Factors affecting Family Physician follow-up 30 days post-discharge from a Canadian Academic Emergency Department

Close outpatient follow-up of patients discharged from the emergency department (ED) has been associated with improved antimicrobial stewardship, medication compliance, and decreased mortality. Despite these clear benefits, studies have shown most patients do not receive follow-up from specialists or Family Physicians (FP). While age, race and insurance status may be factors in Australia and the United States, there remains a paucity of Canadian studies investigating potential factors that influence follow-up. This retrospective cohort study aimed to elucidate factors associated with Family Physician follow up within 30 days at two urban, academic Family Medicine clinics. Our study included patients aged 18 or older who have an academic Family Physician and visited a London Health Sciences Centre ED between January 1, 2021 and June 1, 2021. A binary logistic regression was used to determine if a specific patient or provider factor was associated with follow-up. Of the 367 cases that met criteria, 220 (60%) patients received Family Physician follow-up within 30 days. Additionally, 51 patients (23%) received specialist follow-up within 30 days. A higher number of medications (OR 1.12 p=0.003) and a Family Physician appointment within the 90 days preceding the ED visit (OR 2.51, p<0.001) were significantly predictive of Family Physician follow-up. The use of a Family Physician referral form, documented discharge instructions, and increasing comorbidity (as documented by the Charlson Comorbidity Index) were not associated with a higher odds of follow-up. These data suggest that patients on numerous medications may require close follow-up for monitoring, dose adjustments, and reassessment. Additionally, those patients with recent Family Physician visits may have stronger relationships with their provider, increasing their likelihood of follow-up. Based on this study, there is insufficient evidence to suggest that documented discharge instructions nor the use of a FP referral form impact the rate of follow-up. Future work should focus on an optimal mechanism to ensure Family Physician follow-up, when required, in urban centres. The impact of mental health and substance use disorders on the rate of follow-up should also be evaluated.

Changes in Provider Perceptions and Practices Regarding Dosing Units for Oral Liquid Medications

OBJECTIVE

A 2015 survey of primary care providers (PCPs) found that while many believed that milliliter (mL)-only dosing was safest for oral liquid medications, few would use mL alone in dosing instructions. Since 2015, many recommendations have promoted "mL-only" dosing. In 2019, a follow-up survey was conducted to assess if PCP perceptions and practices have changed.

METHODS

Pediatricians, family medicine physicians, nurse practitioners, and internists participating in the 2015 and 2019 DocStyles cross-sectional, web-based surveys were asked about their perceptions and practices regarding dosing units for oral liquid medications.

RESULTS

In 2019, among 1392 respondents, the proportion of PCPs who reported they believed using mL-only is the safest dosing instruction ranged from 55.1% of internists to 80.8% of pediatricians. While fewer PCPs believed patients/caregivers prefer dosing instructions in mL-only (23.9% of nurse practitioners to 48.4% of pediatricians), more held this belief in 2019 compared to 2015; pediatricians had the greatest absolute increase (+14.4%) and family medicine physicians had the smallest increase (+1.3%). While 61.6% of pediatricians reported they would use mL-only dosing, only 36.0% of internists, 36.6% of nurse practitioners, and 42.5% of family medicine physicians reported they would do so. After controlling for age, gender, region, and specialty, 2019 PCP survey participants were more likely to report that they would use mL-only dosing compared to 2015 participants (adjusted odds ratio 1.51, 95% confidence interval 1.29-1.77).

CONCLUSIONS

Broader educational efforts may be necessary to reach nonpediatricians, to encourage prescribing and communication with patients/caregivers using mL-only dosing.

The impact of hypertension follow-up management on the choices of signing up family doctor contract services: does socioeconomic status matter?

BACKGROUND

This study aimed to explore the association between hypertension follow-up management and family doctor contract services, as well as to examine whether socioeconomic status (SES) had an interaction effect on this relationship among older adults in China.

METHODS

We used data from the sixth National Health Service Survey of Shandong Province, China, including 3,112 older adults (age ≥ 60 years) with hypertension in 2018. Logistic regression models and a margins plot were used to analyze the role of SES in the relationship between hypertension follow-up management and family doctor contract services.

RESULTS

The regular hypertension follow-up management rate and family doctor contracting rate were 81.8% and 70.9%, respectively, among older adults with hypertension. We found that participants with regular hypertension follow-up management were more likely to sign family doctor contract services (OR=1.28, 95%CI: 1.04, 1.58, P=0.018). The interaction effect occurred in the groups who lived in rural areas (OR=1.55, 95%CI: 1.02, 2.35), with high education level (OR=0.53, 95%CI: 0.32, 0.88) and had high incomes (OR=0.53, 95%CI: 0.35, 0.81).

CONCLUSIONS

Our findings suggested that regular hypertension follow-up management was associated with family doctor contract services and SES influenced this relationship. Primary health care should improve the contracting rate of family doctors by strengthening follow-up management of chronic diseases. Family doctors should focus on improving services quality and enriching the content of service packages especially for older adults with higher income and education level.

Factors associated with plans for early retirement among Ontario family physicians during the COVID-19 pandemic: a cross-sectional study

BACKGROUND

Higher numbers of family physicians (FPs) stopped practicing or retired during the COVID-19 pandemic, worsening the family doctor shortage in Canada. Our study objective was to determine which factors were associated with FPs' plans to retire earlier during the COVID-19 pandemic.

METHODS

We administered two cross-sectional online surveys to Ontario FPs asking whether they were "planning to retire earlier" as a result of the pandemic during the first and third COVID-19 pandemic waves (Apr-Jun 2020 and Mar-Jul 2021). We used logistic regression to determine which factors were associated with early retirement planning, adjusting for age.

RESULTS

The age-adjusted proportion of FP respondents planning to retire earlier was 8.2% (of 393) in the first-wave and 20.5% (of 454) in the third-wave. Planning for earlier retirement during the third-wave was associated with age over 50 years (50-59 years odds ratio (OR) 5.37 (95% confidence interval (CI):2.33-12.31), 60 years and above OR 4.18 (95% CI: 1.90-10.23)), having difficulty handling increased non-clinical responsibilities (OR 2.95 (95% CI: 1.79-4.94)), feeling unsupported to work virtually (OR 1.96 (95% CI: 1.19-3.23)) or in-person (OR 2.70 (95% CI: 1.67-4.55)), feeling unable to provide good care (OR 1.82 (95% CI: 1.10-3.03)), feeling work was not valued (OR 1.92 (95% CI: 1.15-3.23)), feeling frightened of dealing with COVID-19 (OR 2.01 (95% CI: 1.19-3.38)), caring for an elderly relative (OR 2.36 (95% CI: 1.69-3.97)), having difficulty obtaining personal protective equipment (OR 2.00 (95% CI: 1.16-3.43)) or difficulty implementing infection control practices in clinic (OR 2.10 (95% CI: 1.12-3.89)).

