Learning or leaving? An international qualitative study of factors affecting the resilience of female family doctors.

​BACKGROUND: Many countries have insufficient numbers of family doctors, and more females than males leave the workforce at a younger age or have difficulty sustaining careers. Understanding the differing attitudes, pressures, and perceptions between genders toward their medical occupation is important to minimise workforce attrition. ​AIM: To explore factors influencing the resilience of female family doctors during lifecycle transitions. ​DESIGN & SETTING: International qualitative study with female family doctors from all world regions. ​METHOD: Twenty semi-structured online Skype interviews, followed by three focus groups to develop recommendations. Data were transcribed and analysed using applied framework analysis. ​RESULTS: Interview participants described a complex interface between competing demands, expectations of their gender, and internalised expectations of themselves. Systemic barriers, such as lack of flexible working, excessive workload, and the cumulative impacts of unrealistic expectations impaired the ability to fully contribute in the workplace. At the individual level, resilience related to: the ability to make choices; previous experiences that had encouraged self-confidence; effective engagement to obtain support; and the ability to handle negative experiences. External support, such as strong personal networks, and an adaptive work setting and organisation or system maximised interviewees' professional contributions. ​CONCLUSION: On an international scale, female family doctors experience similar pressures from competing demands during lifecycle transitions; some of which relate to expectations of the female's 'role' in society, particularly around the additional personal pressures of caring commitments. Such situations could be predicted, planned for, and mitigated with explicit support mechanisms and availability of workplace choices. Healthcare organisations and systems around the world should recognise this need and implement recommendations to help reduce workforce losses. These findings are likely to be of interest to all health professional staff of any gender.

Street Medicine: Creating a "Classroom Without Walls" for Teaching Population Health.

"Street Medicine" programs provide medical care to homeless populations outside of traditional healthcare institutions, literally on the street and in transitional settings where unsheltered homeless people live. Such programs are emerging around the world often based at medical schools and primary care residency programs, and can provide ideal frameworks for twenty-first century "Classrooms Without Walls" aimed at improving Population Health. We provide a 12-step blueprint for creating a Street Medicine program in the context of a medical teaching institution.

Revisiting Primary Care's Critical Role in Achieving Health Equity: Pisacano Scholars' Reflections from Starfield Summit II.

The second Starfield Summit was held in Portland, Oregon, in April 2017. The Summit addressed the role of primary care in advancing health equity by focusing on 4 key domains: social determinants of health in primary care, vulnerable populations, economics and policy, and social accountability. Invited participants represented an interdisciplinary group of primary care clinicians, researchers, educators, policymakers, community leaders, and trainees. The Pisacano Leadership Foundation was one of the Summit sponsors and held its annual leadership symposium in conjunction with the Summit, enabling several Pisacano Scholars to attend the Summit. After the Summit, a small group of current and former Pisacano Scholars formed a writing group to highlight key themes and implications for action discussed at the Summit. The Summit resonated as a call to action for primary care to move beyond identifying existing health inequities and toward the development of interventions that advance health equity, through education, research, and enhanced community partnerships. In doing so, the Summit aimed to build on the foundational work of Dr. Starfield, challenging us to explore the significant role of primary care in truly achieving health equity.

The Chief Primary Care Medical Officer: Restoring Continuity.

The year 2016 marked the 20th anniversary of the hospitalist profession, with more than 50,000 physicians identifying as hospitalists. The Achilles heel of hospitalist medicine, however, is discontinuity. Despite many current payment and delivery systems rewarding this discontinuity and severing long-term relationships between patient and primary care teams at the hospital door, primary care does not stop being important when a person is admitted to the hospital. The notion of a broken primary care continuum is not an academic construct, it causes real harm to patients. As a step toward fixing the discontinuity in our health care systems, we propose that every hospital needs a Chief Primary Care Medical Officer (CPCMO), an expert in practice across the spectrum of care. The CPCMO can lead hospital efforts to create systems that ensure primary care's continuum is complete, while strengthening physician collaboration across specialties, and moving toward achieving the Quadruple Aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers. For hospitals operating on value-based payment structures, anticipated improvement in measurable outcomes such as decreased length of stay, decreased readmission rates, improved transitions of care, improved patient satisfaction, improved access to primary care, and improved patient health, will enhance the rate of return on the hospital's investment. The speciality of family medicine should reevaluate our purpose, and reembrace our mission as personal physicians by championing the creation of Chief Primary Care Medical Officers.

"A Paradox Persists When the Paradigm Is Wrong": Pisacano Scholars' Reflections from the Inaugural Starfield Summit.

The inaugural Starfield Summit was hosted in April 2016 by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care with additional partners and sponsors, including the Pisacano Leadership Foundation (PLF). The Summit addressed critical topics in primary care and health care delivery, including payment, measurement, and team-based care. Invited participants included an interdisciplinary group of pediatricians, family physicians, internists, behaviorists, trainees, researchers, and advocates. Among the family physicians invited were both current and past PLF (Pisacano) scholars. After the Summit, a small group of current and past Pisacano scholars formed a writing group to reflect on and summarize key lessons and conclusions from the Summit. A Summit participant's statement, "a paradox persists when the paradigm is wrong," became a repeated theme regarding the paradox of primary care within the context of the health care system in the United States. The Summit energized participants to renew their commitment to Dr. Starfield's 4 C's of Primary Care (first contact access, continuity, comprehensiveness, and care coordination) and to the Quadruple Aim (quality, value, and patient and physician satisfaction) and to continue to explore how primary care can best shape the future of the nation's health care system.

Back to the future: reflections on the history of the future of family medicine.

These are historic times for family medicine. The profession is moving beyond the visionary blueprint of the Future of Family Medicine (FFM) report while working to harness the momentum created by the FFM movement. Preparing for, and leading through, the next transformative wave of change (FFM version 2.0) will require the engagement of multigenerational and multidisciplinary visionaries who bring wisdom from diverse experiences. Active group reflection on the past will potentiate the collective work being done to best chart the future. Historical competency is critically important for family medicine's future. This article describes the historical context of the development and launch of the FFM report, emphasizing the professional activism that preceded and followed it. This article is intended to spark intergenerational dialog by providing a multigenerational reflection on the history of FFM and the evolution that has occurred in family medicine over the past decade. Such intergenerational conversations enable our elders to share wisdom with our youth, while allowing our discipline to visualize history through the eyes of future generations.

The Future of Family Medicine version 2.0: reflections from Pisacano scholars.

The Future of Family Medicine (FFM) project has helped shape and direct the evolution of primary care medicine over the past decade. Pisacano Scholars, a group of leaders in family medicine supported by the American Board of Family Medicine, gathered for a 2-day symposium in April 2013 to explore the history of the FFM project and outline a vision for the next phase of this work-FFM version 2.0 (v2.0). After learning about the original FFM project (FFM v1.0), the group held interactive discussions using the World Café approach to conversational leadership. This commentary summarizes the discussions and highlights major themes relevant to FFM v2.0 identified by the group. The group endorsed the FFM v1.0 recommendations as still relevant and marvelled at the progress made toward achieving many of those goals. Most elements of FFM v1.0 have moved forward, and some have been incorporated into policy blueprints for reform. Now is the time to refocus attention on facets of FFM v1.0 not yet realized and to identify key aspects missing from FFM v1.0. The Pisacano Scholars are committed to moving the FFM goals forward and hope that this expression of the group's vision will help to do so.