Advancing Telemedicine Within Family Medicine's Core Values.

Telemedicine adoption has been gradual but accelerated during the COVID-19 pandemic. It is important for us to pause and consider how this impacts family medicine. How do we ground ourselves so that we use technology to enhance our practice while maintaining fundamental family medicine values? In this article, we explore how telemedicine interacts with five family medicine tenants: contextual care, continuity of care, access to care, comprehensive care, and care coordination. Keeping this framework in mind and using a health equity lens can help us retain fundamental family medicine values as we adapt to rapid technological change.

Effects of Clinic First Educational Interventions on Resident Wellness and Engagement.

BACKGROUND AND OBJECTIVES: Tensions between clinical and hospital training, along with dysfunctional family medicine training clinics, have resulted in continuity clinic being the least favorite part of training for some residents. These factors are all contributors to burnout. We hypothesized that following Clinic First action steps to prioritize and enhance outpatient clinic would positively affect resident wellness and clinic engagement. This study describes our interventions and their effects within the Oregon Health & Science University (OHSU) Family Medicine 4-year Portland residency program. METHODS: In July 2017 the Oregon Health & Science University Family Medicine Portland residency program implemented scheduling and curricular interventions inspired by the Clinic First model. We conducted a mixed-methods cross-sectional study using focus groups and surveys to understand the effects of these interventions on resident wellness and engagement. RESULTS: Clinic First-inspired interventions, particularly a 2+2 scheduling model, decreased transitions within the day, and a clinic immersion month were associated with improved residents' perception of wellness. These interventions had variable effects on clinic engagement. Eighty-eight percent of interns surveyed about the month-long clinic orientation in the beginning of residency reported that they felt prepared managing continuity patients in the clinic setting and their upcoming rotations. CONCLUSIONS: This study demonstrates that Clinic First-inspired structural changes can be associated with improvement in resident perceptions of wellness and aspects of clinic engagement. This can give educators a sense of hope as well as tangible steps to take to improve these difficult and important issues.

Bull's eye maculopathy associated with hereditary hemochromatosis.

PURPOSE: To report a case of bull's eye maculopathy, a novel finding in a patient with iron overload secondary to hereditary hemochromatosis with a homozygous mutation of the HFE gene. OBSERVATIONS: A 39-year-old man with recently diagnosed hereditary hemochromatosis undergoing treatment by serial phlebotomy presented with bilateral progressive blurry vision and recent onset of photopsias and headaches. Fundus examination revealed a symmetric bull's eye maculopathy with photoreceptor loss and retinal pigment epithelium transmission defects in the area of speckled hyper- and hypo-pigmentation by multimodal imaging. Full field and multifocal electroretinograms demonstrated generalized rod and cone dysfunction with some central preservation of waveforms. Further systemic work-up revealed low ceruloplasmin, mildly decreased serum copper and zinc levels, and low urinary copper. The patient underwent testing for inherited retinal dystrophies, but was not found to have any known pathogenic gene mutations. His ferritin levels normalized with serial phlebotomy and his retinopathy did not appear to progress over 6 months with normalization of his iron levels. CONCLUSIONS AND IMPORTANCE: We report a case of bull's eye maculopathy in a patient with hereditary hemochromatosis with no previous exposure to iron chelators and no known inherited retinal dystrophy. Ocular involvement in hereditary hemochromatosis is relatively rare. In this case, the patient's low serum ceruloplasmin is thought to have increased the amount of redox-active ferrous iron and potentiated retinal iron toxicity resulting in the observed retinopathy. To the authors' knowledge, this is a potentially novel ocular manifestation of hereditary hemochromatosis.

Health Equity and the Tripartite Mission: Moving From Academic Health Centers to Academic-Community Health Systems.

Academic health centers (AHCs) play a significant role in educating the health care workforce, conducting innovative biomedical and clinical research, and delivering high-quality patient care. Much work remains, however, to adequately address the social determinants of health and equity that affect communities where patients live, work, and play. Doing so will help achieve the Quadruple Aim while addressing the unjust social structures that disproportionately impact communities of color and vulnerable populations. AHCs have a timely opportunity to focus their leading roles in education, research, and clinical care on social determinants, moving outside their walls to create academic-community health systems: a collection of academic-community partnerships advancing health equity through collaboration, power sharing, and cocreation.This Perspective proposes four strategies to start developing academic-community health systems. First, embark on all efforts through cocreation with communities. Second, address how future health care professionals are recruited. Third, build the right skills and opportunities for health care professionals to address health inequities. Finally, develop research agendas to evaluate programs addressing inequities. A fully realized vision of an academic-community health system will demonstrate interdependence between AHCs and the community. While considerable AHC resources are invested in building community capacity to improve health and health equity, health systems will also benefit in a multitude of ways, including increasing the diversity of ideas and experiences integrated into health systems. These strategies will support AHCs to embed across each arm of the tripartite mission a focus on partnering with communities to advance health equity together.

A Family Systems Curriculum: Back to the Future?

BACKGROUND AND OBJECTIVES: Although both residents and teaching faculty endorse its value, a recent review of family medicine residency programs confirms minimal formal family systems theory training. We consider the historical context of family systems training in family medicine and other competing priorities in practice and residency curricula. METHODS: We developed a longitudinal family systems curriculum, delivered in the third year of a 4-year residency program, and evaluated 2 years of the program using scales to assess self-reported confidence, knowledge and skills. RESULTS: Our curriculum evaluation showed significant improvement in all self-rating scales for all resident participants. CONCLUSIONS: We concluded the curriculum was successful in generating greater appreciation of family systems thinking and increased self-reported knowledge and skills for intervening and supporting families in the clinical setting. Further study is needed to evaluate change in clinical practice and whether these changes will be sustainable.