CONCLUSIONS

Over 20% of Ontario FP respondents were considering retiring earlier by the third-wave of the COVID-19 pandemic. Supporting FPs in their clinical and non-clinical roles, such that they feel able to provide good care and that their work is valued, reducing non-clinical (e.g., administrative) responsibilities, dealing with pandemic-related fears, and supporting infection control practices and personal protective equipment acquisition in clinic, particularly in those aged 50 years or older may help increase family physician retention during future pandemics.

Approaches to locum physician recruitment and retention: a systematic review

A robust workforce of locum tenens (LT) physicians is imperative for health service stability. A systematic review was conducted to synthesize current evidence on the strategies used to facilitate the recruitment and retention of LT physicians. English articles up to October 2023 across five databases were sourced. Original studies focusing on recruitment and retention of LT's were included. An inductive content analysis was performed to identify strategies used to facilitate LT recruitment and retention. A separate grey literature review was conducted from June-July 2023. 12 studies were retained. Over half (58%) of studies were conducted in North America. Main strategies for facilitating LT recruitment and retention included financial incentives (83%), education and career factors (67%), personal facilitators (67%), clinical support and mentorship (33%), and familial considerations (25%). Identified subthemes were desire for flexible contracts (58%), increased income (33%), practice scouting (33%), and transitional employment needs (33%). Most (67%) studies reported deterrents to locum work, with professional isolation (42%) as the primary deterrent-related subtheme. Grey literature suggested national physician licensure could enhance license portability, thereby increasing the mobility of physicians across regions. Organizations employ five main LT recruitment facilitators and operationalize these in a variety of ways. Though these may be incumbent on local resources, the effectiveness of these approaches has not been evaluated. Consequently, future research should assess LT the efficacy of recruitment and retention facilitators. Notably, the majority of identified LT deterrents may be mitigated by modifying contextual factors such as improved onboarding practices.

Barriers to research in family medicine-interviews with Portuguese family physician researchers

BACKGROUND

There is a need for a deeper understanding of the barriers to research in family medicine (FM) and to consider the perceptions and perspectives of professionals. Our study aims to provide a strategic view for research capacity building in FM. We included the perspective of family physician researchers (FPR) on the existing barriers to investigation in this context.

OBJECTIVES

To understand and characterize the barriers to research in FM (personal and structural), from the perspective of Portuguese family physicians who are researchers.

METHODS

A qualitative study, of phenomenological nature, was performed, through the conduction of semi-structured interviews with FPR, from 2019 to 2022. Data analysis and thematic coding were done on MAxQDA®, with inductive and deductive approaches, until data saturation was reached.

RESULTS

A total of 12 family physicians/researchers were interviewed. Seven main themes were identified as barriers to research: time, professional valorization, funding, ethics committees, infrastructure, management/institutions, and participants. Each theme is divided into subthemes that make it possible to assess how a barrier can affect researchers in performing research activities.

CONCLUSION

Our study highlights the identification of 7 main barriers. Structuring them into sub-themes not only improved the organization of our results but also provided robust support for the next phase, namely the application of a survey with the aim of gaining a deeper insight into the repercussions that these barriers to FPR have at a national level. This research is crucial to laying the foundations for a policy document that offers well-defined and tailored recommendations to address the barriers we have uncovered.

Storylines of family medicine III: core principles-primary care, systems and family

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'III: core principles-primary care, systems, and family', authors address the following themes: 'Continuity of care-building therapeutic relationships over time', 'Comprehensiveness-combining breadth and depth of scope', 'Coordination of care-managing multiple realities', 'Access to care-intersectional, systemic, and personal', 'Systems theory-a core value in patient-centered care', 'Family-oriented practice-supporting patients' health and well-being', 'Family physician as family member' and 'Family in the exam room'. May readers develop new understandings from these essays.

Storylines of family medicine IV: perspectives on practice-lenses of appreciation

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'IV: perspectives on practice-lenses of appreciation', authors address the following themes: 'Relational connections in the doctor-patient partnership', 'Feminism and family medicine', 'Positive family medicine', 'Mindful practice', 'The new, old ethics of family medicine', 'Public health, prevention and populations', 'Information mastery in family medicine' and 'Clinical courage.' May readers nurture their curiosity through these essays.

Storylines of family medicine VIII: clinical approaches

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VIII: clinical approaches', authors address the following themes: 'Evaluation, diagnosis and management I-toward a working diagnosis', 'Evaluation, diagnosis and management II-process steps', 'Interweaving integrative medicine and family medicine', 'Halfway-the art of clinical judgment', 'Seamless integration in family medicine-team-based care', 'Technology-uncovering stories from noise' and 'Caring for patients with multiple long-term conditions'. May readers recognise in these essays the uniqueness of a family medicine approach to care.

Storylines of family medicine VII: family medicine across the lifespan

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VII: family medicine across the lifespan', authors address the following themes: 'Family medicine maternity care', 'Seeing children as patients brings joy to work', 'Family medicine and the care of adolescents', 'Reproductive healthcare across the lifespan', 'Men's health', 'Care of older adults', and 'Being with dying'. May readers appreciate the range of family medicine in these essays.

Storylines of family medicine V: ways of thinking-honing the therapeutic self

Storylines of Family Medicine is a 12-part series of thematically linked essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'V: ways of thinking-honing the therapeutic self', authors present the following sections: 'Reflective practice in action', 'The doctor as drug-Balint groups', 'Cultivating compassion', 'Towards a humanistic approach to doctoring', 'Intimacy in family medicine', 'The many faces of suffering', 'Transcending suffering' and 'The power of listening to stories.' May readers feel a deeper sense of their own therapeutic agency by reflecting on these essays.

Storylines of family medicine II: foundational building blocks-context, community and health

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'II: foundational building blocks-context, community and health', authors address the following themes: 'Context-grounding family medicine in time, place and being', 'Recentring community', 'Community-oriented primary care', 'Embeddedness in practice', 'The meaning of health', 'Disease, illness and sickness-core concepts', 'The biopsychosocial model', 'The biopsychosocial approach' and 'Family medicine as social medicine.' May readers grasp new implications for medical education and practice in these essays.

Storylines of family medicine XI: professional identity formation-nurturing one's own story

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XI: professional identity formation-nurturing one's own story', authors address the following themes: 'The social construction of professional identity', 'On becoming a family physician', 'What's on the test?-professionalism for family physicians', 'The ugly doc-ling', 'Teachers-the essence of who we are', 'Family medicine research-it starts in the clinic', 'Socially accountability in medical education', 'Personal philosophy and how to find it' and 'Teaching and learning with Storylines of Family Medicine'. May these essays encourage readers to find their own creative spark in medicine.

Storylines of family medicine IX: people and places-diverse populations and locations of care

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'IX: people and places-diverse populations and locations of care', authors address the following themes: 'LGBTQIA+health in family medicine', 'A family medicine approach to substance use disorders', 'Shameless medicine for people experiencing homelessness', '''Difficult" encounters-finding the person behind the patient', 'Attending to patients with medically unexplained symptoms', 'Making house calls and home visits', 'Family physicians in the procedure room', 'Robust rural family medicine' and 'Full-spectrum family medicine'. May readers appreciate the breadth of family medicine in these essays.

