a primary specialty in primary care, and after excluding those who further specialized (24%), served as hospitalists (5%), or worked in non-primary care settings (41%), we determined that 179,369 (49%) of them were actually practicing primary care. We identified 287,506 nurse practitioners and 134,083 physician assistants and determined that 88,574 (31%) and 29,781 (22%), respectively, were delivering primary care. We identified 94,489 primary care practices, and found that 45% of them were with one primary care physician, 15% had two physicians, 12% employed nurse practitioners or physician assistants only, and 19% employed both primary care physicians and specialists. CONCLUSIONS: Our approach offers a pragmatic and consistent alternative to the diverse methods currently used to identify and profile primary care workforce and organizations in the USA.

Variation in Family Physicians' Experiences Across Different Electronic Health Record Platforms: a Descriptive Study.

BACKGROUND: Electronic health records (EHRs) have been connected to excessive workload and physician burnout. Little is known about variation in physician experience with different EHRs, however. OBJECTIVE: To analyze variation in reported usability and satisfaction across EHRs. DESIGN: Internet-based survey available between December 2021 and October 2022 integrated into American Board of Family Medicine (ABFM) certification process. PARTICIPANTS: ABFM-certified family physicians who use an EHR with at least 50 total responding physicians. MEASUREMENTS: Self-reported experience of EHR usability and satisfaction. KEY RESULTS: We analyzed the responses of 3358 physicians who used one of nine EHRs. Epic, athenahealth, and Practice Fusion were rated significantly higher across six measures of usability. Overall, between 10 and 30% reported being very satisfied with their EHR, and another 32 to 40% report being somewhat satisfied. Physicians who use athenahealth or Epic were most likely to be very satisfied, while physicians using Allscripts, Cerner, or Greenway were the least likely to be very satisfied. EHR-specific factors were the greatest overall influence on variation in satisfaction: they explained 48% of variation in the probability of being very satisfied with Epic, 46% with eClinical Works, 14% with athenahealth, and 49% with Cerner. CONCLUSIONS: Meaningful differences exist in physician-reported usability and overall satisfaction with EHRs, largely explained by EHR-specific factors. User-centric design and implementation, and robust ongoing evaluation are needed to reduce physician burden and ensure excellent experience with EHRs.

Barriers to care for perinatal patients with opioid use disorder: family physician perspectives.

BACKGROUND: While barriers to care for pregnant patients with opioid use disorder (OUD) have been described, the experiences and challenges of the physicians providing care to these patients are poorly understood. OBJECTIVES: To describe the experiences of family physicians providing comprehensive care to pregnant people with OUD and the challenges they face in providing such care. METHODS: Qualitative thematic analysis of 17 semistructured interviews conducted from July 2019 to September 2020 with family physicians who possess a Drug Enforcement Administration "X" waiver and provide care to pregnant patients. RESULTS: Seventeen family physicians practicing in the United States who care for pregnant people with OUD were interviewed. They described physician-, patient-, and systems-level barriers to providing and accessing care for this patient population. Of the 12 interrelated themes regarding challenges to delivering and accessing this care, 3 were particularly salient: the pervasive effects of social determinants of health, a lack of adequately trained providers, and social stigma associated with pregnant people with OUD. CONCLUSION: A comprehensive, multilevel, and multidisciplinary approach is necessary to address these barriers and move towards health equity for this vulnerable patient population.

Impact of COVID-19 on perinatal care: Perceptions of family physicians in the United States.

