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Credit: Annals of Family Medicine
Primary Care Clinicians Report Benefits and Challenges in Using Telemedicine During COVID-19 Pandemic
Researchers interviewed primary care clinicians to identify trends, facilitators and barriers in implementing and using telemedicine technologies in response to the COVID-19 pandemic. They interviewed 25 leaders from primary care practices from the Patient-Centered Outcomes Research Institute’s PCORnet project. Leaders represented 87 primary care practices in New York, Florida, North Carolina and Georgia.
The team identified four common themes among the surveyed primary care clinicians: 1) The ease of telemedicine adoption depended on the prior experiences of both patients and physicians with virtual health platforms; 2) Regulation of telemedicine varied across states and impacted roll-out processes differently; 3) Visit triage rules remain unclear post-COVID; and 4) Positive and negative impacts of telemedicine on physicians and patients. Additionally, clinicians identified opportunities to ease challenges, including the establishment of visit triage guidelines, adequate staffing and scheduling protocols.
What We Know: The COVID-19 pandemic required rapid implementation of telemedicine in primary care. While telemedicine prevented the spread of the virus and helped optimize the workload of thinly spread medical personnel, the technology also presents challenges, including conducting physical exams, diagnostic testing and imaging. Further, equitable access to telemedicine technology is a significant challenge.
What This Study Adds: The authors identified differences in patient portal usage (which led to different revenue impacts) in various states. They also found that the rapid transition to telemedicine-only visits necessitated implementation of regulations; unclear triage rules; and that telemedicine had positive and negative impacts on providers and patients. The positives included easing access to clinical care through telemedicine for certain types of visits. On the negative side, telemedicine blurred the boundaries for clinicians, who found they worked beyond regular office hours.
The Telemedicine Experience in Primary Care Practices in the United States: Insights From Practice Leaders
Jashvant Poeran, MD, PhD, et al
Institute for Healthcare Delivery Science, Department of Population Health Science & Policy; Department of Orthopedics; Department of Medicine, all at the Icahn School of Medicine at Mount Sinai, New York, New York
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Very Low Carbohydrate Diets can Improve Blood Pressure, Blood Sugar Levels and Weight Control Compared to Diets That Only Target Hypertension
Adults with hypertension, prediabetes, or type 2 diabetes, and who are overweight or obese, are at an increased risk of serious health complications. However, experts disagree about which dietary patterns and support strategies should be recommended. Researchers randomized 94 adults with the aforementioned conditions, using a 2 x 2 diet-by-support factorial design, comparing a very low-carbohydrate (VLC) or ketogenic diet versus a Dietary Approaches to Stop Hypertension (DASH) diet. Additionally, they compared results with and without extra support activities, such as mindful eating, positive emotion regulation, social support and cooking education.
Using intent-to-treat analyses, the VLC diet led to greater improvement in estimated mean systolic blood pressure (SBP; –9.8 mmHg vs. –5.2 mmHg, P =.046), greater improvement in glycosylated hemoglobin (HbA1c; –.4 % vs. –.1 %, P = 0.034), and greater improvement in weight (–19.14 lbs vs. –10.33 lbs, P = 0.0003), compared to the DASH diet. The addition of extra support did not have a statistically significant effect on outcomes.
For adults with hypertension, prediabetes or type 2 diabetes, and are overweight or obese, a VLC diet demonstrated greater improvements in systolic blood pressure, glycemic control, and weight over a four-month period compared to a DASH diet.
What We Know: Nearly half (47%) of adults in the United States have hypertension and about half have prediabetes or type 2 diabetes. Approximately 42% of adults in the United States are also obese. These conditions can trigger stroke, end-stage renal disease, myocardial infarction and premature death. While first-line treatment for these individuals should be a diet and lifestyle intervention, experts disagree about which diet should be recommended.
What This Study Adds: For adults who are overweight or obese, have hypertension, as well as prediabetes or type 2 diabetes, a very low carbohydrate diet demonstrated greater improvements in systolic blood pressure, glycemic control, and weight over a four-month period compared to a DASH diet.