Storylines of family medicine VI: ways of being-in the office with patients

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VI: ways of being-in the office with patients', authors address the following themes: 'Patient-centred care-cultivating deep listening skills', 'Doctor as witness', 'Words matter', 'Understanding others-metaphor and its use in medicine', 'Communicating with patients-making good use of time', 'The patient-centred medical home-aspirations for the future', 'Routine, ceremony or drama?' and 'The life course'. May readers better appreciate the nuances of patient care through these essays.

Storylines of family medicine XII: family medicine and the healthcare system

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XII: Family medicine and the future of the healthcare system', authors address the following themes: 'Leadership in family medicine', 'Becoming an academic family physician', 'Advocare-our call to act', 'The paradox of primary care and three simple rules', 'The quadruple aim-melding the patient and the health system', 'Fit-for-purpose medical workforce', 'Universal healthcare-coverage for all', 'The futures of family medicine' and 'The 100th essay.' May readers of these essays feel empowered to be part of family medicine's exciting future.

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

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'X: standing up for diversity, equity and inclusion', authors address the following themes: 'The power of diversity-why inclusivity is essential to equity in healthcare', 'Medical education for whom?', 'Growing a diverse and inclusive workforce', 'Therapeutic judo-an inclusive approach to patient care', 'Global family medicine-seeing the world "upside down"', 'The inverse care law', 'Social determinants of health as a lens for care', 'Why family physicians should care about human rights' and 'Toward health equity-the opportunome'. May the essays that follow inspire readers to promote change.

Storylines of family medicine I: framing family medicine - history, values and perspectives

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'I: framing family medicine-history, values, and perspectives', the authors address the following themes: 'Notes on Storylines of Family Medicine', 'Family medicine-the generalist specialty', 'Family medicine's achievements-a glass half full assessment', 'Family medicine's next 50 years-toward filling our glasses', 'Four enduring truths of family medicine', 'Names matter', 'Family medicine at its core' and 'The ecology of medical care.' May readers find much food for thought in these essays.

Can family doctor system improve health service utilization for patients with hypertension and diabetes in China? A difference-in-differences study

BACKGROUND

Family doctors, serving as gatekeepers, are the core of primary health care to meet basic health needs, provide accessible care, and improve attainable health. The study objective was to evaluate the impact of the family doctor system on health service utilization among patients with hypertension and diabetes in China.

METHODS

Difference-in-Differences (DID) models are constructed to estimate the net effect of the family doctor system, based on the official health management records and medical insurance claim data of patients with hypertension and diabetes in an eastern city of China.

RESULTS

The family doctor system significantly increases follow-up visits (hypertension patients coef. = 0.13, diabetes patients coef. = 0.08, both p < 0.001) and outpatient visits (hypertension patients coef. = 0.08, diabetes patients coef. = 0.05, both p < 0.001) among the contracted compared to the non-contracted. The proportion of outpatient visits in community health centers among the contracted significantly rose (hypertension patients coef. = 0.02, diabetes patients coef. = 0.04, both p < 0.001) due to significantly more outpatient visits in community health centers and fewer in secondary and tertiary hospitals. It also significantly mitigates the increase in inpatient admissions among hypertension patients but not among diabetes patients.

CONCLUSIONS

The examined family doctor system strengthens primary care, both by increasing follow-up visits and outpatient visits and promoting a rationalized structure of outpatient utilization in China.

Characteristics of primary care practices by proportion of patients unvaccinated against SARS-CoV-2: a cross-sectional cohort study

BACKGROUND

Variations in primary care practices may explain some differences in health outcomes during the COVID-19 pandemic. We sought to evaluate the characteristics of primary care practices by the proportion of patients unvaccinated against SARS-CoV-2.

METHODS

We conducted a population-based, cross-sectional cohort study using linked administrative data sets in Ontario, Canada. We calculated the percentage of patients unvaccinated against SARS-CoV-2 enrolled with each comprehensive-care family physician, ranked physicians according to the proportion of patients unvaccinated, and identified physicians in the top 10% (v. the other 90%). We compared characteristics of family physicians and their patients in these 2 groups using standardized differences.

RESULTS

We analyzed 9060 family physicians with 10 837 909 enrolled patients. Family physicians with the largest proportion (top 10%) of unvaccinated patients (n = 906) were more likely to be male, to have trained outside of Canada, to be older, and to work in an enhanced fee-for-service model than those in the remaining 90%. Vaccine coverage (≥ 2 doses of SARS-CoV-2 vaccine) was 74% among patients of physicians with the largest proportion of unvaccinated patients, compared with 87% in the remaining patient population. Patients in the top 10% group tended to be younger and live in areas with higher levels of ethnic diversity and immigration and lower incomes.

INTERPRETATION

Primary care practices with the largest proportion of patients unvaccinated against SARS-CoV-2 served marginalized communities and were less likely to use team-based care models. These findings can guide resource planning and help tailor interventions to integrate public health priorities within primary care practices.

Barriers and facilitators of the reporting by family doctors of cases of domestic violence - a qualitative study across Portugal

BACKGROUND

Domestic violence (DV) is a serious and prevalent public health problem with devastating consequences for the victims and their families. Whilst the number of cases reported to the authorities has risen in recent years, many victims still chose not to present a complaint. In Portugal, to address this, DV became a public crime. As victims of DV present multiple health problems and frequently seek professional help, family doctors are in a privileged position to detect and report cases of DV to the authorities. However, little is known about what motivates these professionals to report or not the DV cases they encounter in their practice to the authorities.

METHODS

We conducted semi-structured interviews with family doctors from all regional health administrations of continental Portugal. Interviews occurred between July 2020 and September 2022, were conducted in person or remotely, audio recorded, transcribed, and analysed using thematic analysis. Content analysis was conducted to assess the agreement or disagreement regarding mandatory reporting in each of the themes and subthemes.

RESULTS

Fifty-four family doctors took part in this study (n = 39 women, n = 15 men). The main themes that arose from the analysis were: "Barriers related to the physician's activity," "Barriers related to the victim or aggressor," "Facilitators related to the physician's activity," "Facilitators related to the victim or aggressor." Although different barriers were described, most doctors agreed with the mandatory reporting of DV cases.

CONCLUSIONS

Family doctors encounter multiple barriers and facilitators when considering reporting a DV case to the authorities. The results of this study can help develop new interventions to address the barriers described by the doctors, increasing their compliance with mandatory reporting, the protection of victims and the just persecution of the aggressor.

Barriers and facilitators for family physicians prescribing opioid agonist therapy in Saskatchewan

OBJECTIVE

To explore barriers and facilitators for family physicians in Saskatchewan prescribing opioid agonist therapy (OAT).

DESIGN

Self-administered postal survey.

SETTING

Family medicine practices in Saskatchewan.

PARTICIPANTS

A total of 218 Saskatchewan family physicians who were not authorized to prescribe OAT as of June 2022.

