COVID-19 Impact on Family Medicine Residents Exam Performance

BACKGROUND AND OBJECTIVES

The COVID-19 pandemic began interrupting family medicine residency training in spring 2020. While a decline in scores on the American Board of Family Medicine In-Training Examination (ITE) has been observed, whether this decline has translated into the high-stakes Family Medicine Certification Examination (FMCE) is unclear. The goal of this study was to systematically assess the magnitude of COVID-19 impact on medical knowledge acquisition during residency, as measured by the ITE and FMCE.

METHODS

A total of 19,101 initial certification candidates from 2017 to 2022 were included in this study. Annual ITE scores and FMCE scores were reported on the same scale (200-800) and served as the outcome measure. We conducted multilevel regression analysis to determine ITE score growth and FMCE scores compared to cohorts prior to COVID-19.

RESULTS

During COVID-19, the increase in ITE scores from postgraduate year 2 (PGY-2) to PGY-3 was 25.5 points less, representing a 57.6% relative decrease; and from PGY-3 ITE to FMCE, it was 8.6 points less, a 12.7% relative decrease, compared with cohorts prior to COVID-19. FMCE scores were 6.6 points less during COVID-19, representing a 1.2% relative decline from the average FMCE score prior to COVID-19.

CONCLUSIONS

This study found nonsubstantive COVID-19 impact on FMCE scores, but a considerable knowledge acquisition decline during residency, especially during the PGY-2 to PGY-3 period. While COVID-19 impacted learning, our findings indicated that residencies were largely able to remediate knowledge deficits before residents took the FMCE.

Differences in Physician Performance and Self-rated Confidence on High- and Low-Stakes Knowledge Assessments in Board Certification

INTRODUCTION

Evidence links assessment to optimal learning, affirming that physicians are more likely to study, learn, and practice skills when some form of consequence ("stakes") may result from an assessment. We lack evidence, however, on how physicians' confidence in their knowledge relates to performance on assessments, and whether this varies based on the stakes of the assessment.

METHODS

Our retrospective repeated-measures design compared differences in patterns of physician answer accuracy and answer confidence among physicians participating in both a high-stakes and a low-stakes longitudinal assessment of the American Board of Family Medicine.

RESULTS

After 1 and 2 years, participants were more often correct but less confident in their accuracy on a higher-stakes longitudinal knowledge assessment compared with a lower-stakes assessment. There were no differences in question difficulty between the two platforms. Variation existed between platforms in time spent answering questions, use of resources to answer questions, and perceived question relevance to practice.

DISCUSSION

This novel study of physician certification suggests that the accuracy of physician performance increases with higher stakes, even as self-reported confidence in their knowledge declines. It suggests that physicians may be more engaged in higher-stakes compared with lower-stakes assessments. With medical knowledge growing exponentially, these analyses provide an example of the complementary roles of higher- and lower-stakes knowledge assessment in supporting physician learning during continuing specialty board certification.

Racial/Ethnic Group Trajectory Differences in Exam Performance Among US Family Medicine Residents

Background and Objectives: Racial/ethnic score disparities on standardized tests are well documented. Such differences on the American Board of Family Medicine (ABFM) certification examination have not been previously reported. If such differences exist, it could be due to differences in knowledge at the beginning of residency or due to variations in the rate of knowledge acquisition during residency. Our objective was to examine the residents’ mean initial scores and score trajectories using the In-Training Examination (ITE) and certification examination. Methods: A total of 17,275 certification candidates from 2014 to 2019 were included in this study. Annual ITE scores and certification examination scores are reported on the same scale and serve as the outcome. We conducted multilevel longitudinal regression to determine initial knowledge and growth in knowledge acquisition during residency by race/ethnicity categories. Results: The mean postgraduate year 1 (PGY-1) ITE score was 393.3, with minority residents scoring 16.2 to 36.0 points lower compared to White residents. The mean increase per year in exam performance from PGY-1 ITE to the certification exam was 39.9 points (95% CI, 38.7, 41.1) with additional change among race/ethnicity categories per year of -3.2 to 1.9 points. Conclusions: This study found that there were initial score disparities across race/ethnicity groups in PGY-1, and these disparities continued at the same rate throughout residency training, suggesting equality in acquisition of knowledge during family medicine residency training but with a persistent gap throughout training.

