The Effect of Patient-Physician Concordance on Perinatal Care: The Family Physicians' Perspective.

Demographic concordance between patients and clinicians has been associated with better outcomes. The current perinatal care workforce is not adequately diverse to allow for patient-clinician concordance. In this mixed-methods study, we aimed to understand family physicians' perception of the impact of patient-clinician concordance on perinatal care. The predominantly (91%) non-Hispanic White sample of 1,505 family physicians (FPs) perceived gender and language concordance to affect perinatal care more than racial or ethnic concordance. Religious concordance is not perceived to greatly affect perinatal care. Nearly half (721) of the respondents chose to leave a free-text comment on the impact of concordance on perinatal care. Four categories emerged (patients, physicians, the patient-physician relationship, and potential ways to mitigate the impact of discordance). Based on the perceptions of FPs experienced in perinatal care, intentionally supporting continuity of care between patients and clinicians may help to mitigate the negative impact of discordance on perinatal outcomes.

Utilizing Community Procedure Clinics to Enhance Resident Procedural Education.

Introduction: Procedure training in family medicine residency is important for future full-spectrum practice. Some residency programs have cited difficulty providing adequate procedure education. Residency collaboration with nonfaculty attending physicians working at community nonresidency clinics may help programs increase resident exposure to procedures. We assessed the feasibility of such an educational model by establishing recurring procedure clinics in a nonresidency family medicine site supervised by nonfaculty physicians. Methods: Twice monthly, half-day procedure clinics were conducted at a community site, where family medicine residents were supervised by nonfaculty community family physicians. After participation, we surveyed residents about their perceptions of the clinics. Using retrospective chart review, we determined quantity and type of procedures performed. Results: Fifteen residents participated in 21 procedure clinics, featuring 18 procedure types and 268 procedures. Skin lesion excision, nail removal, punch and shave procedures, joint injection, newborn circumcision, and implantable contraception management were most consistently performed. Residents rated clinics highly and were satisfied with procedure number and variety, opportunity to learn new procedures and techniques, and feedback received. Over 80% of residents noted experiences in procedures that were less commonly encountered in their residency. Conclusion: Procedure clinics at a nonresidency site hosted by nonfaculty attending physicians provided additional training in a variety of primary care procedures. The clinics were favorable to residents and may help programs address training gaps.

Retaining the perinatal care workforce: Lessons learned from experienced physicians who no longer attend deliveries.

OBJECTIVE: To inform policy supporting the retention of family physicians (FPs) in the perinatal care workforce by identifying physician characteristics that are associated with retention. DATA SOURCES AND STUDY SETTING: We surveyed FPs who had been in practice for at least 11 years and reported attending deliveries as part of their practice. STUDY DESIGN: We compared the characteristics of FPs who continue to provide perinatal care to those who have ceased and explored their reasons for no longer attending deliveries. DATA COLLECTION/EXTRACTION METHODS: We estimated a probit regression with the dependent variable: whether the physician currently delivers babies. Open-ended survey responses were analyzed and close-coded using a conceptual content analysis approach. PRINCIPLE FINDINGS: Of the FPs who received a survey, 1505 (37%) responded. Those who continue attending deliveries were more likely to receive a stipend or be paid per hour/shift in addition to their salary versus those paid a salary (percentage point difference = 13), and less likely to work part-time versus full-time (percentage point difference = -20). Those who ceased attending deliveries cite lifestyle (n = 208), call structure (n = 113), and delivery volume (n = 89) among the reasons for doing so. CONCLUSIONS: Evidence-based policies aimed at preventing attrition from the perinatal care workforce, which might include targeting compensation models and work-life balance.

Folie À Trois: A Case of Shared Delusions Between a Patient, Her Sister, and Another Patient in the In-Patient Psychiatric Unit.