MAIN OUTCOME MEASURES

Descriptive and inferential statistics of physicians' self-reported barriers to and facilitators of prescribing OAT for opioid use disorder (OUD).

RESULTS

Most respondents (84.8%) had some comfort with diagnosing OUD. However, more than half (58.3%) did not feel confident or knowledgeable about prescribing OAT. Barriers to OAT prescribing included lack of time, incomplete training requirements, lack of interest, insufficient funding or support, feeling overwhelmed, and perceiving that OAT does not work and thus is not necessary. Physicians working in core neighbourhoods and those receiving fee-for-service compensation reported the least available time to prescribe OAT. Conversely, physicians working in interdisciplinary team settings had increased time for OAT prescribing compared with physicians in other settings. Having a close personal relationship with someone with OUD was correlated with increased comfort in diagnosing OUD as well as with knowledge about and confidence in prescribing OAT. Themes identified as facilitators to increasing OAT prescribing included the addition of resources and supports, increased training, more awareness about OUD and OAT, enhanced compensation, and altered prescribing regulations.

CONCLUSION

Despite the presence of several real and perceived barriers limiting OAT prescribing by Saskatchewan family physicians, there are family physicians interested in providing this therapy. Increased clinical resources and support, including increased interdisciplinary practice, are actionable steps that should be considered by policy decision makers to address this issue. Additionally, increased OUD and OAT education, which includes the perspectives of those with lived experience of OUD, would help address physician confidence, knowledge, and awareness in this area.

Factors that influence scope-of-practice decisions of early-career family physicians: Focus group study in Canada

OBJECTIVE

To explore perceptions of early-career family physicians on the personal, educational, organizational, community, and system factors that had influenced their scope-of-practice decisions and to compare the similarities and differences among these factors across all 13 Canadian jurisdictions.

DESIGN

Qualitative descriptive study.

SETTING

Canada.

PARTICIPANTS

Fifty-nine early-career family physicians who were 2 to 5 years into independent practice.

METHODS

Data were collected using focus groups and were analyzed using deductive and inductive analysis techniques to identify patterns in the data within and across jurisdictions.

MAIN FINDINGS

Participants across all jurisdictions highlighted that personal factors (ie, interest, work-life balance and family life, financial considerations, and self-perceived competence and confidence) were most influential on scope-of-practice decisions. Educational (ie, exposure during training, mentorship), organizational (ie, collegial support), community (ie, needs), and system (ie, payment models, funding for team-based care, governance) factors also influenced decisions about scope of practice. Experiences were similar across all jurisdictions for personal factors. Differences in experiences were reported across jurisdictions for educational, organizational, community, and system factors.

CONCLUSION

Decisions about scope of practice by early-career family physicians are highly influenced by personal factors followed by organizational, educational, community, and system factors. These findings suggest numerous strategies are needed to increase individuals' interest in providing comprehensive care in Canada. Educators should cultivate interest in comprehensive care among learners, strategically recruit trainees, provide targeted exposure and experiences, ensure competence and confidence are evaluated throughout and at the end of training, and introduce formal mentorship programs. Policy-makers should invest in the spread of effective team models and alternative payment models. Together, these strategies could broaden the scopes of practice of family physicians and their capacity to deliver accessible and comprehensive care to Canadians.

The views of family physicians on National Health Insurance in Gauteng Province, South Africa

BACKGROUND

 Universal health coverage (UHC) improves national health outcomes while addressing social inequalities in access to quality healthcare services. The district health system (DHS) is critical to the success of UHC in South Africa through the National Health Insurance (NHI) scheme. Family physicians (FPs), as champions of primary care, are central to the DHS operation and implementation of NHI.

METHODS

 This was a qualitative exploratory study that used semi-structured interviews to explore FPs views and engagement on NHI policy and implementation in their districts. Ten FPs were included through purposive sampling.

RESULTS

 Most of the FPs interviewed were not engaged in either policy formulation or strategic planning. The NHI bill was seen as a theoretical ideology that lacked any clear plan. Family physicians expressed several concerns around corruption in governmental structures that could play out in NHI implementation. Family physicians felt unsupported within their district structures and disempowered to engage in rollout strategies. The FPs were able to provide useful solutions to health system challenges because of the design of their training programmes, as well as their experience at the primary care level.

CONCLUSION

 Healthcare governance in South Africa remains located in national and provincial structures. Devolution of governance to the DHS is required if NHI implementation is to succeed. The FPs need to be engaged in NHI strategies, to translate plans into actionable objectives at the primary care level.Contribution: This study highlights the need to involve FPs as key actors in implementing NHI strategies at a decentralised DHS governance level.

Racial Inequities in Female Family Physicians Providing Women's Health Procedures

Patient-physician race concordant dyads have been shown to improve patient outcomes; the race and ethnicity of family physicians providing women's health procedures has not been described. Using self-reported data, this analysis highlights the racial disparities in scope of practice; underrepresented in medicine (URiM) females are less likely to perform women's health procedures which may lead to disparities in care received by minority women.

Investigating the Effect of Weather Events on Primary Care Clinicians Across the United States

BACKGROUND

When we consider weather impacts, we mainly consider how the event affects the person, not the clinicians treating them. There is a paucity of studies discussing the effect of weather on the clinicians and the care of their patients.

METHODS

A survey covering weather effects was distributed to American Academy of Family Physicians National Research Network (AAFP NRN) members in August 2020. Descriptive statistics and Fisher's exact tests were completed on the survey responses. Postsurvey interviews were conducted with selected respondents about specific weather events.

RESULTS

Survey respondents were US physicians (88.7%) and 84.9% indicated more than 1 type of event has affected their practice. Respondents were most affected by snow/snowstorm (81.1%) and indicated they had to close for the day or longer and staff were unable to make it into clinic (79.2%). Respondents indicated respiratory (94.5%), mental health (81.8%), and musculoskeletal conditions (50.9%) were most affected by weather. Interviews with selected respondents covered weather topics including winter, summer, and flooding.

DISCUSSION

Survey respondents/interviewees indicated weather affects them in a variety of ways including issues with patients' conditions and practice effects. Clinicians have noticed a change to their areas' weather over the years, but, generally, warming is occurring.

Variation in Practice Patterns of Early- and Later-Career Family Physicians

INTRODUCTION

Understanding how physicians' practice patterns change over a career is important for workforce and medical education planning. This study examined trends in self-reported practice activity among early- and later-career stage family physicians (FPs).

METHODS

Data on early career FPs came from the American Board of Family Medicine's National Graduate Survey (NGS) and on later career FPs from its Continuous Certification Questionnaire (CCQ). Both cohorts could complete the Practice Demographic Survey (PDS) 3 years later. Longitudinal cohorts were from 2016 to 2019 and 2017 to 2020, respectively. All surveys included identical items on scope of practice, practice type, organization, and location. We characterized physicians as outpatient continuity only, outpatient and inpatient care (mixed practice), and no outpatient continuity (for example, hospitalist). We conducted repeated cross-sectional and longitudinal analysis of practice type.