Triple Aim Is Triply Tough: Can You Focus on Three Things at Once?

BACKGROUND AND OBJECTIVES

The I3 POP Collaborative sought to improve health of patients attending North Carolina, South Carolina, and Virginia primary care teaching practices using the triple aim framework of better quality, appropriate utilization, and enhanced patient experience. We examined change in triple aim measures over 3 years, and identified correlates of improvement.

METHODS

Twenty-nine teaching practices representing 23 residency programs participated. The Institute for Health Care Improvement Breakthrough Series Collaborative model was tailored to focus on at least one triple aim goal and programs submitted data annually on all collaborative measures. Outcome measures included quality (chronic illness, prevention); utilization (hospitalization, emergency department visits, referrals) and patient experience (access, continuity). Participant interviews explored supports and barriers to improvement.

RESULTS

Six of 29 practices (21%) were unable to extract measures from their electronic health records (EHR). All of the remaining 23 practices reported improvement in at least one measure, with 11 seeing at least 10% improvement; seven (24%) improved measures in all three triple aim areas, with two experiencing at least 10% improvement. Practices with a greater number of patient visits were more likely to show improved measures (odds ratio [OR] 10.8, 95% confidence interval [CI]: .68-172.2, P=0.03). Practice interviews revealed that engaged leadership and systems supports were more common in higher performing practices.

CONCLUSIONS

Simultaneous attainment of improvement in all three triple aim goals by teaching practices is difficult. I3 POP practices that were able to pull and report data improved on at least one measure. Future work needs to focus on cultivating leadership and systems supporting large scale improvement.

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.

Driving Improvement in Health and Health Care: Setting Metrics for Medicaid Outcomes

Clinical performance metrics are the foundation of the design and ultimate performance of North Carolina's Medicaid reform plan. This commentary describes the general approach of the state's Department of Health and Human Services in setting metrics, including goals, assumptions, and starting principles.

Piloting the Mobile Medical Milestones Application (M3App©): A Multi-Institution Evaluation

BACKGROUND AND OBJECTIVES

Competency-based evaluation of the Accreditation Council for Graduate Medical Education (ACGME) Milestones requires the development of new evaluation tools that can better capture learners' behavior. This study describes the implementation and initial assessment of an innovative point-of-care mobile application, the M3App,© linked to the Family Medicine Milestones.

METHODS

Seven family medicine residency programs in North Carolina implemented the M3App.© Program faculty and residents were surveyed prior to implementation regarding current evaluation methods and their quality and use and acceptability of electronic evaluation tools. Surveys were repeated after implementation for comparison.

RESULTS

All seven programs successfully implemented the M3App. Most faculty members found the tool well designed, easy to use, beneficial to the quality and efficiency of feedback they provide, and to their knowledge of Milestones. Residents reported significant increases in the volume and quality of written feedback they receive.

CONCLUSIONS

The M3App provides an efficient, convenient tool for assessing Milestones that can improve the quantity and quality of feedback residents receive from faculty. Improved faculty perception of knowledge of Milestones after M3App implementation suggests that the tool is also effective for faculty development.

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.

Continuity and Access in an Academic Family Medicine Center

BACKGROUND AND OBJECTIVES

A personal physician and enhanced access to care are principles of the patient-centered medical home. Despite the importance of these concepts, measuring and improving interpersonal continuity of care and access to care in academic family medicine centers has received little attention. The authors describe their program's methods and results to maximize continuity of care and minimize delays for care using proven principles from improvement science.

METHODS

In 2004, a diverse quality improvement team from our family medicine center joined a breakthrough collaborative with other primary care practices focused on improving appointment access and continuity of care. We followed the model for improvement with a specific aim, explicit measures, and ambitious goals. The team adapted and applied principles from a change package presented in the collaborative to improve access and continuity. We planned and performed small tests of change that were subsequently optimized and spread to the entire practice.

RESULTS

Average time to third available appointment for a routine physical improved from 22 days to 8 days. Average usual provider continuity (UPC) across all primary care physicians in the practice improved from 54% to 68%. Among resident physicians, UPC improved from 55% to 68%. These results have been sustained over 5 years.

CONCLUSIONS

Despite multiple challenges in academic teaching practices, the continuous use of improvement methods to apply proven change concepts minimizes delay for care and maximizes continuity of care. The residency continuity practice can and should be a cornerstone of residency curriculum.