BACKGROUND: Patient-centered care is the best practice in the care of pregnant and postpartum patients. The COVID-19 pandemic prompted changes in perinatal care policies, which were often reactive, resulting in unintended consequences, many of which made the delivery of patient-centered care more difficult. This study aimed to understand the impact of the COVID-19 pandemic on perinatal health care delivery from the perspective of family physicians in the United States. METHODS: From October 5 to November 4, 2020, we surveyed mid- to late-career family physicians who provide perinatal care. We conducted descriptive analyses to measure the impact of COVID-19 on prenatal care, labor and delivery, postpartum care, patient experience, and patient volume. An immersion-crystallization approach was used to analyze qualitative data provided as open-text comments. RESULTS: Of the 1518 survey respondents, 1062 (69.8%) stated that they currently attend births; 595 of those elaborated about the impact of COVID-19 on perinatal care in free-text comments. Eight themes emerged related to the impact of COVID-19 on perinatal care: visitation, patient decisions, testing, personal protective equipment, care continuity, changes in care delivery, reassignment, and volume. The greatest perceived impact of COVID-19 was on patient experience. CONCLUSIONS: Family physicians who provided perinatal care during the COVID-19 pandemic noted a considerable impact on patient experience, which particularly affected the ability to deliver patient-centered and family-centered care. Continued research is needed to understand the long-term impact of policies affecting the delivery of patient-centered perinatal care and to inform more evidence-based, proactive policies to be implemented in future pandemic or disaster situations.

Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups.

PURPOSE: We investigated whether physician race and ethnicity were associated with burnout among a nationally representative sample of family physicians. METHODS: We undertook a cross-sectional observational study using survey data from 1,510 American Board of Family Medicine recertification applicants in 2017 and 1,586 respondents to the 2017 National Graduate Survey. Of the 3,096 total family physicians, 450 (15%) were from racial and ethnic groups underrepresented in medicine. We used structural equation models to test the effects of underrepresented status on single-item measures of emotional exhaustion and depersonalization. RESULTS: Family physicians underrepresented in medicine were significantly less likely than their non-underrepresented counterparts to report emotional exhaustion (adjusted odds ratio = 0.82; 95% CI, 0.69-0.99; total effect) and depersonalization (adjusted odds ratio = 0.54; 95% CI, 0.41-0.71; total effect). The underrepresented physicians were more likely than non-underrepresented peers to practice in more racially and ethnically diverse counties and less likely to practice obstetrics, both of which partly mediated the protective effect of underrepresented status on depersonalization. CONCLUSIONS: Although factors such as racism might be expected to adversely affect the well-being of underrepresented clinicians, underrepresented family physicians reported a lower frequency of emotional exhaustion and depersonalization. The mediating protective effect of working in more racially and ethnically diverse counties is consistent with evidence of the beneficial effect of cultural diversity on health outcomes for minorities. Because physician burnout is a known predictor of job turnover and may also be associated with poorer quality of care, the lower burnout observed among underrepresented family physicians may be an asset for the health care system as a whole.

Maternity Care and Buprenorphine Prescribing in New Family Physicians.

The American Board of Family Medicine routinely surveys its Diplomates in each national graduating cohort 3 years out of training. These data were used to characterize early career family physicians whose services include management of pregnancy and prescribing buprenorphine. A total of 261 (5.1%) respondents both provide maternity care and prescribe buprenorphine. Family physicians who care for pregnant women and also prescribe buprenorphine represented 50.4% of all buprenorphine prescribers. The family physicians in this group were trained in a small number of residency programs, with only 15 programs producing at least 25% of graduates who do this work.

A qualitative study of trainee experiences in Family Medicine-Obstetrics fellowships.

BACKGROUND: Family Medicine-Obstetrics fellowships provide family physicians with advanced obstetrics training. No accreditation system exists for these fellowships, which leads to variable training. Variation of fellows' experiences is not well understood. Our objective is to understand the motivations, training, and overall experiences of fellows in Family Medicine-Obstetrics fellowships, which may inform opportunities for improvement in fellowship design and suggest how Family Medicine-Obstetrics fellowship-trained physicians are prepared to practice among other obstetrics providers postgraduation. METHODS: We conducted semistructured interviews with current and past Family Medicine-Obstetrics fellows between Spring 2014 and Winter 2015. We used a snowball sampling approach. Interviews were recorded, transcribed, and coded following an inductive approach to content analysis. RESULTS: We contacted 47 and interviewed 21 current and past Family Medicine-Obstetrics fellows from 15 programs from across the country. Fellowships varied in cohort size, length, co-occurring presence of obstetrics and gynecology training programs, and structure and curriculum. Interviewees were motivated to complete a fellowship because of inadequate obstetrics training in residency, or because of an interest in rural or urban underserved practice. Fellowship experiences were shaped by fellowship leadership, program structure and curriculum, and relationships with obstetricians. Some felt prepared to forge collaborative professional relationships with obstetricians. CONCLUSIONS: The diversity of fellows' experiences suggests possible avenues of improvement for Family Medicine-Obstetrics fellowships. These fellowships can prepare physicians to provide obstetric services in a variety of settings, including working in multispecialty integrated maternity care systems.