Folie à deux is a rare condition in which a single person (often with a psychiatric disorder) develops a delusion that is shared by another person. Folie à troix is when a delusion is shared by three people. This case report documents the unusual case of an individual who shared delusions with two different people simultaneously. This report inspires questions about this person, her delusions, and what made them so believable to others. It is known that the development of shared delusions most commonly occurs in relative isolation and disproportionately affects individuals with preexisting psychiatric comorbidities. Because of these risk factors, delusions in a psychiatric unit may be even more "contagious" than in the general population. To our knowledge, this case report is the first to document a newly developed delusion shared between two unrelated patients in a single psychiatric unit. While physical separation of patients is the best practice in such cases, a risk-benefit analysis is needed prior to this intervention given the social barriers that may limit such an approach. Further research is needed to diagnose, manage, and optimize treatment for shared delusions in settings such as inpatient psychiatric facilities.

The Workforce Providing Prenatal and Postpartum Care Decreases When Family Physicians Stop Attending Deliveries.

The impact of the declining proportion of family physicians who attend deliveries on the provision of other perinatal care during pregnancy, postpartum, and neonatal periods is unclear. We found a strong association between stopping attending deliveries and stopping providing prenatal and postpartum care among family physicians, suggesting that policies which support family physicians to maintain a full scope of practice including all or some aspects of perinatal care may help alleviate shortages in the perinatal workforce and fill gaps in access to obstetric care.

Providing Obstetric Care: Suggestions From Experienced Family Physicians.

BACKGROUND AND OBJECTIVES: The number of family physicians who include obstetric care in their scope of practice is declining, resulting in lower access for patients to obstetric care, especially in rural and underserved communities. In our study, we aimed to understand the experiences of mid- to late-career family physicians and capture suggestions regarding how to maintain obstetric deliveries as part of practice throughout their careers. METHODS: We administered a 30-item online survey to mid- to late-career family physicians regarding their obstetrical care practice and their suggestions for family physicians to continue attending deliveries throughout the course of their career. We developed descriptive statistics of individual and practice characteristics and thematically analyzed open-text comments offering suggestions for continuing to provide obstetric care. RESULTS: About 1,500 family physicians agreed to participate in the online survey, 992 of whom responded to an open-text question asking for suggestions for family physicians hoping to continue providing obstetric care throughout their careers (56% response rate). The primary themes included suggestions regarding interprofessional relationships, call coverage/backup, training and education, practice characteristics, practice setting, work-life balance, job seeking, policy, and compensation. CONCLUSIONS: The findings revealed individual- and structural-level considerations to improve longevity in obstetric scope of practice. Support from multiple levels is necessary to ensure that competent family physicians continue attending deliveries throughout their careers. Practices and hospital systems can have a sizeable impact by directly helping family physicians provide obstetric primary care within their scope of practice, while national organizations can influence health care system-level changes.

Impact of COVID-19 on perinatal care: Perceptions of family physicians in the United States.

BACKGROUND: Patient-centered care is the best practice in the care of pregnant and postpartum patients. The COVID-19 pandemic prompted changes in perinatal care policies, which were often reactive, resulting in unintended consequences, many of which made the delivery of patient-centered care more difficult. This study aimed to understand the impact of the COVID-19 pandemic on perinatal health care delivery from the perspective of family physicians in the United States. METHODS: From October 5 to November 4, 2020, we surveyed mid- to late-career family physicians who provide perinatal care. We conducted descriptive analyses to measure the impact of COVID-19 on prenatal care, labor and delivery, postpartum care, patient experience, and patient volume. An immersion-crystallization approach was used to analyze qualitative data provided as open-text comments. RESULTS: Of the 1518 survey respondents, 1062 (69.8%) stated that they currently attend births; 595 of those elaborated about the impact of COVID-19 on perinatal care in free-text comments. Eight themes emerged related to the impact of COVID-19 on perinatal care: visitation, patient decisions, testing, personal protective equipment, care continuity, changes in care delivery, reassignment, and volume. The greatest perceived impact of COVID-19 was on patient experience. CONCLUSIONS: Family physicians who provided perinatal care during the COVID-19 pandemic noted a considerable impact on patient experience, which particularly affected the ability to deliver patient-centered and family-centered care. Continued research is needed to understand the long-term impact of policies affecting the delivery of patient-centered perinatal care and to inform more evidence-based, proactive policies to be implemented in future pandemic or disaster situations.

Barriers to care for perinatal patients with opioid use disorder: family physician perspectives.