Bringing Patients Into the Patient-Centered Medical Home: Lessons Learned in a Large Primary Care Practice

There is consensus that patients need to be engaged with their care, but how to do this in a primary care setting remains unclear. This case study demonstrates Patient Advisory Council engagement with the operations of a patient-centered medical home.

Tackling the triple aim in primary care residencies: the I3 POP Collaborative

BACKGROUND AND OBJECTIVES

The I3 POP Collaborative's goal is to improve care of populations served by primary care residencies in North Carolina, South Carolina, and Virginia by dramatically improving patients' experience, quality of care, and cost-effectiveness. We examine residency baseline triple aim measures, compare with national benchmarks, and identify practice characteristics associated with data reporting.

METHODS

We used a cross-sectional design, with 27 primary care residency programs caring for over 300,000 patients. Outcome measures were obtained via data pulls from electronic health records and practice management system submitted by residencies; they include quality measure sets for chronic illness and prevention, patient experience (usual provder continuity and time to third available), and utilization (emergency visits, hospitalizations, referrals, high-end radiology).

RESULTS

Thirteen practices (48%) reported all required baseline measures. We found associations between data reporting ability with registry use (59% versus 0%) and having a faculty member involved in data management (69% versus 29%). Reported measures varied widely; examples include colorectal cancer screening (median: 61%, range: 28%--80%), provider continuity (median: 52%, range: 1%--68%), subspecialty referral rate (median: 24%, range: 10%--51%). Seventy percent of patient-centered medical homes (PCMH) recognized practices had usual provider continuity (UPC) > or = collaborative median versus 0% of non-PCMH recognized practices. Median data were similar to national comparisons for chronic disease measures, lower for prevention and better for utilization.

CONCLUSIONS

Baseline triple aim data are highly variable among residencies, but residency care is comparable to available national standards. Registry use and faculty leadership in data management are critical success factors for assessing practice performance.

A majority of family physicians use a hospitalist service when their patients require inpatient care

BACKGROUND

The hospitalist movement in the United States has risen in prominence over the past 2 decades with more physicians practicing as hospitalists. Our objective was to examine different strategies used by family physicians when their patients require inpatient care.

METHODS

Secondary analysis of a cross-sectional survey of physicians accessing the American Board of Family Medicine Web site in 2011 and the 2011 Area Resource File. Logistic regression assessed for associations between using hospitalists, managing inpatients personally, or with a group partner, and then comparing and contrasting these physicians with health care market characteristics.

RESULTS

A total of 3857 physicians had data on practice characteristics and could be geocoded to their county of residence. Compared with other physicians meeting inclusion criteria in the American Board of Family Medicine database, our sample was slightly older and more likely to be female. In all, 54% of respondents reported using hospitalist services while 18% reported managing hospitalized patients themselves. Respondents more likely to use hospitalist services were female and resided in urban areas. However, one third of these physicians living in isolated rural areas reported using hospitalist services. Respondents more likely to personally manage their patients in the hospital were more likely to be male and an international medical graduate. The likelihood of using hospitalist services increased with higher availability of hospitalist services.

CONCLUSIONS

Overall, a majority of family physicians are using hospitalist services. Family physicians seem more likely to use hospitalist services when they are available which may lead to fragmentation of care.

Innovations in the education of health professionals

Dramatic and unprecedented changes in health care have altered the health care landscape and have significant implications for health professions education. This issue of the NCMJ explores these changes and highlights innovative models across the health professions that are designed to prepare graduates to practice in the emerging health care system and to deliver high-quality care in a cost-effective manner. These new educational programs--which include training for future doctors, nurses, dentists, pharmacists, and various allied health professionals--aim to prepare providers to meet the needs of North Carolina communities, and they use new educational models to give graduates the competencies they need to practice in health care teams and to contribute in other ways to improved health outcomes for the people of the state.