Comparing Very Low-Carbohydrate vs DASH Diets for Overweight or Obese Adults With Hypertension and Prediabetes or Type 2 Diabetes: A Randomized Trial
Laura R. Saslow, PhD, et al
Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan
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Rural Patients With Diabetes Experience Worse Health Outcomes Than Urban Patients
Mayo Clinic researchers conducted a study within their health care system to identify factors associated with quality of care among rural and urban patients with diabetes. The study evaluated patient attainment of a five-component diabetic care metric, known as the D5 metric. This metric includes no tobacco use, hemoglobin A1C <8%, blood pressure <140/90, statin use, and aspirin use. Researchers considered age, sex, race, Adjusted Clinical Group score (a series of mutually exclusive, health status categories defined by morbidity, age, and sex), insurance type, primary care clinician type, and health care use data.
Researchers analyzed records from 45,279 patients with diabetes receiving treatment from primary care providers. 54.4% of these patients lived in rural locations. 39.9% of rural patients and 43.2% of urban patients (P<0.001) met all five D5 criteria. Rural patients were significantly less likely to have attained all metric goals than urban patients (AOR 0.93 [95% CI 0.88-0.97]). Compared to patients in urban areas, rural patients had fewer outpatient visits (mean visits 3.2 vs 3.9, P<.0001) and fewer endocrinology visits (5.5% vs 9.3%, P<.0001)
Patients with an endocrinology visit during the study period were less likely to meet metric goals (0.80 [95% CI 0.73-0.86]). The reason for this could be that seriously ill patients are typically referred to endocrinologists. The number of outpatient visits was positively associated with metric goal attainment (1.03 [95% CI 1.03, 1.04]).
Researchers concluded that rural patients had worse diabetic quality outcomes than their urban counterparts, even after adjusting for other contributing factors and despite being part of the same integrated health system. The team speculated that decreased visit frequency and specialty involvement in the rural setting were possible contributing factors to this disparity.
What We Know: Type 2 diabetes is a growing national health concern in the United States, with approximately 11% of the population living with the disease. Researchers assert that it's critical to know more about the complex issues that contribute to successful treatment of diabetes and its comorbid disorders. Of the many social determinants of health that have an impact on diabetes, rurality plays a role in the higher likelihood that a person will be diagnosed with diabetes.
What This Study Adds: The researchers determined that rural patients have worse diabetic quality metrics than their urban counterparts, in spite of participating patients belonging to the same integrated health system and differences in doctors and clinic settings. Visit frequency and specialty doctor involvement are possible contributing factors to disparities although the study accounted for these differences in patient-level health usage. Authors argue that broader interventions need to be created to improve the way doctors care for patients with diabetes who live in rural settings.
Disparities in Diabetes Care: Differences Between Rural and Urban Patients Within a Large Health System
Randy Foss, MD, et al
Department of Family Medicine, Mayo Clinic Health System, Lake City, Minnesota
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Focusing on Satiety and Satiation May Aid Long-Term Weight Loss Compared to Calorie Counting Diets
Researchers hypothesized that focusing on satiety (feeling free of hunger) and satiation (feeling satisfied with a meal) through the consumption of fruits and vegetables may be better targets for weight loss success. The researchers compared the impact of two diets — Diabetes Prevention Program Calorie Counting versus MyPlate — on satiation (feeling satisfied with a meal), satiety (feeling free of hunger) and on body fat composition in primary care patients. Two hundred and sixty-one overweight, adult, low-income Latina patients, participated in the randomized control trial over a 12 month period. Over the course of the study, community health workers conducted two home education visits; two group education sessions; and seven telephone coaching calls for each participant over a six-month period. The researchers measured satiation and satiety, as well as waist circumference and body weight among participants. These measures were assessed at the beginning of the trial and again at six- and 12-month follow-up visits.
The researchers found satiation and satiety scores increased for participants on both diets. Both MyPlate and Calorie Counting participants reported higher quality of life and emotional well-being, as well as decreased waist circumference and high satisfaction with their assigned weight loss program. MyPlate participants experienced lower systolic blood pressure at a six month follow-up visit although this was not sustained over the 12-month trial period. Results suggest that the MyPlate-based intervention may be a practical alternative to the more traditional calorie counting approach.