BACKGROUND: While barriers to care for pregnant patients with opioid use disorder (OUD) have been described, the experiences and challenges of the physicians providing care to these patients are poorly understood. OBJECTIVES: To describe the experiences of family physicians providing comprehensive care to pregnant people with OUD and the challenges they face in providing such care. METHODS: Qualitative thematic analysis of 17 semistructured interviews conducted from July 2019 to September 2020 with family physicians who possess a Drug Enforcement Administration "X" waiver and provide care to pregnant patients. RESULTS: Seventeen family physicians practicing in the United States who care for pregnant people with OUD were interviewed. They described physician-, patient-, and systems-level barriers to providing and accessing care for this patient population. Of the 12 interrelated themes regarding challenges to delivering and accessing this care, 3 were particularly salient: the pervasive effects of social determinants of health, a lack of adequately trained providers, and social stigma associated with pregnant people with OUD. CONCLUSION: A comprehensive, multilevel, and multidisciplinary approach is necessary to address these barriers and move towards health equity for this vulnerable patient population.

Faculty and Resident Contraceptive Opt Outs and Training Site Restrictions: A CERA Study.

BACKGROUND AND OBJECTIVES: Contraception is a core component of family medicine residency curriculum. Institutional environments can influence residents' access to contraceptive training and thus their ability to meet the reproductive health needs of their patients. METHODS: Contraceptive training questions were included in the 2020 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors. The survey asked how many faculty and residents opt out of providing contraceptive methods for moral or religious reasons, and whether training sites have institutional restrictions on contraception. We performed descriptive statistics and regression to identify program characteristics associated with having a resident or faculty opt out of providing contraceptive care. RESULTS: Of 626 program directors, 249 responded to the survey, and 237 answered the contraceptive questions. Percentages of program directors reporting any residents or faculty who opted out of contraceptive services are as follows: pill/patch/ring (residents 27%; faculty 17%), emergency contraception (residents 40%, faculty 33%), or intrauterine devices/implants (resident 29%; faculty 23%). Programs in the South (OR 2.78; 1.19-6.49) and those with Catholic affiliation (OR 2.35; 1.23-4.91) had higher adjusted odds of at least one opt-out faculty but were not associated with having opt-out residents. Eleven percent of programs had at least one training site with institutional restrictions on contraception. CONCLUSIONS: To ensure that residents have access to adequate contraceptive training, residencies should proactively seek faculty and training environments that meet residents' needs, and should make limitations on services clear to potential residents and patients.

A cross-sectional study of the practice types of US adult primary care physician specialists.

BACKGROUND: Many physicians listed as primary care in databases such as the American Medical Association (AMA) Masterfile do not provide traditional ambulatory primary care. OBJECTIVE: To compare physicians listed in the AMA Masterfile as primary care physician (PCPs) specialists for adult patients with their actual practice type. METHODS: We conducted a cross-sectional study of the AMA Masterfile report for PCPs who care for adults (listed as family medicine, internal medicine, medicine-paediatrics, and geriatrics) in the summer and fall of 2018 (spring of 2019 for Hartford, CT) in the primary counties of 8 metropolitan areas across the United States. We searched multiple websites to determine the actual practice type of each physician in the study counties. We correlated the 2 datasets: the AMA Masterfile list vs the results of our searches. RESULTS: Family physicians were more likely to function as traditional ambulatory PCPs than internists [1,738/2,101 (82.7%) vs 1,241/2,025 (60.9%), P < 0.001], and less likely to be hospitalists [83/2,101 (4.0%) vs 631/2,025 (31.0%), P < 0.001]. Other practice types included urgent care [105 (5.0%) family physicians, 16 (0.8%) internists] and emergency medicine [49 (2.3%) family physicians, 20 (1.0%) internists]. The AMA Masterfile identified 4,892 practicing PCPs for adult patients in the study counties, of which 3,084 (63.0%) matched by location and ambulatory PCP practice type [3,695 (75.5%) for ambulatory PCP practice type only]. CONCLUSIONS: We provide an updated estimate using a unique methodology to estimate how to correct the AMA Masterfile for PCPs who actually provide traditional ambulatory primary care to adult patients.

Measuring State-Level Racial Inequity in Severe Maternal Morbidity in the Medicaid Population.