The role of academic health centers and their partners in reconfiguring and retooling the existing workforce to practice in a transformed health system

Inspired by the Affordable Care Act and health care payment models that reward value over volume, health care delivery systems are redefining the work of the health professionals they employ. Existing workers are taking on new roles, new types of health professionals are emerging, and the health workforce is shifting from practicing in higher-cost acute settings to lower-cost community settings, including patients' homes. The authors believe that although the pace of health system transformation has accelerated, a shortage of workers trained to function in the new models of care is hampering progress. In this Perspective, they argue that urgent attention must be paid to retraining the 18 million workers already employed in the system who will actually implement system change.Their view is shaped by work they have conducted in helping practices transform care, by extensive consultations with stakeholders attempting to understand the workforce implications of health system redesign, and by a thorough review of the peer-reviewed and gray literature. Through this work, the authors have become increasingly convinced that academic health centers (AHCs)-organizations at the forefront of innovations in health care delivery and health workforce training-are uniquely situated to proactively lead efforts to retrain the existing workforce. They recommend a set of specific actions (i.e., discovering and disseminating best practices; developing new partnerships; focusing on systems engineering approaches; planning for sustainability; and revising credentialing, accreditation, and continuing education) that AHC leaders can undertake to develop a more coherent workforce development strategy that supports practice transformation.

Natural history of practice transformation: development and initial testing of an outcomes-based model

PURPOSE

Practice transformation is the cornerstone of the future of family medicine and health care reform, but little is known about how the process occurs. We sought to develop and test a model of the natural history of practice transformation.

METHODS

We developed an outcomes-based model of how a practice moves through practice transformation in 2 phases: (1) initial model created through meetings with collaborative experts and practice facilitators, and (2) clinical and practice systems change reports examined from the first group of participating North Carolina Improving Performance In Practice practices to test and further refine the model.

RESULTS

The resultant model described motivators and supports to transformation. Three emerging practice patterns were identified with the model: transformed practices experiencing robust improvement, activated practices with moderate change, and engaged practices with minimal change in measured quality over a 2-year period. Transformed practices showed broad-based improvement; some reached a threshold and others continued to improve. These practices had highly engaged leadership and used data to drive decisions. Activated practices had a slower improvement trajectory, usually encountering a barrier that took time to overcome (eg, extracting population data, spreading practice changes). Engaged practices did not improve or were unable to sustain change; despite good intentions, multiple competing distractions interfered with practice transformation.

CONCLUSIONS

Practice transformation is a continuous and long-term process. Internal and external practice motivations and specific practice supports provided by a community-based quality improvement program appear to have an impact on engagement, rate of quality improvement, and long-term sustainability. Early successes play a key role as practices learn how to change their performance.

Competence and confidence with basic procedural skills: the experience and opinions of fourth-year medical students at a single institution

PURPOSE

Data indicate that students are unprepared to perform basic medical procedures on graduation. The authors' aim was to characterize graduating students' experience with and opinions about these skills.

METHOD

In 2011, an online survey queried 156 fourth-year medical students about their experience with, and actual and desired levels of competence for, nine procedural skills (Foley catheter insertion, nasogastric tube insertion, venipuncture, intravenous catheter insertion, arterial puncture, basic suturing, endotracheal intubation, lumbar puncture, and thoracentesis). Students self-reported competence on a four-point Likert scale (4=independently performs skill; 1=unable to perform skill). Data were analyzed by analysis of variance and Student t test. A five-point Likert scale was used to assess student confidence.

RESULTS

One hundred thirty-four (86%) students responded. Two skills were performed more than two times by over 50% of students: Foley catheter insertion and suturing. Mean level of competence ranged from 3.13±0.75 (Foley catheter insertion) to 1.7±0.7 (thoracentesis). A gap in desired versus actual level of competence existed for all procedures (P<.0001). There was a correlation between the number of times a procedure had been performed and self-reported competence for all skills except arterial puncture and suturing.

CONCLUSIONS

Participants had performed most skills infrequently and rated themselves as being unable to perform them without assistance. Strategies to improve student experience and competence of procedural skills must evolve to improve the technical competency of graduating students because their current competency varies widely.