What We Know: Approximately 42% of Americans are considered obese, according to the National Center for Health Statistics. Traditional methods of addressing obesity have been to restrict calories while reducing food intake. This has short-term efficacy.
What This Study Adds: Comparing the MyPlate and Calorie Counting interventions among an adult, low-income, mostly Latina population, researchers found that both programs increased levels of satiation and satiety among participants, as well as promoting better quality of life, emotional well-being, and program satisfaction. The simpler MyPlate diet led to weight loss and lower systolic blood pressure in the short-term although not long-term. The team recommended more research to investigate satiety-enhancing approaches for desirable weight control in diverse populations and the use of community health workers as change agents.
Randomized Comparative Effectiveness Trial of 2 Federally Recommended Strategies to Reduce Excess Body Fat in Overweight, Low-Income Patients: MyPlate.gov vs Calorie Counting
William J. McCarthy, PhD, et al
Center for Cancer Prevention & Control Research, Fielding School of Public Health and Department of Psychology, University of California-Los Angeles, Los Angeles, California
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Too Few Primary Care Doctors Address Obesity With Their Patients, Highlighting Need for Weight Loss Tool
After finding that few to no clinicians provided weight management care, researchers developed a weight loss tool called PATHWEIGH. This tool was designed to remove clinician barriers in providing patient care that addressed weight. Early success with the tool led to PATHWEIGH being implemented in the health system’s 57 primary care clinics.
Researchers describe the characteristics of patients to determine the current state of weight management efforts in 57 primary care clinics. Patients included in the analysis were 18 years and older; had a body mass index (BMI) of more than 25 kg/m2; and had had a weight-prioritized visit between March 17, 2020 and March 16, 2021. Twelve percent (n=20,383) of patients that matched these criteria during this baseline period had a weight-prioritized visit.
Overall, patients who had had a weight-prioritized visit had a mean age of 52 years (SD=16), 58% women, 76% non-Hispanic whites, 64% with commercial insurance, and a mean BMI of 37 kg/m2. Documented referral for weight-related concerns was low (<6%) and only 334 prescriptions for anti-obesity medications were noted. Even though most patients were privately insured, referral to any weight-related service or prescription of anti-obesity medication was uncommon.
What We Know: Obesity is a complex, multifactorial condition in which excess body fat may put a person at health risk. It is responsible for 4 million deaths and the loss of 120 million healthy life years due to disability each year. Primary care serves as a common setting for addressing prevention and treatment of disorders caused by obesity, such as diabetes and hypertension, and many patients note weight management as a top priority. However, evidence-based interventions shown to be effective for weight loss are not commonly delivered in the primary care context.
What This Study Adds: These results fortify the rationale for strategies to improve weight management in primary care.
Baseline Characteristics of PATHWEIGH: A Stepped-Wedge Cluster Randomized Study for Weight Management in Primary Care
Leigh Perreault, MD, et al
Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus, and Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
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Understanding Economic Barriers to Care Can Help Improve Weight Management and Population Health
Professor Denise Campbell-Scherer, MD, PhD, a member of the faculty of Medicine and Dentistry at the University of Alberta, writes this issue’s editorial about four papers focusing on addressing the challenges of obesity and diabetes on population health and well-being.
The highlighted papers provide new insights into obesity, which affects approximately 42% of people in the United States and increases the likelihood of being diagnosed with other health conditions. Two papers (Saslow et al and McCarthy et al) focus on dietary changes, which can help to control not only obesity but other conditions such as hypertension and diabetes.
One paper compared the DASH (Dietary Approaches to Stop Hypertension) diet to a very low carb diet for hypertension in patients who also had diabetes or pre-diabetes and obesity. A second paper compared the effects of the MyPlate diet that focused on fruit and vegetable consumption and a calorie counting strategy—on weight loss, blood sugar, hypertension, and diabetes, as well as feeling of satiety and satiation as a means of weight loss and management.