RESULTS

Our sample included 8,492 NGS and 30,491 CCQ FPs. In both groups, the vast majority provided outpatient continuity of care (77% to 81%). Approximately 25% of NGS had a mixed practice compared with approximately 16% of the CCQ group. The percent of FPs who had a mixed practice declined in both groups (34.21% to 27.10% and 23.88% to 19.33%). In both groups, physicians with higher odds of leaving mixed practice were in metropolitan counties or changed practice types.

CONCLUSION

Although early-career FPs more frequently reported providing both inpatient and outpatient care and serving as hospitalists compared with later-career FPs, both groups had a decline in frequency of providing mixed practice. This change after only 3 years in practice has significant implications for patient care and medical education.

Why patients self-refer to the emergency service for nonurgency?: A mix-method survey from a family medicine perspective

The definition of "nonurgent emergency service visits" is visits to conditions for medical conditions that require attention but are not life-threatening immediately or severe enough to require urgent intervention. This study aims to investigate the reasons why patients choose to self-refer to the emergency service (ES) instead of their primary care health center for nonurgent complaints. The study was carried out in a tertiary hospital. The survey consisted of 2 parts with sociodemographic questions, knowledge of their family physician, and the reason why it has been applied to the ES with multiple choice answers. Of the 325 patients, the mean age was 34.5 years and 54.2% were women. Also, 26 of the patients were reported as "urgent" by the doctor. The main reasons underlying self-referred patients were classified into 4 themes: "urgency" (13.8%), advantages of ES (12.9%); disadvantages of primary care (25.1%), and other (45.9%). The most common reason patients self-refer to the ES was their belief in "being urgent" (61%). In this study, 26.8%, (n = 84) of the patients are not happy with their family physicians, while only 13.2% (N = 43) prioritize the ES advantages.

Family physicians' preferences for education to support family caregivers: a sequential mixed methods study

BACKGROUND

One in four Canadians is a family caregiver. Family caregivers (carers, care-partners) are relatives or chosen family, friends, or neighbors who provide 75 to 90% of the care for people with physical or mental illness, disabilities, or frailty living in community homes and assist with 15 to 30% of the care in congregate care. However, a recent (2022) Statistics Canada population health study reports 44% of family caregivers are distressed. Family physicians and primary care teams are well-positioned to support family caregivers; yet, family caregiver needs assessments tend to be ad hoc and their most common needs remain unmet. Research recommends training healthcare professionals to enhance their knowledge and skills to support family caregivers.

METHODS

The objective of this sequential mixed methods research, a survey followed by qualitative interviews, was to explore family physicians' desire and preferences for education about supporting family caregivers. 85 family physicians completed the online survey and eight took part in the interviews. Results from the survey and interviews were compared, contrasted, and interpreted together.

RESULTS

Primary care physicians expressed a desire to be better equipped to assess and support FCGs' needs. Even though most physicians (61%) were very/confident about addressing family caregivers' needs, 72% were highly/interested in education to support family caregivers of their patients. Topics with the most interest were assessing family caregivers needs in an organized way, assisting family caregivers to access resources, and address system and practice barriers to support family caregivers. The overarching theme running through the interviews was physicians hope for education to help change the patient-focused culture to inclusion of FCGs. The three themes reflect physicians' conviction about including family caregivers in patient care: We need to take care of their caregivers, Practice and system barriers thwart including family caregivers, and Practical education might help.

CONCLUSIONS

This study of family physicians' preferences for education to support family caregivers will inform the development of education about supporting family caregivers for family physicians and trainees.

"Family doctors are also people": a qualitative analysis of how family physicians managed competing personal and professional responsibilities during the COVID-19 pandemic

BACKGROUND

Family physicians (FPs) fill an essential role in public health emergencies yet have frequently been neglected in pandemic response plans. This exclusion harms FPs in their clinical roles and has unintended consequences in the management of concurrent personal responsibilities, many of which were amplified by the pandemic. The objective of our study was to explore the experiences of FPs during the first year of the COVID-19 pandemic to better understand how they managed their competing professional and personal priorities.

METHODS

We conducted semi-structured interviews with FPs from four Canadian regions between October 2020 and June 2021. Employing a maximum variation sampling approach, we recruited participants until we achieved saturation. Interviews explored FPs' personal and professional roles and responsibilities during the pandemic, the facilitators and barriers that they encountered, and any gender-related experiences. Transcribed interviews were thematically analysed.

RESULTS

We interviewed 68 FPs during the pandemic and identified four overarching themes in participants' discussion of their personal experiences: personal caregiving responsibilities, COVID-19 risk navigation to protect family members, personal health concerns, and available and desired personal supports for FPs to manage their competing responsibilities. While FPs expressed a variety of ways in which their personal experiences made their professional responsibilities more complicated, rarely did that affect the extent to which they participated in the pandemic response.

CONCLUSIONS

For FPs to contribute fully to a pandemic response, they must be factored into pandemic plans. Failure to appreciate their unique role and circumstances often leaves FPs feeling unsupported in both their professional and personal lives. Comprehensive planning in anticipation of future pandemics must consider FPs' varied responsibilities, health concerns, and necessary precautions. Having adequate personal and practice supports in place will facilitate the essential role of FPs in responding to a pandemic crisis while continuing to support their patients' primary care needs.

Evaluation of FamMed essentials: a blended-learning program for capacity building of general practitioners in Pakistan

BACKGROUND

To provide access to primary care and universal health coverage, Pakistan requires 60,000 trained family physicians by 2030. At present, most primary care is provided by general practitioners (GPs) who do not have any post-graduate training. Empowering GPs through competency-based programs, that strengthen their knowledge and skills, may be a cost-effective strategy for improving healthcare quality. We describe the development and evaluation of FamMed Essentials, a modular, blended-learning program to improve clinical knowledge and skills of GPs.

METHODS

This is a mixed method study. We used the CIPP (content, input, process and product) framework for course development and evaluation. We describe the steps used in content development, strategies for teaching and assessments, and evaluation of strengths and weaknesses of the program. In depth focus group discussions were conducted to gather insight on participants' and faculty's perceptions regarding the program's effectiveness.

RESULTS

Of the 137 participants who have completed the program, 72% were women and 49% had been practicing for more than five years. We saw a significant improvement in knowledge across all modules (p = < 0.001) and perceived confidence in clinical skills (p = < 0.001). An objective assessment showed participants' competence in patient management. Participants reported a high level of satisfaction (4.4 ± 0.83 on a 5-point Likert Scale). Focus group discussions revealed a positive impact on clinical practice. Flexibility and use of different teaching and learning strategies were additional strengths. In addition, participants reported an interest in further training. Power outages were highlighted as a major challenge.

CONCLUSION

In resource-constrained health systems, a modular, blended-learning, competency-based program is helpful to upgrade GPs knowledge without impacting their busy schedules. Accreditation of such programs and provision of a career trajectory for the trained GPs are pivotal to expansion of such initiatives.