Challenges Faced by Family Physicians Providing Advanced Maternity Care.

Introduction Maldistribution of maternity care (MC) providers in the U.S. limits access to full spectrum MC services. Obstetricians are concentrated in urban areas with many rural areas reliant on family physicians (FP) to provide MC, yet fewer FPs are providing MC. The objective of this study was to understand the challenges FPs face in gaining skills in and providing advanced MC. Methods We conducted qualitative semi-structured interviews with 51 purposively sampled key stakeholders in family medicine MC (21 family medicine-OB fellowship directors, 19 past fellows, and 10 family medicine residency directors of programs with advanced MC training). Interviews were recorded, transcribed, and analyzed using an inductive approach to qualitative content analysis. Results Three primary challenges for FPs providing advanced MC emerged from the interviews. Training: most family medicine residency programs do not provide sufficient surgical OB training, so fellowship training is an important alternative for FPs to acquire such skills. Credentialing: obtaining hospital privileges to perform cesarean sections is unpredictable and highly variable by institution. Professional relationships: "turf battles" with other MC providers can limit FPs' ability to provide care commensurate with their level of training. Discussion As the predominant provider of MC in rural and underserved areas, FPs need to be supported to provide advanced MC services. Possible strategies to accomplish this include: enhanced family medicine training in MC; policy changes to address credentialing inconsistencies; and improved team-based care for pregnant women to ensure that every woman has access to high quality MC.

Retaining the perinatal care workforce: Lessons learned from experienced physicians who no longer attend deliveries.

OBJECTIVE: To inform policy supporting the retention of family physicians (FPs) in the perinatal care workforce by identifying physician characteristics that are associated with retention. DATA SOURCES AND STUDY SETTING: We surveyed FPs who had been in practice for at least 11 years and reported attending deliveries as part of their practice. STUDY DESIGN: We compared the characteristics of FPs who continue to provide perinatal care to those who have ceased and explored their reasons for no longer attending deliveries. DATA COLLECTION/EXTRACTION METHODS: We estimated a probit regression with the dependent variable: whether the physician currently delivers babies. Open-ended survey responses were analyzed and close-coded using a conceptual content analysis approach. PRINCIPLE FINDINGS: Of the FPs who received a survey, 1505 (37%) responded. Those who continue attending deliveries were more likely to receive a stipend or be paid per hour/shift in addition to their salary versus those paid a salary (percentage point difference = 13), and less likely to work part-time versus full-time (percentage point difference = -20). Those who ceased attending deliveries cite lifestyle (n = 208), call structure (n = 113), and delivery volume (n = 89) among the reasons for doing so. CONCLUSIONS: Evidence-based policies aimed at preventing attrition from the perinatal care workforce, which might include targeting compensation models and work-life balance.

The Effect of Patient-Physician Concordance on Perinatal Care: The Family Physicians' Perspective.

Demographic concordance between patients and clinicians has been associated with better outcomes. The current perinatal care workforce is not adequately diverse to allow for patient-clinician concordance. In this mixed-methods study, we aimed to understand family physicians' perception of the impact of patient-clinician concordance on perinatal care. The predominantly (91%) non-Hispanic White sample of 1,505 family physicians (FPs) perceived gender and language concordance to affect perinatal care more than racial or ethnic concordance. Religious concordance is not perceived to greatly affect perinatal care. Nearly half (721) of the respondents chose to leave a free-text comment on the impact of concordance on perinatal care. Four categories emerged (patients, physicians, the patient-physician relationship, and potential ways to mitigate the impact of discordance). Based on the perceptions of FPs experienced in perinatal care, intentionally supporting continuity of care between patients and clinicians may help to mitigate the negative impact of discordance on perinatal outcomes.

Female Family Physicians Are More Racially Diverse Than Their Male Counterparts in Federal Sites.