A third paper (Perrault et al) described clinical interventions—or lack thereof—for adult patients seen in primary care who have a BMI of 25 or higher. Among 160,000 patients, only 12 percent received a weight-prioritized visit; fewer than six percent had a weight-related referral, and only 334 were prescribed anti-obesity medications. This suggests that there is a greater need for clinical intervention addressing obesity in the primary care setting.
A fourth paper (Foss et al) analyzed the disparities in diabetes care between rural and urban patients. The study found that rural patients have worse diabetes outcome attainment than urban patients. Campbell-Scherer finds a common element across all four studies in that people who are in vulnerable circumstances such as poverty struggle with obesity management. They also don’t receive the help that can address obesity and related diseases.
“As we conduct studies on strategies to advance care for people living with obesity and diabetes, seeking to understand the contextual factors affecting diverse people in vulnerable circumstances’ access to food and care will inform interventions and implementation strategies to address the population-level impacts of these chronic diseases,” Campbell-Scherer argues.
New Insights and Future Directions: The Importance of Considering Poverty in Studies of Obesity and Diabetes
Denise Campbell-Scherer, MD, PhD
Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Artificial Intelligence Can Help Categorize and Triage Primary Care Patients With Respiratory Symptoms
Researchers from Iceland trained a machine learning model with artificial intelligence to triage patients with respiratory symptoms before the patients visit a primary care clinic. To train the machine learning model, the researchers used only questions that a patient might be asked about before a clinic visit. Information was extracted from 1,500 clinical text notes that included a physician's interpretation of the patient's symptoms and signs, as well as reasons for clinical decisions made during the consultation, such as imaging referrals and prescriptions. Patients were categorized into one of five diagnostic categories based on information in clinical notes. Patients from all primary care clinics in the capital area of Iceland were included. The model scored each patient in two extrinsic datasets and divided patients into 10 risk groups. The researchers then analyzed selected outcomes in each group.
Patients in risk groups 1-5 were younger, had lower rates of lung inflammation, were less likely to be re-evaluated in primary and emergency care, were less likely to receive antibiotic prescriptions or chest X-ray referrals, as compared to higher risk groups 6-10. The lowest five groups contained no chest X-rays with signs of pneumonia or a pneumonia diagnosis by a physician. Researchers concluded that the model can reduce the number of chest X-ray referrals by eliminating them in risk groups 1-5.
What We Know: Respiratory symptoms are common reasons people visit primary care clinicians . However, many of their symptoms are self-resolving. Researchers argue that triaging patients before physician consultations may reduce unnecessary diagnostic testing; health care costs; and overprescription of antibiotics, which can lead to greater bacterial resistance.
What This Study Adds: Researchers found that a machine learning model can effectively categorize patients among 10 risk groups, allowing clinicians to communicate with lower-risk patients in ways that don’t add to their heavy work schedule and can allow for them to care for higher-risk patients and those with severe respiratory symptoms. The team asserts that the machine learning model could reduce costs for patients, the health care system, and society.
Triaging Patients With Artificial Intelligence for Respiratory Symptoms in Primary Care to Improve Patient Outcomes: A Retrospective Diagnostic Accuracy Study
Emil L. Sigurdsson, MD, PhD, et al
Primary Health Care of the Capital Area; Development Center for Primary Health Care in Iceland, and Department of Family Medicine, University of Iceland, Reykjavík, Iceland
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Standardized Measures are Needed to Quantify EHR Workload Outside Time Scheduled With Patients
Amid an uptick in publications looking to quantify the electronic health record (EHR) workload faced by clinicians, researchers propose three recommendations to ensure the accuracy and replicability of research in this space. Their recommendations include: 1) separating all time working in the EHR outside time scheduled with patients from time working in the EHR during time scheduled with patients, 2) including any time before or after scheduled appointments as “after-hours,” and 3) encouraging the EHR vendor and research communities to develop validated methods for measuring active EHR use. Attributing all EHR work outside time scheduled with patients to Work Outside of Work (WOW), regardless of when it occurs, will produce an objective and standardized measure better suited for use in efforts to reduce burnout, set policy, and facilitate research.