OBJECTIVE: Severe maternal morbidity represents a "near miss" mortality and is an important measure of quality and safety. Racial inequity in maternal morbidity is stark and the reasons for this disparity are poorly understood. We aimed to identify states achieving racial equity in maternal morbidity in order to identify policies that may promote racial equity. METHODS: We analyzed Medicaid deliveries from 2008 to 2009 in a sample that included 28 states and the District of Columbia. This dataset included approximately 80% of all Medicaid enrollees and 90% of minority Medicaid enrollees in the US. We determined the Non-Hispanic Black/Non-Hispanic white SMMI rate ratio for each state and categorized the states into groups by rate ratio. We described demographic features of both the general population and study population for these groups of states. RESULTS: In a sample that included a total of 1,489,134 births, we found that no state/district is achieving equity in severe maternal morbidity. The severe maternal morbidity rate is higher for Non-Hispanic Black than Non-Hispanic white patients in every state included. With a rate ratio ranging from 1.14 to 2.66, there are varying degrees of inequity. States in the group with the most equitable maternal morbidity rates had less inequity across racial subgroups with respect to educational attainment and poverty. CONCLUSIONS: Identifying geographic areas with varying degrees of inequity may be key to identifying policies to promote equity. Socioecological disparities and inadequate access to care may be factors in racial inequity in maternal morbidity.

Racial and Ethnic Diversity of Family Physicians Delivering Maternity Care.

BACKGROUND: Maternal and birth outcomes represent some of the most profound racial and ethnic disparities in health in the USA, and are, in part, attributed to a lack of diversity in the maternity care workforce. Family physicians are an often-overlooked part of the maternity care workforce, yet frequently provide care to underserved populations. This study aims to characterize the family physician workforce providing obstetric care in terms of race/ethnicity. METHODS: In this cross-sectional study, we used data collected via the American Board of Family Medicine Exam Registration Questionnaire from 2017 to 2019. Respondents included family physicians seeking to continue their certification in those years. We conducted bivariate tests and an adjusted analysis using logistic regression to examine associations with providing obstetric deliveries. Variables included race, ethnicity, age, gender, degree type, international medical graduate status, practice site, and rurality. RESULTS: Of 20,820 family physicians in our sample, those identifying as Black/African American (OR 0.55, CI 0.41 to 0.74) and Asian (OR 0.40, CI 0.31 to 0.51) had significantly lower odds of including obstetrics in their practice than those identifying as White. We found no significant difference in practicing obstetrics between Hispanic and non-Hispanic family physicians (OR 0.94, CI 0.73 to 1.20). Asian (OR 0.40, CI 0.31 to 0.51) and Black/African American (OR 0.55, CI 0.41 to 0.74) physicians still have significantly lower odds of providing obstetric care than White physicians after controlling for rurality. CONCLUSIONS: Family physicians who identified as Black/African American or Asian are less likely to include obstetrics in their practice. A diverse and racially/ethnically representative maternity care workforce, including family physicians, may help to ameliorate disparities in maternal and birth outcomes. Enhanced efforts to diversify the family physician maternity care workforce should be implemented.

Maternity Care Tracks at US Family Medicine Residency Programs.

BACKGROUND AND OBJECTIVES: The number of family physicians providing maternity care continues to decline, jeopardizing access to needed care for underserved populations. Accreditation changes in 2014 provided an opportunity to create family medicine residency maternity care tracks, providing comprehensive maternity care training only for interested residents. We examined the relationship between maternity care tracks and residents' educational experiences and postgraduate practice. METHODS: We included questions on maternity care tracks in an omnibus survey of family medicine residency program directors (PDs). We divided respondent programs into three categories: "Track," "No Track Needed," and "No Track." We compared these program types by their characteristics, number of resident deliveries, and number of graduates practicing maternity care. RESULTS: The survey response rate was 40%. Of the responding PDs, 79 (32%) represented Track programs, 55 (22%) No Track Needed programs, and 94 (38%) No Track programs. Residents in a track attended more deliveries than those not in a track (at Track programs) and those at No Track Needed and No Track programs. No Track Needed programs reported the highest proportion of graduates accepting positions providing inpatient maternity care in 2019 (21%), followed by Track programs (17%) and No Track programs (5%; P<.001). CONCLUSIONS: Where universal robust maternity care education is not feasible, maternity care tracks are an excellent alternative to provide maternity care training and produce graduates who will practice maternity care. Programs that cannot offer adequate experience to achieve competence in inpatient maternity care may consider instituting a maternity care track.