Supporting a diverse family physician workforce is an integral component of achieving health equity. This study compared the racial/ethnic composition of Federal family physicians (Military, Veterans Administration/Department of Defense) to the entire cohort of family physicians and stratified by gender. Female family physicians serving at Federal sites were more diverse than the overall population of female family physicians and, also than their male Federal counterparts. This gendered trend among Federal physicians needs further exploration.

The Workforce Providing Prenatal and Postpartum Care Decreases When Family Physicians Stop Attending Deliveries.

The impact of the declining proportion of family physicians who attend deliveries on the provision of other perinatal care during pregnancy, postpartum, and neonatal periods is unclear. We found a strong association between stopping attending deliveries and stopping providing prenatal and postpartum care among family physicians, suggesting that policies which support family physicians to maintain a full scope of practice including all or some aspects of perinatal care may help alleviate shortages in the perinatal workforce and fill gaps in access to obstetric care.

Challenges Meeting Training Requirements in the Care of Children in Family Medicine Residency Programs: A CERA Study.

BACKGROUND AND OBJECTIVE: In 2014, the Accreditation Council for Graduate Medical Education (ACGME) implemented numeric requirements for family medicine (FM) pediatric patient encounters. Impact on residency programs is unclear. We aimed to identify any difficulties faced by FM program directors (PDs) meeting these numeric requirements. METHODS: Questions about pediatric training in family medicine residencies were included in a survey of PDs conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA). We performed univariate analysis of the demographic and program characteristics. We then used χ2 tests of independence to test for bivariate associations between these characteristics and our primary outcome: the most difficult ACGME pediatric care requirement to meet. RESULTS: Most programs reported the hospital as the primary location of training (n=131, 46%) and their family medicine practice (FMP) patient population consisted of over 20% pediatric patients (n=153, 56%). Over 80% of program directors reported challenges meeting FM requirements for the care of children. Challenges meeting pediatric requirements were associated with fewer than 20% FMP patients under 19 years of age (P<.0001), fewer than 50% of core FM faculty caring for sick children (P=.0128), and primary location of pediatric training in a family health center (P=.0006). CONCLUSION: Difficulty meeting ACGME requirements for the care of children in FM residency programs is common, especially for programs with fewer than 20% FMP patients under 19 years of age. Further research is needed to determine how best to assure FM resident competencies in the care of children and adolescents.

Maternity Access in Rural America: The Role of Family Physicians in Providing Access to Cesarean Sections.

INTRODUCTION: As an increasing number of rural hospitals close their maternity care units, many of the approximately 28 million reproductive-age women living in rural America do not have local access to obstetric services. We sought to describe the characteristics and distribution of cesarean section-providing family physicians who may provide critical services in maintaining obstetric access in rural hospitals. METHODS: Using a cross-sectional study design, we linked data from the 2017 to 2022 American Board of Family Medicine's Continuting Certification Questionnaire on provision of cesarean sections as primary surgeon and practice characteristics to geographic data. Logistic regression determined associations with provision of cesarean sections. RESULTS: Of 28,526 family physicians, 589 (2.1%) provided cesarean sections as primary surgeon. Those who provided cesarean sections were more likely to be male (odds ratio (OR) = 1.573, 95% confidence limits (CL) 1.246-1.986), and work in rural health clinics (OR = 2.157, CL 1.397-3.330), small rural counties (OR = 4.038, CL 1.887-8.642), and in counties without obstetrician/gynecologists (OR = 2.163, CL 1.440-3.250). DISCUSSION: Although few in number, family physicians who provide cesarean sections as primary surgeon disproportionately serve rural communities and counties without obstetrician/gynecologists, suggesting that they provide access to obstetric services in these communities. Policies that support family physician training in cesarean sections and facilitate credentialing of trained family physicians could reverse the trend of closing obstetric units in rural communities and reduce disparities in maternal and infant health outcomes.

Providing Obstetric Care: Suggestions From Experienced Family Physicians.