The researchers argue that refining vendor-defined measures to better match the intention behind standardized “after-hours” EHR workload metrics, including WOW and WOW8 (i.e. time spent in the EHR outside of time scheduled with patients, per eight hours scheduled with patients) will improve comparative research among health systems regardless of their EHR platforms.
What We Know: Workload associated with electronic health record (EHR) documentation has contributed to increased rates of burnout among clinicians. This has been exacerbated by an increase in virtual care and the speed at which test results are released into patient portals, as well as increased portal messages. Understanding how to accurately quantify EHR workload is critical for understanding occupational stress associated with ambulatory clinic environments.
What This Study Adds: The authors argue that refining vendor-defined measures to better match the intention behind standardized “after-hours” EHR workload metrics will improve comparative research among health systems regardless of their EHR platforms and will illuminate how the work may be contributing to provider burnout.
Refining Vendor-Defined Measures to Accurately Quantify EHR Workload Outside Time Scheduled With Patients
Brian G. Arndt, MD, et al
Department of Family Medicine and Community Health, University of Wisconsin-Madison, Madison, Wisconsin
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Updated Literature Review Reinforces Link Between Care Continuity, Lower Health Care Costs and More Appropriate Care Usage
In this systematic review, the authors summarized the wide range of peer-reviewed literature that links continuity of the doctor-patient relationship to health care costs and care utilization. This information is important to establish continuity measurement in value-based payment design.
The authors conducted a literature review of articles published between 2002 and 2022 about "continuity of care" and "continuity of patient care," as well as payor-relevant outcome categories, such as cost of care, health care costs, total cost of care, utilization, ambulatory care sensitive conditions (ACSC), and ACSC hospitalizations.
The authors found interpersonal continuity between the doctor and patient continues to be significantly associated with reduced health care costs and increased appropriate care utilization across the literature. Out of 83 studies, 18 examined the association between continuity and health care costs; 79 assessed the association between continuity and utilization. Studies from 2002 through 2022 reported significantly lower costs associated with interpersonal continuity. Overall, the authors found that much of the literature found that interpersonal continuity between the doctor and patient remains significantly associated with lower health care costs and more appropriate care utilization.
What We Know: Research published from 1962 to the early 2000’s found that continuity of care was associated with decreased costs, improved health care utilization through fewer hospitalizations, and greater use of preventive services. In the 20 years since this research was published, health systems have undergone a rapid transformation including the improvement of health care data systems; adoption of the patient-centered medical home model; and growth in the number of insured patients.
What this Study Adds: The new systematic review of published medical literature reaffirms the potential power of continuity and its effects on patient care, which are important in an age of value-based payment systems that strive to reduce unnecessary health care spending and inappropriate medical usage.
The Impact of Interpersonal Continuity of Primary Care on Health Care Costs and Use: A Critical Review
Andrew Bazemore, MD, MPH, et al
The American Board of Family Medicine, Lexington, Kentucky
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Gratitude Practice Among Health Care Workers Shows Positive Effects on Well-Being, With Limitations
Researchers tested a digital version of a positive psychology intervention called “Three Good Things” (3GT) among health care workers to assess whether gratitude practice improved well-being. Two hundred and twenty-three participants—all of whom were based at a single, large academic medicine department—were randomized to an immediate intervention or delayed intervention control group. During the study, participants received text messages three times per week, prompting them to document three things for which they were grateful.
Participants completed surveys measuring levels of depression, positive affect, gratitude, and life satisfaction at the study’s launch and then one month and three months post-intervention. Control group participants completed additional measures at months four and six after completing the delayed intervention. They used linear mixed models to compare intervention and control groups and to look at the effects of department role, gender, age, and time on outcomes.
The intervention group and control group showed no significant differences in depression, gratitude, or satisfaction with life scores at months 0, 1, or 3. For depression and gratitude, scores in the intervention group were favorable immediately after the intervention but gains had been mostly lost by month 3 and were not significant. Measures of positive affect were significantly different between groups over time, particularly in the first month when the intervention group had more than a two-point jump in scores (versus 0.25 jump for the control group) that was statistically significant at the 0.05 level. However, gains had mostly disappeared by month 3. There were no differences in self-reported mental and physical health ratings between groups.