Distribution of Physician Specialties by Rurality.

PURPOSE: Physicians of all specialties are more likely to live and work in urban areas than in rural areas. Physician availability affects the health and economy of rural communities. This study aimed to measure and update the availability of physician specialties in rural counties. METHODS: This analysis included all counties with a Rural-Urban Continuum Code (RUCC) between 4 and 9. Geographically identified physician data from the 2019 American Medical Association Masterfile was merged with 2019 County Health Rankings, the Census Bureau's 2010 county-level population data, and 2010 Topologically Integrated Geographic Encoding and Referencing shapefiles. Multivariate logistic regression was performed to assess the availability of physicians by specialty in rural counties. FINDINGS: Of the 1,947 rural counties in our sample, 1,825 had at least 1 physician. Specialties including emergency medicine, cardiology, psychiatry, diagnostic radiology, general surgery, anesthesiology, and OB/GYN were less available than primary care physicians (PCPs) in all rural counties. The probability of a rural county having a PCP was the highest in RUCC 4 (1.0) and lowest in RUCC 8 (0.93). Of all primary care specialties, family medicine was the most evenly distributed across the rural continuum, with a probability of 1.0 in RUCC 4 and 0.88 in RUCC 9. CONCLUSIONS: Family medicine is the physician specialty most likely to be present in rural counties. Policy efforts should focus on maintaining the training and scope of practice of family physicians to serve the health care needs of rural communities where other specialties are less likely to practice.

The Overlap Between Rural Hospital Needs and Medical Student Goals in Texas.

INTRODUCTION: The rural health workforce in the United States is difficult to maintain and harder to increase. This may contribute to worse health outcomes in rural areas and threaten the sustainability of rural hospitals. Previous studies have attempted to identify medical student characteristics and strategies to help grow this workforce. In this study, we aimed to understand the needs of medical students and hospital administrators to identify potential strategies to improve the rural health workforce. METHODS: We conducted medical student and hospital administrator focus groups. We analyzed focus group data separately to identify themes, and reviewed these themes for overlap between groups and potential actionable areas. We calculated Cohen κ statistics. RESULTS: We identified 26 themes in the medical student focus groups, and 14 themes in the hospital administrator focus group. Of these themes, three were identical between groups (scope of practice, loan repayment and financial concerns, and exposure to rural health in training), and two were similar between the groups (family and leadership). CONCLUSION: The identification of two themes that are similar but not identical between medical students and hospital administrators may serve as part of future strategies to improving rural physician recruitment. Future studies should determine if a shift in language or focus in these areas specifically help to improve the rural health workforce.

Point-of-Care Ultrasound in Family Medicine Residencies 5-Year Update: A CERA Study.

BACKGROUND AND OBJECTIVES: In 2014, family medicine residency programs began to integrate point-of-care ultrasound (POCUS) into training, although very few had an established POCUS curriculum. This study aimed to evaluate the resources, barriers, and scope of POCUS training in family medicine residencies 5 years after its inception. METHODS: Questions regarding current training and use of POCUS were included in the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors, and results compared to similar questions on the 2014 CERA survey. RESULTS: POCUS is becoming a core component of family medicine training programs, with 53% of program directors reporting establishing or an established core curriculum. Only 11% of program directors have no current plans to add POCUS training to their program, compared to 41% in 2014. Despite this increase in training, the reported clinical use of POCUS remains uncommon. Only 27% of programs use six of the eight surveyed POCUS modalities more than once per year. The top three barriers to including POCUS in residency training in 2019 have not changed since 2014, and are (1) a lack of trained faculty, (2) limited access to equipment, and (3) discomfort with interpreting images without radiologist review. CONCLUSIONS: Training in POCUS has increased in family medicine residencies over the last 5 years, although practical use of this technology in the clinical setting may be lagging behind. Further research should explore how POCUS can improve outcomes and reduce costs in the primary care setting to better inform training for this technology.