Current Procedural Practices of Family Medicine Teaching Physicians

BACKGROUND AND OBJECTIVES

Proficiency in procedural care achieved during residency is a major driver of family physician scope of practice. To date, no inventory exists of the advanced procedures and clinical skills performed by teaching family physicians. This study comprises the first such survey and assesses the attitude of respondents toward the importance of family physicians performing procedures.

METHODS

We sent a clinical skills inventory to a convenience sample of teaching family physicians employed at 18 medical school-affiliated, community, and military residency programs across the United States.

RESULTS

The overall response rate was 46% (N=337). Respondents performed a median of 12 advanced procedures and clinical skills (IQR: 8-18). Endorsed procedures ranged from skin biopsy (n=316, 93.8%) and joint injection (n=279, 82.8%) to colonoscopy (n=21, 6.2%) and cesarean delivery (n=23, 6.8%), and reported skills ranged from medication-assisted treatment (n=181, 53.7%) to highly active antiretrovial therapy (n=35, 10.4%). Gender and career stage were associated with statistically significant differences in endorsement of specific procedures. For example, fracture management was more likely to be performed by late- versus early-career faculty (54.1% vs 24.2%, P<.001) and by male versus female respondents (54.9% vs 24.2%, P<.001). Most respondents (84.3%) agreed that future family physicians should learn procedures and advanced clinical skills.

CONCLUSIONS

Family medicine teaching faculty perform a wide array of procedures and advanced skills. Apparent differences by career stage and gender identity in the performance of some of the procedural and skill areas may portend a shift in the procedural training of future family physicians.

[Diabetes and women, why are we different?]

Diabetes affects men and women differently and the mistaken assumption of equality in its clinical expression can lead to errors and delays in the diagnostic process and the therapeutic strategy adopted. The objective is to show the gender differences that influence the approach to this pathology and what the role of the family doctor is in the monitoring of women with diabetes. It is a review of the impact of diabetes at different stages of a woman's life, how hormonal changes affect glycemic control, gestational diabetes, how diabetes affects the development of chronic complications in women and their consequences, the existing differences in the control of cardiovascular risk factors and the differential aspects by sex of the different families of drugs used in the treatment of diabetes.

Prevalence and Predictors of Burnout Among Resident Family Physicians

BACKGROUND AND OBJECTIVES

Resident burnout may affect career choices and empathy. We examined predictors of burnout among family medicine residents.

METHODS

We used data from the 2019-2021 American Board of Family Medicine Initial Certification Questionnaire, which is required of graduating residents. Burnout was a binary variable defined as reporting callousness or emotional exhaustion once a week or more. We evaluated associations using bivariate and multilevel multivariable regression analyses.

RESULTS

Among 11,570 residents, 36.4% (n=4,211) reported burnout. This prevalence did not significantly vary from 2019 to 2021 and was not significantly attributable to the residency program (ICC=0.07). Residents identifying as female reported higher rates of burnout (39.0% vs 33.4%, AOR=1.29 [95% CI 1.19-1.40]). Residents reporting Asian race (30.5%, AOR=0.78 [95% CI 0.70-0.86]) and Black race (32.3%, AOR=0.71 [95% CI 0.60-0.86]) reported lower odds of burnout than residents reporting White race (39.2%). We observed lower rates among international medical graduates (26.7% vs 40.3%, AOR=0.54 [95% CI 0.48-0.60]), those planning to provide outpatient continuity care (36.0% vs 38.7%, AOR=0.77 [95% CI 0.68-0.86]), and those at smaller programs (31.7% for <6 residents per class vs 36.3% for 6-10 per class vs 40.2% for >10 per class). Educational debt greater than $250,000 was associated with higher odds of burnout than no debt (AOR=1.29 [95% CI 1.15-1.45]).

CONCLUSIONS

More than one-third of recent family medicine residents reported burnout. Odds of burnout varied significantly with resident and program characteristics.

Joe's Story: How a Capitated Payment Model Lets Me Be the Physician I Want to Be

For many years I cared for Joe, following him through diagnoses of strokes, end-stage renal disease, and metastatic prostate cancer. Gaining his trust, coordinating his care across specialist visits and hospitalizations, and helping him and his family clarify goals of care took an investment of time and relationship-building. I was able to spend this time with Joe, and all of my medically complex patients, because I had taken a job in a Program of All-Inclusive Care for the Elderly (PACE), a fully capitated model of care. With care organized around the patient instead of the visit, this payment model transformed my work life. As I reflect on the care that I provided for Joe over the years, I consider how health care organization and finance can either help or hinder our ability to provide patient-centered, coordinated, continuous care for our patients. Evolving payment models can help make space for family physicians to provide the robust primary care we are trained to deliver.

The Associations Between United States Medical Licensing Examination Performance and Outcomes of Patient Care

PURPOSE

The United States Medical Licensing Examination (USMLE) comprises a series of assessments required for the licensure of U.S. MD-trained graduates as well as those who are trained internationally. Demonstration of a relationship between these examinations and outcomes of care is desirable for a process seeking to provide patients with safe and effective health care.

METHOD

This was a retrospective cohort study of 196,881 hospitalizations in Pennsylvania over a 3-year period (January 1, 2017 to December 31, 2019) for 5 primary diagnoses: heart failure, acute myocardial infarction, stroke, pneumonia, or chronic obstructive pulmonary disease. The 1,765 attending physicians for these hospitalizations self-identified as family physicians or general internists. A converted score based on USMLE Step 1, Step 2 Clinical Knowledge, and Step 3 scores was available, and the outcome measures were in-hospital mortality and log length of stay (LOS). The research team controlled for characteristics of patients, hospitals, and physicians.

RESULTS

For in-hospital mortality, the adjusted odds ratio was 0.94 (95% confidence interval [CI] = 0.90, 0.99; P < .02). Each standard deviation increase in the converted score was associated with a 5.51% reduction in the odds of in-hospital mortality. For log LOS, the adjusted estimate was 0.99 (95% CI = 0.98, 0.99; P < .001). Each standard deviation increase in the converted score was associated with a 1.34% reduction in log LOS.

CONCLUSIONS

Better provider USMLE performance was associated with lower in-hospital mortality and shorter log LOS for patients, although the magnitude of the latter is unlikely to be of practical significance. These findings add to the body of evidence that examines the validity of the USMLE licensure program.

Skills Training for Family Medicine Residents to Attenuate the Impact of Childhood Trauma: A Pilot Study

BACKGROUND AND OBJECTIVES

Toxic stress and trauma are prevalent in the pediatric population. The sequela can be significant, leading to disruptive behaviors in early childhood to chronic medical conditions in adulthood. Two factors that can mitigate negative outcomes of developmental traumatic stress include relational health care and healthy parental relationships. Family physicians are poised to play a significant role in both attenuating factors. Therefore, focused pediatric trauma-informed knowledge and skills training for family medicine residents is important.