What We Know: Physicians, nurses and other health care professionals have experienced increasing rates of mental distress and burnout, which have been exacerbated by the COVID-19 pandemic. Research on high-quality interventions is limited. However, researchers hypothesized that individual interventions, such as the gratitude intervention “Three Good Things,” (3GT) may help alleviate emotional burden and improve well-being among health care professionals.
What This Study Adds: While the 3GT intervention showed initial improvement in well-being among participants directly after the intervention began, sustaining those feelings of well-being proved elusive in the longer term.
“Three Good Things” Digital Intervention Among Health Care Workers: A Randomized Controlled Trial
Katherine J. Gold, MD, MSW, MS, et al
Department of Family Medicine and Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Allowing Patients With Disabilities to Describe Their Own Clinical Experiences Can Improve Doctor Communications
Researchers looking to better understand patient experiences are turning to patient-guided tours (PGT) of health facilities, an approach drawn from the experience-based design literature. However, little research has assessed how patients with disabilities perceive the approach. In this qualitative study, 18 patients were asked to walk through the clinic as they would on a typical visit while describing their experiences. Patients’ experiences and perceptions of the tours were audiotaped and transcribed. Additionally, investigators took field notes and completed thematic content analyses.
Their findings support the value of PGT methodology in understanding the experiences of patients with disabilities in the clinic setting. Patients reported that walking through the facility elicited experiences that participants said they would not have recalled using other research methods. They also reported feeling empowered when leading investigators through the clinic space and guiding researchers to “see through their eyes.” Patient-guided tours encouraged patients to be active participants, which increased their comfort levels and sense of collaboration with the medical team. However, patient-guided tours may exclude patients who have severe disabilities.
What We Know: Researchers striving to improve patient experiences are moving away from the traditional measurements of patient satisfaction (such as surveys or focus groups) to newer strategies. Exploring patient experiences can lead to better patient-provider communication and promote a more collaborative health care approach. Implementing a patient-centered approach, however, requires system-level changes and shared decision making.
What This Study Adds: Through the use of patient-guided tours, researchers gained a greater understanding of the experiences of patients with disabilities in the clinic setting and showed that these tours are a valuable tool to measure in-clinic experiences by patients with disabilities.
Patient Guided Tours: A Patient-Centered Methodology to Understand Patient Experiences of Health Care
Sakina Walji, MD, CCFP, MPH, and June Carroll, MD, CCFP, FCFP
Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, and Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Arts and Poetry Can Make Clinical Visits and Work Environments More Meaningful and Satisfying
Family physicians Nguyen and Shapiro document their experiences incorporating arts and poetry into their practice at the University of California-Irvine’s Federally Qualified Health Center in Orange, California. Through the program, Nguyen provides short training sessions to other providers and medical assistants on how to incorporate art and literature into their interactions with patients, with ongoing training that incorporates best practices. The authors posit that patients and clinicians benefit from exposure to a poem, drawing or other art forms. Anecdotal feedback suggests that the inclusion of arts-based activities in the clinic makes patients feel welcomed and at home. Additionally, clinicians and staff experience greater job satisfaction. Having a physical and electronic collection of materials facilitates choosing the appropriate arts-based modality. According to the researchers, flexibility and creativity are key to making a patient’s visit memorable and meaningful for everyone involved.
What We Know: From a medical professional’s standpoint, working in a Federally Qualified Health Center presents many challenges, including having limited amounts of time to develop a deeper understanding of patients’ complex health issues and psychosocial needs. Patients who are served in these medical settings are also frustrated at the lack of time and bond they could possibly develop with members of their health care team.
What This Study Adds: Allowing patients and medical staff to express themself through poetry, literature and art can help patients feel welcomed and at home while clinicians and staff can experience greater job satisfaction, as well as more compassion, insight and understanding with patients.