Academic health centers and community health centers partnering to build a system of care for vulnerable patients: lessons from Carolina Health Net

Academic health centers (AHCs) are challenged to meet their core missions in a time of strain on the health care system from rising costs, an aging population, increased rates of chronic disease, and growing numbers of uninsured patients. AHCs should be leaders in developing creative solutions to these challenges and training future leaders in new models of care. The authors present a case study describing the development, implementation, and early results of Carolina Health Net, a partnership between an AHC and a community health center to manage the most vulnerable uninsured by providing access to primary care medical homes and care management systems. This partnership was formed in 2008 to help transform the delivery of health care for the uninsured. As a result, 4,400 uninsured patients have been connected to primary care services. Emergency department use by enrolled patients has decreased. Patients have begun accessing subspecialty care within the medical home. More than 2,200 uninsured patients have been assisted to enroll in Medicaid. The experience of Carolina Health Net demonstrates that developing a system of care with primary care and wrap-around services such as pharmacy and case management can improve the cost-effectiveness and quality of care, thereby helping AHCs meet their broader missions. This project can serve as a model for other AHCs looking to partner with community-based providers to improve care and control costs for underserved populations.

Medication documentation in a primary care network serving North Carolina medicaid patients: results of a cross-sectional chart review

Background

Medical records that do not accurately reflect the patient’s current medication list are an open invitation to errors and may compromise patient safety.

Methods

This cross-sectional study compares primary care provider (PCP) medication lists and pharmacy claims for 100 patients seen in 8 primary care practices and examines the association of congruence with demographic, clinical, and practice characteristics. Medication list congruence was measured as agreement of pharmacy claims with the entire PCP chart, including current medication list, visit notes, and correspondence sections.

Results

Congruence between pharmacy claims and the PCP chart was 65%. Congruence was associated with large chronic disease burden, frequent PCP visits, group practice, and patient age ≥45 years.

Conclusion

Agreement of medication lists between the PCP chart and pharmacy records is low. Medication documentation was more accurate among patients who have more chronic conditions, those who have frequent PCP visits, those whose practice has multiple providers, and those at least 45 years of age. Improved congruence among patients with multiple chronic conditions and in group practices may reflect more frequent visits and reviews by providers.

Family physician participation in maintenance of certification

PURPOSE

The American Board of Family Medicine has completed the 7-year transition of all of its diplomates into Maintenance of Certification (MOC). Participation in this voluntary process must be broad-based and balanced for MOC to have any practical national impact on health care. This study explores family physicians' geographic, demographic, and practice characteristics associated with the variations in MOC participation to examine whether MOC has potential as a viable mechanism for dissemination of information or for altering practice.

METHODS

To investigate characteristics associated with differential participation in MOC by family physicians, we performed a cross-sectional comparison of all active family physicians using descriptive and multinomial logistic regression analyses.

RESULTS

Eighty-five percent of active family physicians in this study (n = 70,323) have current board certification. Ninety-one percent of all active board-certified family physicians eligible for MOC are participating in MOC. Physicians who work in poorer neighborhoods (odds ratio [OR] = 1.105; 95% confidence interval [CI], 1.038-1.176), who are US-born or foreign-born international medical graduates (OR = 1.221; 95% CI, 1.124-1.326; OR = 1.444; 95% CI, 1.238-1.684, respectively), or who are solo practitioners (OR = 1.460; 95% CI, 1.345-1.585) are more likely to have missed initial MOC requirements than those from a large, undifferentiated reference group of certified family physicians. When age is held constant, female physicians are less likely to miss initial MOC requirements (OR = 0.849; 95% CI, 0.794-0.908). Physicians practicing in rural areas were found to be performing similarly in meeting initial MOC requirements to those in urban areas (OR = 0.966; 95% CI, 0.919-1.015, not significant).

CONCLUSION

Large numbers of family physicians are participating in MOC. The significant association between practicing in underserved areas and lapsed board certification, however, warrants more research examining causes of differential participation. The penetrance of MOC engagement shows that MOC has the potential to convey substantial practice-relevant medical information to physicians. Thus, it offers a potential channel through which to improve health care knowledge and medical practice.

Rethinking professionalism in medical education through formation

Contemporary educational approaches to professionalism do not take into account the dominant influence that the culture of academic medicine has on the nascent professional attitudes, beliefs, and behaviors of medical learners. This article examines formation as an organizing principle for professionalism in medical education. Virtue, the foundation to understanding professionalism, is the habits and dispositions that are fostered in individuals but that are embedded in learning environments. Formation, the ongoing integration of an individual, growing in self-awareness and in recognition of a life of service, with others who share in the common mission of a larger group, depicts this process. One model of formation considers a continuum from novice to more advance stages that is predicated on rules that must be applied in greater contextually shaped situations. Within medical education, formation is the process by which lives of service are created and sustained by learning communities that promote human capacities for intuition, empathy, and compassion. An imagined curriculum in formation would link the lived experiences of mentors and learners with an interdisciplinary set of didactic materials in an intentionally progressive fashion.