METHODS

One family medicine residency program added a training module for residents, with two objectives: increase in-exam room trauma-informed interaction skills, and increase knowledge and skills for physicians to coach parents on strengthening the parent-child relationship. The training included didactics and skills training. Knowledge and skills were measured pre- and posttraining.

RESULTS

A total of 39 residents participated in the study over 3 years. The knowledge score increased by 4.49 points from pre- to posttraining. The number of trauma-informed interactional skills the residents demonstrated at posttraining had increased significantly. During the pilot, all participants moved from below mastery of skills to full mastery.

CONCLUSIONS

After being instructed in best practices in trauma-informed pediatric interactions, residents demonstrated an increased number of behaviors that cultivate pediatric relational health care. Residents demonstrated knowledge and skills gains that denoted their ability to interact with patients and coach parents in evidence-based ways that can mitigate the impact of childhood trauma exposure.

Quality, Accuracy, and Bias in ChatGPT-Based Summarization of Medical Abstracts

PURPOSE

Worldwide clinical knowledge is expanding rapidly, but physicians have sparse time to review scientific literature. Large language models (eg, Chat Generative Pretrained Transformer [ChatGPT]), might help summarize and prioritize research articles to review. However, large language models sometimes "hallucinate" incorrect information.

METHODS

We evaluated ChatGPT's ability to summarize 140 peer-reviewed abstracts from 14 journals. Physicians rated the quality, accuracy, and bias of the ChatGPT summaries. We also compared human ratings of relevance to various areas of medicine to ChatGPT relevance ratings.

RESULTS

ChatGPT produced summaries that were 70% shorter (mean abstract length of 2,438 characters decreased to 739 characters). Summaries were nevertheless rated as high quality (median score 90, interquartile range [IQR] 87.0-92.5; scale 0-100), high accuracy (median 92.5, IQR 89.0-95.0), and low bias (median 0, IQR 0-7.5). Serious inaccuracies and hallucinations were uncommon. Classification of the relevance of entire journals to various fields of medicine closely mirrored physician classifications (nonlinear standard error of the regression [SER] 8.6 on a scale of 0-100). However, relevance classification for individual articles was much more modest (SER 22.3).

CONCLUSIONS

Summaries generated by ChatGPT were 70% shorter than mean abstract length and were characterized by high quality, high accuracy, and low bias. Conversely, ChatGPT had modest ability to classify the relevance of articles to medical specialties. We suggest that ChatGPT can help family physicians accelerate review of the scientific literature and have developed software (pyJournalWatch) to support this application. Life-critical medical decisions should remain based on full, critical, and thoughtful evaluation of the full text of research articles in context with clinical guidelines.

Comparing the implementation of advanced access strategies among primary health care providers

The advanced access (AA) model is among the most recommended innovations for improving timely access in primary health care (PHC). Originally developed for physicians, it is now relevant to evaluate the model's implementation in more interprofessional practices. We compared AA implementation among family physicians, nurse practitioners, and nurses. A cross-sectional online open survey was completed by 514 PHC providers working in 35 university-affiliated clinics. Family physicians delegated tasks to other professionals in the team more often than nurse practitioners (p = .001) and nurses (p < .001). They also left a smaller proportion of their schedules open for urgent patient needs than did nurse practitioners (p = .015) and nurses (p < .001). Nurses created more alternatives to in-person visits than family physicians (p < .001) and coordinated health and social services more than family physicians (p = .003). During periods of absence, physicians referred patients to walk-in services for urgent needs significantly more often than nurses (p = .003), whereas nurses planned replacements between colleagues more often than physicians (p <.001). The variations among provider categories indicate that a one-size-fits-all implementation of AA principles is not recommended.

How family physicians introduce palliative care to patients with chronic illnesses

OBJECTIVE

Increasing numbers of Canadians living with complex, life-limiting conditions demand high-quality palliative care. Timely access to palliative care can help to reduce stress, improve quality of life, and provide relief for patients and their families. The purpose of this study is to explore the experiences of family physicians (FPs) regarding the decision and process of introducing palliative care to patients with chronic diseases.

METHODS

Interpretive description methodology was used to guide the investigation of the research question. Thirteen Calgary Zone FPs participated in individual interviews. Data was collected iteratively and analyzed using constant comparative analysis.

RESULTS

Analysis of interviews identified the overarching themes of dignity and empowerment, which describe the experience of FPs introducing palliative care to chronically ill patients. Four subthemes were woven throughout, including the art of conversation, therapeutic relationships, timing, and preparation of the patient and family.

DISCUSSION

While the benefits of palliative conversations are widely accepted, a deeper understanding of how FPs can be supported in developing this aspect of their practice is needed. Understanding their experience provides knowledge that can serve as a framework for future education, mentorship, and competency development.

Artificial intelligence for family medicine research in Canada: current state and future directions: Report of the CFPC AI Working Group

OBJECTIVE

To understand the current landscape of artificial intelligence (AI) for family medicine (FM) research in Canada, identify how the College of Family Physicians of Canada (CFPC) could support near-term positive progress in this field, and strengthen the community working in this field.

COMPOSITION OF THE COMMITTEE

Members of a scientific planning committee provided guidance alongside members of a CFPC staff advisory committee, led by the CFPC-AMS TechForward Fellow and including CFPC, FM, and AI leaders.

METHODS

This initiative included 2 projects. First, an environmental scan of published and gray literature on AI for FM produced between 2018 and 2022 was completed. Second, an invitational round table held in April 2022 brought together AI and FM experts and leaders to discuss priorities and to create a strategy for the future.

REPORT

The environmental scan identified research related to 5 major domains of application in FM (preventive care and risk profiling, physician decision support, operational efficiencies, patient self-management, and population health). Although there had been little testing or evaluation of AI-based tools in practice settings, progress since previous reviews has been made in engaging stakeholders to identify key considerations about AI for FM and opportunities in the field. The round-table discussions further emphasized barriers to and facilitators of high-quality research; they also indicated that while there is immense potential for AI to benefit FM practice, the current research trajectory needs to change, and greater support is needed to achieve these expected benefits and to avoid harm.

CONCLUSION

Ten candidate action items that the CFPC could adopt to support near-term positive progress in the field were identified, some of which an AI working group has begun pursuing. Candidate action items are roughly divided into avenues where the CFPC is well-suited to take a leadership role in tackling priority issues in AI for FM research and specific activities or initiatives the CFPC could complete. Strong FM leadership is needed to advance AI research that will contribute to positive transformation in FM.

Small Independent Primary Care Practices Serving Socially Vulnerable Urban Populations

PURPOSE

This mixed methods study sought to describe the extent to which family physicians in urban communities serve socially vulnerable patients and to better understand their practices, their challenges, and the structural supports that could facilitate their patient care.

METHODS

We conducted a quantitative analysis of questionnaire data from 100% of US physicians recertifying for family medicine from 2017 to 2020. We conducted qualitative analysis of in-depth interviews with 22 physician owners of urban, small, independent practices who reported that the majority of their patients were socially vulnerable.

