Diversity, Equity, and Inclusion Milestones: Creation of a Tool to Evaluate Graduate Medical Education Programs.

Background: As the Accreditation Council for Graduate Medical Education (ACGME) began to ask programs to report their efforts surrounding diversity, equity, and inclusion (DEI), program directors felt ill prepared to evaluate their programs and measure change. Objective: To develop a tool that would allow graduate medical education (GME) programs to evaluate the current state of DEI within their residencies, identify areas of need, and track progress; to evaluate feasibility of using this assessment method within family medicine training programs; and to analyze and report pilot data from implementation of these milestones within family medicine residency programs. Methods: The Association of Family Medicine Residency Directors (AFMRD) Diversity and Health Equity (DHE) Task Force developed a tool for program DEI evaluation modeled after the ACGME Milestones. These milestones focus on DEI assessment in 5 key domains: Institution, Curriculum, Evaluation, Resident Personnel, and Faculty Personnel. After finalizing a draft, a pilot implementation of the milestones was conducted by a convenience sample of 10 AFMRD DHE Task Force members for their own programs. Results: Scores varied widely across surveyed programs for all milestones. Highest average scores were seen for the Curriculum milestone (2.65) and the lowest for the Faculty Personnel milestone (2.0). Milestone assessments were completed within 10 to 40 minutes using various methods. Conclusions: The AFMRD DEI Milestones were developed for program assessment, goal setting, and tracking of progress related to DEI within residency programs. The pilot implementation showed these milestones were easily used by family medicine faculty members in diverse settings.

Teaching residents to prescribe buprenorphine for opioid use disorder: Insights from a community-based residency program.

INTRODUCTION: Despite the impact of the opioid overdose crisis on the United States, few physicians are trained to provide treatment with buprenorphine. While research has described some factors contributing to comfort in providing buprenorphine treatment, more research is needed to identify optimal strategies to produce physicians who prescribe this medication. METHODS: A community-based family medicine residency in Massachusetts sought to improve residents' comfort with prescribing buprenorphine by integrating patients treated with buprenorphine directly into resident continuity clinic panels in addition to existing mandatory didactic teaching. RESULTS: The program saw a significant increase in buprenorphine prescribing among residency graduates three years after graduation after integration of patients on buprenorphine into resident continuity panels. CONCLUSION: Efforts to further increase the number of graduates prescribing buprenorphine nationwide should emphasize supervised management of patients treated with buprenorphine during residency.

Family Medicine Residents' Experience During Early Phases of the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Residents have been thrust onto the front lines of the US medical response to COVID-19. This study aimed to quantify and describe the experiences of family medicine residents nationally during the early phases of the pandemic. Specific areas of interest included training received and the residents' personal sense of safety. The purpose of this study was to look for differences among residents based on geographic location. METHOD: This May 2020 survey was conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA) of a random sample of 5,000 resident members of the American Academy of Family Physicians (AAFP). RESULTS: The overall response rate for the survey was 5.66% (283/5,000). More than 40% of residents reported having felt in moderate to significant personal danger during the COVID-19 pandemic. Fewer than 20% had been tested for COVID-19 themselves. Among all respondents, 176 (65.7%) of the residents had provided direct patient care for COVID-19-positive patients. Most had been trained on personal protective equipment and the medical aspects of COVID-19, but 16.2% reported no training on how to care for COVID-19 patients. Minority residents, and residents in larger urban areas were less likely to receive timely training. CONCLUSIONS: The COVID-19 pandemic has had a major impact on family medicine residents' medical education and their sense of safety. Regional variations in residents' educational experiences during the pandemic exist. Training prior to COVID-19 exposure was not universal. In our sample, minority residents were less likely to receive timely training than White residents.

Interconception Care for Mothers at Well Child Visits After Implementation of the IMPLICIT Model.

INTRODUCTION: Interconception care (ICC) is recommended to reduce maternal risk factors for poor birth outcomes between pregnancies. The IMPLICIT ICC model includes screening and brief intervention for mothers at well child visits (WCVs) for smoking, depression, multivitamin use, and family planning. Prior studies demonstrate feasibility and acceptability among providers and mothers, but not whether mothers recall receipt of targeted messages. METHODS: Mothers accompanying their child at 12- and 24-month WCVs at four sites of a family medicine academic practice were surveyed pre (2012) and post (2018) ICC model implementation. Survey items assessed health history, behaviors, and report of whether their child's physician addressed maternal depression, tobacco use, family planning, and folic acid supplementation during WCVs. Pre and post results are compared using logistic regression adjusting for demographics and insurance. RESULTS: Our sample included 307 distinct mothers with 108 and 199 respondents in the pre and post periods, respectively. Mothers were more likely to report discussions with their child's doctor post-intervention for family planning (31% pre to 86% post; aOR 18.65), depression screening (63-85%; aOR 5.22), and taking a folic acid supplement (53-68%; aOR 2.54). Among mothers who smoked, the percentage that reported their child's doctor recommended cessation increased from 56 to 75% (aOR = 3.66). DISCUSSION: The IMPLICIT ICC model resulted in increased reported health care provider discussions of four key areas of interconception health by mothers attending WCVs. This model holds promise as a primary care strategy to systematically address maternal risks associated with poor pregnancy outcomes.