Infrastructure for large-scale quality-improvement projects: early lessons from North Carolina Improving Performance in Practice

INTRODUCTION

Little is known regarding how to accomplish large-scale health care improvement. Our goal is to improve the quality of chronic disease care in all primary care practices throughout North Carolina.

METHODS

Methods for improvement include (1) common quality measures and shared data system; (2) rapid cycle improvement principles; (3) quality-improvement consultants (QICs), or practice facilitators; (4) learning networks; and (5) alignment of incentives. We emphasized a community-based strategy and developing a statewide infrastructure. Results are reported from the first 2 years of the North Carolina Improving Performance in Practice (IPIP) project.

RESULTS

A coalition was formed to include professional societies, North Carolina AHEC, Community Care of North Carolina, insurers, and other organizations. Wave One started with 18 practices in 2 of 9 regions of the state. Quality-improvement consultants recruited practices. Over 80 percent of practices attended all quarterly regional meetings. In 9 months, almost all diabetes measures improved, and a bundled asthma measure improved from 33 to 58 percent. Overall, the magnitude of improvement was clinically and statistically significant (P = .001). Quality improvements were maintained on review 1 year later. Wave Two has spread to 103 practices in all 9 regions of the state, with 42 additional practices beginning the enrollment process.

DISCUSSION

Large-scale health care quality improvement is feasible, when broadly supported by statewide leadership and community infrastructure. Practice-collected data and lack of a control group are limitations of the study design. Future priorities include maintaining improved sustainability for practices and communities. Our long-term goal is to transform all 2000 primary-care practices in our state.

Community care of North Carolina: improving care through community health networks

The United States leads the world in health care costs but ranks far below many developed countries in health outcomes. Finding ways to narrow this gap remains elusive. This article describes the response of one state to establish community health networks to achieve quality, utilization, and cost objectives for the care of its Medicaid recipients. The program, known as Community Care of North Carolina, is an innovative effort organized and operated by practicing community physicians. In partnership with hospitals, health departments, and departments of social services, these community networks have improved quality and reduced cost since their inception a decade ago. The program is now saving the State of North Carolina at least $160 million annually. A description of this experience and the lessons learned from it can inform others seeking to implement effective systems of care for patients with chronic illness.

Responses to medical students' frequently asked questions about family medicine

This article provides answers to many questions medical students ask about the specialty of family medicine. It was developed through the collaborative efforts of several family medicine organizations, including the American Academy of Family Physicians, the Society of Teachers of Family Medicine, the Association of Family Medicine Residency Directors, and the Association of Departments of Family Medicine. The article discusses the benefits of primary care and family medicine, the education and training of family physicians, the scope of medical practice in the specialty, and issues related to lifestyle and medical student debt.

Shaping the future of academic health centers: the potential contributions of departments of family medicine

Academic health centers (AHCs) must change dramatically to meet the changing needs of patients and society, but how to do this remains unclear. The purpose of this supplement is to describe ways in which departments of family medicine can play leadership roles in helping AHCs evolve. This overview provides background for case studies and commentaries about the contribution of departments of family medicine in 5 areas: (1) ambulatory and primary care, (2) indigent care, (3) education in community and international settings, (4) workforce policy and practice, and (5) translational research. The common theme is a revitalization of the relationship between AHCs and the communities they serve across all missions. Family medicine leadership can provide dramatic organizational improvement in primary and ambulatory care networks and foster opportunities for leadership by AHCs in improving the health of the population. Departments of family medicine can also play a leading role in developing new partnerships with community-based organizations, managing the care of the indigent, and developing new curricula in community and international settings. Finally, family medicine departments and their faculty have a central role in helping AHCs respond to workforce needs and in developing translational research that emphasizes the health of the population and effectiveness of care. AHCs are a public good that must now evolve substantially to meet the needs of patients and society. By pushing for substantial change, by helping to reinvigorate the relationship between AHCs and the communities they serve, and by emphasizing fundamental innovation in clinical care, teaching, and research, family medicine can help lead the renewal of the AHC.