Arts and Poetry in the Clinic: A Novel Approach to Enhancing Patient Care and Job Satisfaction
Clinical Professor Tan Q. Nguyen, MD, and Professor Emerita Johanna Shapiro, PhD Department of Family Medicine, University of California, Irvine, Orange, California.
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Former Annals of Family Medicine Editor in Chief Reflects on Publication’s 20th Anniversary
Kurt C. Stange, a family physician at Case Western Reserve University and founding editor of Annals of Family Medicine, writes an editorial in celebration of this publication’s 20th anniversary. Stange notes that at the time Annals of Family Medicine was created, those in primary care felt they should strive to prepare half of the health care workforce to provide a “basket of services'' for what was known as a “New Model of Practice.” Twenty years later, Stange encourages primary care physicians to challenge the health care system and invest in developing primary care. He argues that family physicians need to stop enabling a dysfunctional health care system that devalues their profession. He also believes family medicine should be revered for its ability to serve diverse populations; should be respected for providing care that is altruistic, humanistic and just; and that primary care physicians should be remunerated similarly to specialists. He claims that in doing whatever it takes to integrate care into a disintegrating health care system, primary care physicians are enabling and sustaining an unsustainable, unfair and ineffective system. It is a system that asks doctors to meet business goals while putting patients second―a recipe for burnout and a sense of being undervalued, he asserts. “How ironic is it that we take the most complex task in medicine―integrating, personalizing, and prioritizing care for whole people―try to cram it into 10 minutes, and pay those doing this work less than those providing narrow technical care?” Stange writes.
He suggests that his fellow family physicians focus their practice on delivering the highest quality care for a feasible number of people and to let growing demand drive needed systemic changes. Stange asserts that it is time to invest in developing primary care that serves as the foundation of an effective, sustainable, and fair health care system. Fragments of change are already occurring, he notes, with physicians who see both advantaged and disadvantaged patients; those who work in physician-led accountable care organizations; and in a new generation of primary care physicians who want to have the fairness, balance and health in their own lives that they seek for their patients.
Stange concludes that family physicians can show the kind of care that fosters health and healing through relationships with patients and communities, and can be the change they want to see.
Time for Family Medicine to Stop Enabling a Dysfunctional Health Care System
Kurt C. Stange, MD, PhD
Center for Community Health Integration, Case Western Reserve University, Cleveland, Ohio
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Family Medicine Doctor Reflects on Her Choice to Give Up Practicing Obstetrics to Focus on Her Outpatient Practice
Serena Schrager, MD, writes an essay about her decision to give up practicing obstetrics to focus on her outpatient practice. She worries about no longer practicing in a hospital setting and what that would mean for her identity as a family medicine physician. Balancing joy and stress while taking obstetrics calls had become challenging. She realized that by limiting her practice scope, it would allow her to be present with her other patients and to balance responsibilities of her own young adult children and aging parents.
“The feeling of ‘rightness’ that I experience when seeing multiple generations of a family embodies to me what family medicine is at its core,” she writes. “We are patient centered, family centered, and community centered. We see people in the context of their daily lives, not as medical problems. And that can be done no matter the setting.”
Three Thirty-Two AM: My Last Call
Sarina B. Schrager, MD
Department of Family Medicine, University of Wisconsin, Madison, Wisconsin
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Patient Teaches Family Medicine Resident the Importance of Meaningful Connections
On the heels of a recent breakup, Tanushree Nair, DO, a second-year resident in the Department of Family Medicine at the University of Chicago, writes about a serendipitous encounter on Valentine’s Day with a woman in her 80s who embraced her own messy journey to finding love. “I hadn’t expected the epitome of a successful dating life to come from someone my grandmother’s age,” Nair writes. “Despite her age, this woman had managed to unlock the door to love, while I was still struggling with the keys.”
Nair adds that she was deeply moved by her patient’s keen insight into her romantic life and that it taught Nair a vital skill in both medicine and personal relationships―the importance of being open to the unexpected.
How Can You Mend a Broken Heart?
Tanushree Nair, DO
University of Chicago Family Medicine, Chicago, Illinois
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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and The College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal’s website, www.AnnFamMed.org.
Media Contact: Adrieanna Norse
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