Financing the Fourth Year: Experiences of Required 4-Year Family Medicine Residency Programs.

The optimal length of family medicine training has been debated since the specialty's inception. Currently there are four residency programs in the United States that require 4 years of training for all residents through participation in the Accreditation Council for Graduate Medical Education Length of Training Pilot. Financing the additional year of training has been perceived as a barrier to broader dissemination of this educational innovation. Utilizing varied approaches, the family medicine residency programs at Middlesex Health, Greater Lawrence Health Center, Oregon Health and Science University, and MidMichigan Medical Center all demonstrated successful implementation of a required 4-year curricular model. Total resident complement increased in all programs, and the number of residents per class increased in half of the programs. All programs maintained or improved their contribution margins to their sponsoring institutions through additional revenue generation from sources including endowment funding, family medicine center professional fees, institutional collaborations, and Health Resources and Services Administration Teaching Health Center funding. Operating expense per resident remained stable or decreased. These findings demonstrate that extension of training in family medicine to 4 years is financially feasible, and can be funded through a variety of models.

Residency Setting Association With Resident Substance Use Disorder Training: A CERA Secondary Data Analysis.

BACKGROUND AND OBJECTIVES: As the opioid crisis worsens across the United States, the factors that impact physician training in management of substance use disorders become more relevant. A thorough understanding of these factors is necessary for family medicine residency programs to inform their own residency curricula. The objective of our study was to identify factors that correlate with increased residency training in addiction medicine across a broad sample of family medicine residencies. METHODS: We performed secondary analysis of a national family medicine residency program director survey conducted in 2015-2016 (CERA Survey PD-8). We obtained data from the Council of Academic Family Medicine Educational Research Alliance (CERA) Data Clearinghouse. We analyzed residency clinic site designation as a patient-centered medical home (PCMH), federally-qualified health center (FQHC), or both, for their correlation with faculty member possession of DEA-X buprenorphine waiver license, as well as required residency curriculum in addiction medicine. RESULTS: Residency programs situated in an FQHC were more likely to have faculty members who possessed DEA-X buprenorphine waiver licenses (P=.025). Residency clinics that were both a PCMH as well as an FQHC also correlated strongly (P=.001). Furthermore, residencies with faculty who possessed a DEA-X license were significantly more likely to have a required curriculum in addiction medicine (P=.002). CONCLUSIONS: Our quantitative secondary analysis of CERA survey data of family medicine residency program directors revealed that resident training in addiction medicine is strongly correlated with both residency clinic setting (FQHC or FQHC/PCMH) as well as residency faculty possession of DEA-X licenses.

Maternity Care Update: Prenatal Care and Specific Conditions.

Early initiation of prenatal care is associated with improved health outcomes for women and newborns. An essential element of prenatal care is determining the estimated due date, ideally using a first-trimester ultrasound. Laboratory tests should be obtained to screen for conditions that can affect pregnancy. Routine immunizations for all pregnant women include influenza vaccine; tetanus toxoid, reduced diphtheria, acellular pertussis (Tdap) vaccine. All women should be screened for gestational diabetes mellitus in midpregnancy. Women with risk factors also should be screened in the first trimester. Aspirin (ie, 60 to 150 mg/day) starting at 12 to 16 weeks reduces the risk of preeclampsia for women at high risk. Chronic medical conditions should be managed according to guidelines to promote optimal control. Women with such conditions may require testing in the late third trimester. Induction of labor may be offered to these women before 41 weeks, based on the condition and relative risks and benefits of continued pregnancy. Women without maternal or fetal indications should not be offered elective delivery before 39 weeks, but should be offered induction at 41 weeks with a recommendation for delivery before 42 weeks.

Maternity Care Update: Labor and Delivery.

