Palliative Care Education in the Family Medicine Clerkship: A CERA Study

More Than Half of Family Medicine Clerkships Do Not Address Systemic Racism: A CERA Study

BACKGROUND AND OBJECTIVES

The influence of racism in medicine is increasingly acknowledged, and the negative effect of systemic racism on individual and population health is well established. Yet, little is known about how or whether medical students are being educated on this topic. This study investigated the presence and features of curricula related to systemic racism in North American family medicine clerkships.

METHODS

We conducted a survey of North American family medicine clerkship directors as part of the 2021 Council of Academic Family Medicine's Educational Research Alliance (CERA) survey.

RESULTS

The survey response rate was 49% (78/160). Almost all clerkship directors agreed (n=68; 97.1%) that teaching about racism at all levels of medical education was appropriate. Yet, 60% (n=42) of family medicine clerkship directors reported no formalized curriculum for teaching about racism or bias. Teaching about systemic racism was more likely to be present in the family medicine clerkship at institutions where clerkship directors reported that faculty receive 5 or more hours of training in racism and bias, as compared to institutions where faculty receive 4 or fewer hours of training in racism/bias (odds ratio 2.82, 95% CI 1.05-8.04, P=.045). Programs reported using racism in medicine curricula based in cultural competency (20%); structural competency (10%); both cultural and structural competency (31%); and neither or uncertain (40%). Clerkship directors reported high faculty, student, and institutional engagement in addressing systemic racism. We did not find an association between underrepresented in medicine director identity and racism curricula.

CONCLUSIONS

In more than half of family medicine clerkships, systemic racism is not addressed, despite interest from students and institutional support. A higher number of hours of faculty training time on the topic of racism was associated with having a systemic racism module in the clerkship curriculum, but we lacked data to identify a causal relationship. Investments in faculty development to teach systemic racism, including discussion of structural competency, are needed.

Trends of Geriatric Certification and Practice Patterns of Family Physicians: 1988-2019

BACKGROUND AND OBJECTIVES

Demand for geriatric care is increasing due to aging population. Trends in maintaining certification in geriatrics are unreported. Our objective was to describe the historic trend of family physicians who certified in geriatric medicine (FPs-GM) since 1988 and to assess differences in practice patterns between FPs-GM and family physicians (FPs).

METHODS

We performed a retrospective descriptive study using administrative data collected by the American Board of Family Medicine (ABFM). The study population was family physicians registering to continue their ABFM certification from 2017 to 2019. Medicare public use billing data was linked to ABFM administrative data on certification history. We used univariate analysis for descriptive analysis and logistic regression to identify contributors of recertification in geriatrics.

RESULTS

We identified a total of 3,207 FPs-GM between 1988 and 2019. More than half maintained GM certification since 2009 (57%), with male gender, White race, and urban practice associated with maintaining GM certification; 61% of their patients were older adults. FPs-GM were more likely to be in an academic practice setting with nearly half (53%) also practicing in hospitals or nursing homes. In the adjusted regression model, younger FPs or FPs who treat more older patients were significantly more likely to be recertified in geriatrics whereas other demographics and practice characteristics were not significant.

CONCLUSIONS

Most FPs who recently earned GM certification tended to retain certification since the required accredited fellowship started in 1995.

Timing of Palliative Care in Colorectal Cancer Patients: Does It Matter?

BACKGROUND

Palliative care can improve end-of-life care and reduce health care expenditures, but the optimal timing for initiation remains unclear. We sought to characterize the association between timing of palliative care, in-hospital deaths, and health care costs.

METHODS

This is a retrospective cohort study including all patients who were diagnosed and died of colorectal cancer between 2004 and 2012 in Manitoba, Canada. The primary exposure was timing of palliative care, defined as no involvement, late involvement (less than 14 d before death), early involvement (14 to 60 d before death), and very early involvement (>60 d before death). The primary outcome was in-hospital deaths and end-of-life health care costs.

RESULTS

A total of 1607 patients were included; 315 (20%) received palliative care and 162 (10%) died in hospital. Compared to those who did not receive palliative care, patients with early and very early involvement experienced significantly decreased odds of dying in hospital (OR 0.21 95% CI 0.06-0.69 P = 0.01 and OR 0.11 95% CI 0.01-0.78 P = 0.03, respectively) and significantly lower health care costs. There were no significant differences in in-hospital deaths and health care costs between patients without palliative care and those who received late palliative care.

CONCLUSIONS

Early palliative care involvement is associated with decreased odds of dying in hospital and lower health care utilization and costs in patients with colorectal cancer. These findings provide real-world evidence supporting early integration of palliative care, although the optimal timing (early versus very early) remains a matter of debate.