BACKGROUND AND OBJECTIVES: The number of family physicians who include obstetric care in their scope of practice is declining, resulting in lower access for patients to obstetric care, especially in rural and underserved communities. In our study, we aimed to understand the experiences of mid- to late-career family physicians and capture suggestions regarding how to maintain obstetric deliveries as part of practice throughout their careers. METHODS: We administered a 30-item online survey to mid- to late-career family physicians regarding their obstetrical care practice and their suggestions for family physicians to continue attending deliveries throughout the course of their career. We developed descriptive statistics of individual and practice characteristics and thematically analyzed open-text comments offering suggestions for continuing to provide obstetric care. RESULTS: About 1,500 family physicians agreed to participate in the online survey, 992 of whom responded to an open-text question asking for suggestions for family physicians hoping to continue providing obstetric care throughout their careers (56% response rate). The primary themes included suggestions regarding interprofessional relationships, call coverage/backup, training and education, practice characteristics, practice setting, work-life balance, job seeking, policy, and compensation. CONCLUSIONS: The findings revealed individual- and structural-level considerations to improve longevity in obstetric scope of practice. Support from multiple levels is necessary to ensure that competent family physicians continue attending deliveries throughout their careers. Practices and hospital systems can have a sizeable impact by directly helping family physicians provide obstetric primary care within their scope of practice, while national organizations can influence health care system-level changes.

Family Physicians Increasingly Deliver Care in Diverse Languages.

The proportion of family physicians reporting provision of patient care in Spanish changed little between 2013 to 2020 but rose substantially for care delivered in other non-English languages. Physician-patient language concordance is associated with better clinical outcomes and higher patient satisfaction, serves as a proxy indicator for workforce diversity, and should be monitored and encouraged as the US population continues to diversify.

Family Physician Racial Identity: An Analysis of "Other" Race Selection and Implications for Future Data Collection.

Family physicians who report their race as "Other" in a single best option question find the existing categories and forced choice of one category to be problematic. Our analysis of open-text responses in the "Other" race category supports a modification in the way these data are collected to provide more accurate and meaningful ways to understand the workforce and move toward more diverse, equitable, and inclusive policies in family medicine.

Racial and Ethnic Diversity of Family Physicians Delivering Maternity Care.

BACKGROUND: Maternal and birth outcomes represent some of the most profound racial and ethnic disparities in health in the USA, and are, in part, attributed to a lack of diversity in the maternity care workforce. Family physicians are an often-overlooked part of the maternity care workforce, yet frequently provide care to underserved populations. This study aims to characterize the family physician workforce providing obstetric care in terms of race/ethnicity. METHODS: In this cross-sectional study, we used data collected via the American Board of Family Medicine Exam Registration Questionnaire from 2017 to 2019. Respondents included family physicians seeking to continue their certification in those years. We conducted bivariate tests and an adjusted analysis using logistic regression to examine associations with providing obstetric deliveries. Variables included race, ethnicity, age, gender, degree type, international medical graduate status, practice site, and rurality. RESULTS: Of 20,820 family physicians in our sample, those identifying as Black/African American (OR 0.55, CI 0.41 to 0.74) and Asian (OR 0.40, CI 0.31 to 0.51) had significantly lower odds of including obstetrics in their practice than those identifying as White. We found no significant difference in practicing obstetrics between Hispanic and non-Hispanic family physicians (OR 0.94, CI 0.73 to 1.20). Asian (OR 0.40, CI 0.31 to 0.51) and Black/African American (OR 0.55, CI 0.41 to 0.74) physicians still have significantly lower odds of providing obstetric care than White physicians after controlling for rurality. CONCLUSIONS: Family physicians who identified as Black/African American or Asian are less likely to include obstetrics in their practice. A diverse and racially/ethnically representative maternity care workforce, including family physicians, may help to ameliorate disparities in maternal and birth outcomes. Enhanced efforts to diversify the family physician maternity care workforce should be implemented.

Variation in Scope and Area of Practice by Family Physician Race and Ethnicity.

Family physicians who are self-identified members of Black, Hispanic, and American Indian/Alaska Native racial groups are more likely to practice in disadvantaged areas but also tend to have narrower scopes of practice when compared with White family physicians, despite holding the same certification. Considering the established benefits of comprehensive primary care, these results suggest the need for policies incentivizing and supporting broader scopes of practice in disadvantaged areas.