Labor is defined as contractions with cervical change and active labor starts when the cervix is dilated 6 cm. Updated labor curves and definitions should be used to define labor dystocia. Oxytocin and amniotomy have important roles in the management of labor dystocia. Structured intermittent fetal monitoring should be considered for women with low-risk pregnancies but continuous electronic fetal monitoring still is used most commonly. Moderate fetal heart rate variability is the most reliable marker of fetal well-being. Epidural analgesia is used in more than half of all births in the United States. It is not associated with an increase in the rate of cesarean deliveries but is associated with a longer second stage of labor. Interventions that may reduce the need for cesarean delivery include use of the new definitions of labor dystocia, a trial of manual rotation of occiput posterior presentations, use of cervical ripening agents for induction of labor with an unfavorable cervix, and encouragement of women with previous cesarean deliveries to attempt vaginal delivery.

Maternity Care Update: Preconception Care.

Family physicians are in a unique position to ensure that women receive preconception care. The Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians recommend preconception care for all women, but particularly for women with comorbid conditions such as obesity, diabetes, and chronic hypertension. Family physicians should ask all women of reproductive age who are at risk of unintended pregnancy if they desire pregnancy within the next year and, based on this answer, provide counseling on contraception or preconception care. Given that more than half of all pregnancies in the United States are unplanned, all women of reproductive age should be prescribed at least 400 mcg/day of folic acid. They also should be counseled to modify risk factors such as smoking, alcohol use, overweight and obesity, and travel to countries where Zika virus infection is endemic. Women with significant chronic conditions should be counseled to achieve optimum control of their conditions before conception. Long-term treatment of such conditions with drugs should be reviewed and modified to prevent potentially teratogenic effects after the risks and benefits of continuing the drugs are considered.

Maternity Care Update: Postpartum Care.

Family physicians are uniquely situated to play a major role in postpartum care. Postpartum issues that should be monitored and addressed include reproductive and contraceptive planning, breastfeeding counseling and support, and maternal mental health. All women should be screened for postpartum depression using a validated tool at the postpartum visit and/or at well-child visits. Patients with positive screening results should be offered support and treatment. Women are more likely to breastfeed if they are provided with breastfeeding support and counseling routinely during the prenatal and postpartum periods. All women should be asked about their reproductive life plans, counseled about potential risks associated with short and prolonged interpregnancy intervals, and offered contraception.

Characteristics of Graduating Family Medicine Residents Who Intend to Practice Maternity Care.

BACKGROUND AND OBJECTIVES: Prior research found that 24% of graduating family medicine residents intend to provide obstetrical deliveries, but only 9% of family physicians 1 to 10 years into practice are doing so. Our study aims to describe the individual and residency program characteristics associated with intention to provide obstetrical deliveries and prenatal care. METHODS: Cross-sectional data on 2014-2016 graduating residents were obtained from the American Board of Family Medicine certification examination demographic questionnaire that asked about intended provision of specific clinical activities. A hierarchical model accounting for clustering within residency programs was used to determine associations between intended provision of maternity care with individual and residency program characteristics. RESULTS: Of 9,541 graduating residents, 22.7% intended to provide deliveries and 51.2% intended to provide prenatal care. Individual characteristics associated with a higher likelihood of providing deliveries included female gender, graduation from an allopathic medical school, and participation in a loan repayment program. Residency characteristics included geographic location in the Midwest or West region, training at a federally qualified health center (FQHC)-based clinic, funding as a teaching health center (THC), more months of required maternity care rotations, larger residency class size, and maternity care fellowship at residency. CONCLUSIONS: Our findings suggest that increasing the proportion of graduating family medicine residents who intend to provide maternity care may be associated with increased exposure to maternity care training, more family medicine training programs in FQHCs and THCs, and expanded loan repayment programs.

Association of Group Prenatal Care in US Family Medicine Residencies With Maternity Care Practice: A CERA Secondary Data Analysis.

BACKGROUND AND OBJECTIVES: Group prenatal care has been shown to improve both maternal and neonatal outcomes. With increasing adaption of group prenatal care by family medicine residencies, this model may serve as a potential method to increase exposure to and interest in maternity care among trainees. This study aims to describe the penetration, regional and program variations, and potential impacts on future maternity care practice of group prenatal care in US family medicine residencies. METHODS: The CAFM Educational Research Alliance (CERA) conducted a survey of all US family medicine residency program directors in 2013 containing questions about maternity care training. A secondary data analysis was completed to examine relevant data on group prenatal care in US family medicine residencies and maternity care practice patterns. RESULTS: 23.1% of family medicine residency programs report provision of group prenatal care. Programs with group prenatal care reported increased number of vaginal deliveries per resident. Controlling for average number of vaginal deliveries per resident, programs with group prenatal care had a 2.35 higher odds of having more than 10% of graduates practice obstetrics and a 2.93 higher odds of having at least one graduate in the past 5 years enter an obstetrics fellowship. CONCLUSIONS: Residency programs with group prenatal care models report more graduates entering OB fellowships and practicing maternity care. Implementing group prenatal care in residency training can be one method in a multifaceted approach to increasing maternity care practice among US family physicians.