RESULTS

In 2020, in urban areas across the United States, 19.3% of family physicians served in independent practices with 1 to 5 clinicians, down from 22.6% in 2017. Nearly one-half of these physicians reported that >10% of their patients were socially vulnerable. Interviews with 22 physicians who reported that the majority of their patients were socially vulnerable revealed 5 themes: (1) substantial time spent addressing access issues and social determinants of health, (2) minimal support from health care entities, such as independent practice associations and health plans, and insufficient connection to community-based organizations, (3) myriad financial challenges, (4) serious concerns about the future, and (5) deep personal commitment to serving socially vulnerable patients in independent practice.

CONCLUSIONS

Small independent practices serving vulnerable patients in urban communities are surviving because deeply committed physicians are making personal sacrifices. Health equity-focused policies could decrease the burden on these physicians and bolster independent practices so that socially vulnerable patients continue to have options when seeking primary care.

Mastering your fellowship: Part 3, 2024

The series 'Mastering your Fellowship' provides examples of the question formats encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series aims to help family medicine registrars (and supervisors) prepare for this examination.

"Technology has allowed us to do a lot more but it's not necessarily the panacea for everybody": Family physician perspectives on virtual care during the COVID-19 pandemic and beyond

INTRODUCTION

Early in the COVID-19 pandemic, Canadian primary care practices rapidly adapted to provide care virtually. Most family physicians lacked prior training or expertise with virtual care. In the absence of formal guidance, they made individual decisions about in-person versus remote care based on clinical judgement, their longitudinal relationships with patients, and personal risk assessments. Our objective was to explore Canadian family physicians' perspectives on the strengths and limitations of virtual care implementation for their patient populations during the COVID-19 pandemic and implications for the integration of virtual care into broader primary care practice.

METHODS

We conducted semi-structured qualitative interviews with family physicians working in four Canadian jurisdictions (Vancouver Coastal health region, British Columbia; Southwestern Ontario; the province of Nova Scotia; and Eastern Health region, Newfoundland and Labrador). We analyzed interview data using a structured applied thematic approach.

RESULTS

We interviewed 68 family physicians and identified four distinct themes during our analysis related to experiences with and perspectives on virtual care: (1) changes in access to primary care; (2) quality and efficacy of care provided virtually; (3) patient and provider comfort with virtual modalities; and (4) necessary supports for virtual care moving forward.

CONCLUSIONS

The move to virtual care enhanced access to care for select patients and was helpful for family physicians to better manage their panels. However, virtual care also created access challenges for some patients (e.g., people who are underhoused or living in areas without good phone or internet access) and for some types of care (e.g., care that required access to medical devices). Family physicians are optimistic about the ongoing integration of virtual care into broader primary care delivery, but guidance, regulations, and infrastructure investments are needed to ensure equitable access and to maximize quality of care.

Impact of COVID-19 on antibiotic usage in primary care: a retrospective analysis

The COVID-19 pandemic has contributed to many changes in the medical practice, including a wider access to tele-consultations. It not only influenced the type of treatment but also shed light on mistakes often made by doctors, such as the abuse of antibiotics. This study aimed to evaluate the antibiotic treatment, and the impact of the COVID-19 pandemic on antibiotic prescribing during a GP's visit. The retrospective medical history analysis involved data from a first-contact medical center (Pantamed, Olsztyn, Poland), from 1 January 2018 to 31 May 2023. Quantities of prescribed antibiotics were assessed and converted into the so-called active list for a given working day of adult patients (> 18 years of age). Statistical analysis based on collective data was performed. During the COVID-19 pandemic, a decline in the number of medical consultations has been observed, both remotely via tele-medicine and in personal appointments, compared to the data from before the pandemic: n = 95,251 versus n = 79,619. Also, during the COVID-19 pandemic, there was a decrease in the total amount of prescribed antibiotics relative to the data before the pandemic (2.44 vs. 4.54; p > 0.001). The decrease in the quantities of prescribed antibiotics did not depend on the way doctor consultations were provided. The COVID-19 pandemic has contributed to changing the family doctors' management of respiratory infections. The ability to identify the etiological agent-the SARS-COV2 virus-contributed to the reduction of the antibiotics use.

Towards a Regulatory Framework for Workflow Improvement in Electronic Medical Records

Physicians have to complete several time-consuming and burnout-inducing tasks in their EMRs for everyday care of patients. Poor workflow design generates increased effort for physicians. In this study, we measure time doctors take to retrieve and review information in the patient chart at the beginning of a visit; one of approximately 12 tasks a doctor must do in the EMR during the visit. Information retrieval takes approximately 40 minutes per day. Automation could save 75% of that time. We estimate that if every family doctor in Canada could save 30 minutes through automation of just this one process, we could free up time equivalent to >3000 physicians and >5 million patients; enough to absorb the vast majority of patients who currently do not have a doctor. We know of no more powerful intervention than workflow automation in Canadian EMRs to increase the supply of doctors while simultaneously reducing a major cause of burnout. We recommend an accelerated research program to identify additional opportunities for workflow automation and a regulatory program to ensure that every physician has access to workflow automation in their EMR.

Self-care interventions to assist family physicians with mental health care of older patients during the COVID-19 pandemic: Feasibility, acceptability, and outcomes of a pilot randomized controlled trial

BACKGROUND

The COVID-19 pandemic has required family physicians to rapidly address increasing mental health problems with limited resources. Vulnerable home-based seniors with chronic physical conditions and commonly undermanaged symptoms of anxiety and depression were recruited in this pilot study to compare two brief self-care intervention strategies for the management of symptoms of depression and/or anxiety.

METHODS

We conducted a pilot RCT to compare two tele-health strategies to address mental health symptoms either with 1) validated CBT self-care tools plus up to three telephone calls from a trained lay coach vs. 2) the CBT self-guided tools alone. The interventions were abbreviated from those previously trialed by our team, to enable their completion in 2 months. Objectives were to assess the feasibility of delivering the interventions during a pandemic (recruitment and retention); and assess the comparative acceptability of the interventions across the two groups (satisfaction and tool use); and estimate preliminary comparative effectiveness of the interventions on severity of depression and anxiety symptoms. Because we were interested in whether the interventions were acceptable to a wide range of older adults, no mental health screening for eligibility was performed.

RESULTS

90 eligible patients were randomized. 93% of study completers consulted the self-care tools and 84% of those in the coached arm received at least some coaching support. Satisfaction scores were high among participants in both groups. No difference in depression and anxiety outcomes between the coached and non-coached participants was observed, but coaching was found to have a significant effect on participants' use and perceived helpfulness of the tools.

CONCLUSION

Both interventions were feasible and acceptable to patients. Trained lay coaching increased patients' engagement with the tools. Self-care tools offer a low cost and acceptable remote activity that can be targeted to those with immediate needs. While effectiveness results were inconclusive, this may be due to the lack of eligibility screening for mental health symptoms, abbreviated toolkit, and fewer coaching sessions than those used in our previous effective interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT0460937.