Interconception Care for Mothers During Well-Child Visits With Family Physicians: An IMPLICIT Network Study.

PURPOSE: Interconception care (ICC) is recommended to improve birth outcomes by targeting maternal risk factors, but little is known about its implementation. We evaluated the frequency and nature of ICC delivered to mothers at well-child visits and maternal receptivity to these practices. METHODS: We surveyed a convenience sample of mothers accompanying their child to well-child visits at family medicine academic practices in the IMPLICIT (Interventions to Minimize Preterm and Low Birth Weight Infants Through Continuous Improvement Techniques) Network. Health history, behaviors, and the frequency of the child's physician addressing maternal depression, tobacco use, family planning, and folic acid supplementation were assessed, along with maternal receptivity to advice. RESULTS: Three-quarters of the 658 respondents shared a medical home with their child. Overall, 17% of respondents reported a previous preterm birth, 19% reported a history of depression, 25% were smoking, 26% were not using contraception, and 58% were not taking folic acid. Regarding advice, 80% of mothers who smoked were counseled to quit, 59% reported depression screening, 71% discussed contraception, and 44% discussed folic acid. Screening for depression and family planning was more likely when the mother and child shared a medical home (P <.05). Most mothers, nearly 95%, were willing to accept health advice from their child's physician regardless of whether a medical home was shared (P >.05). CONCLUSIONS: Family physicians provide key elements of ICC at well-child visits, and mothers are highly receptive to advice from their child's physician even if they receive primary care elsewhere. Routine integration of ICC at these visits may provide an opportunity to reduce maternal risk factors for adverse subsequent birth outcomes.

Evaluation of a group prenatal care-based curriculum in a family medicine residency.

BACKGROUND: There is a growing trend within family medicine residency training programs to implement group prenatal care programs. While the clinical benefits of group prenatal care have been well documented, there have been no published studies to date evaluating the educational impact of using group prenatal care in residency training programs. METHODS: A retrospective cohort study of both patient care performance and outcome measures over a 4-year time span in a pre- and post-intervention design in a single family medicine training program was used. RESULTS: A total of 184 women were cared for by residents educated under the old curriculum, and 195 women were cared for under the new curriculum. Patients cared for by residents under the new curriculum had significantly fewer cesarean sections compared to patients cared for under the old curriculum (17.53% versus 26.92%) and also trended toward having a lower rate of preterm births (4.15% versus 8.33%) that reached significance when controlled for parity and insurance status. CONCLUSIONS: The ultimate measure of how well we train our residents is how well they care for their patients. Our evaluation of teaching residents maternity care through group prenatal visits and the IMPLICIT quality improvement initiative found that we improved not only several processes of care outcomes but most importantly the key maternity care outcomes of cesarean section and preterm birth rates.

Effect of a weight-based prescribing method within an electronic health record on prescribing errors.

PURPOSE: The effect of a weight-based prescribing method within the electronic health record (EHR) on the rate of prescribing errors was studied. METHODS: A report was generated listing all patients who received a prescription by a clinic provider for either infants' or children's acetaminophen or ibuprofen from January 1 to July 28, 2005 (preintervention group) and from July 29 to December 30, 2005 (postintervention group). Patients were included if they were 12 years old or younger, had a prescription ordered for infants' or children's acetaminophen or ibuprofen within the EHR, and had a weight documented in the chart on the visit day. The dosing range for acetaminophen was 10-15 mg/kg every four to six hours as needed, and the regimen for ibuprofen was 5-10 mg/kg every six to eight hours as needed. Dosing errors were defined as overdosage of strength, overdosage of regimen, underdosage of strength, under-dosage of regimen, and incomprehensible dosing directions. RESULTS: Totals of 316 and 224 patient visits were analyzed from the preintervention and postintervention groups, respectively. Significantly more medication errors were found in the preintervention group than in the postintervention group (103 versus 46, p = 0.002). Significantly fewer strength overdosing errors occurred in the postintervention group (8.9% versus 4.0%, p = 0.028). CONCLUSION: An automated weight-based dosing calculator integrated into an EHR system in the outpatient setting significantly reduced medication prescribing errors for antipyretics prescribed to pediatric patients. This effect appeared to be strongest for reducing overdose errors.