Diversity, Inclusion, and Health Equity in Academic Family Medicine.

BACKGROUND AND OBJECTIVES: Diversity, inclusion, and health equity (DIHE) are integral to the practice of family medicine. Academic family medicine has been grappling with these issues in recent years, particularly with a focus on racism and health inequity. We studied the current state of DIHE activities in academic family medicine departments and suggest a framework for departments to become more diverse, inclusive, antiracist, and focused on health equity and racial justice. METHODS: As part of a larger annual membership survey, family medicine department chairs were asked for their assessment of departmental DIHE and antioppression activities, and infrastructure and resources committed to increasing DIHE. RESULTS: More than 60% of family medicine department chairs participating in this study rate their departments highly in promoting DIHE and antioppression, and 66% of chairs report an institutional infrastructure that is working well. Just over half of departments or institutions have had a climate survey in the past 3 years, 47.3% of departments have a diversity officer, and 26% of departments provide protected time or resources for a diversity officer. CONCLUSIONS: The majority of family medicine department chairs rate their departments highly on DIHE. However, only 50% of departments have formally assessed climate in the past 3 years, fewer have diversity officers, and even fewer invest resources in their diversity officers. This disconnect should motivate academic family medicine departments to undertake formal self-assessment and implement a strategic plan that includes resource investment in DIHE, measurable outcomes, and sustainability.

COVID-19 Exposure Risk, Burnout, and Shifts in Family Medicine Faculty's Efforts: A National Survey.

BACKGROUND AND OBJECTIVES: In response to the COVID-19 pandemic, academic family physicians had to change their clinical, teaching, research, and administrative efforts, while simultaneously balancing their home environment demands. It is unclear how the changes in effort affected physicians' personal well-being, particularly burnout. This study sought to identify changes in faculty's clinical, teaching, research, and administrative efforts during the COVID-19 pandemic and how effort shifts were associated with burnout. We also examined associations with important demographics and burnout. METHODS: We took data from the 2020 Council of Academic Family Medicine's Educational Research Alliance survey of family medicine educators and practicing physicians during November 2020 through December 2020. We analyzed self-report measures of demographics, effort (clinical, teaching, research, and administrative) before and during the pandemic, COVID-19 exposure level, and rates of burnout (emotional exhaustion and depersonalization) using logistic regressions. RESULTS: Most participants reported no change in efforts. If changes were reported, clinical (21.6%) and administrative (24.8%) efforts tended to increase from before to during the pandemic, while teaching tended to decrease (27.7%). Increases in teaching and clinical efforts were associated with higher rates of emotional exhaustion. Higher depersonalization was associated with increased clinical efforts. Being older and working in a rural setting was associated with lower burnout, while being female was associated with higher burnout. CONCLUSIONS: Shifts in effort across academic family physicians' multiple roles were associated with emotional exhaustion and, to a lesser degree, depersonalization. The high rates of burnout demand additional attention from directors and administrators, especially among female physicians.

Faculty Engagement and Productivity During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: COVID-19 has had an unprecedented effect on faculty of academic family medicine departments. We sought to characterize faculty's self-reported changes in engagement and productivity in clinical, education, and scholarly efforts during the COVID-19 pandemic, and to correlate the changes with age, gender, and level of COVID-19 exposure. We also sought to determine if differences in faculty engagement and productivity were related to departmental efforts to create virtual community, manage conflict, foster engagement with colleagues, and support faculty emotional well-being. METHODS: We surveyed family medicine department faculty nationally on the effects of the COVID-19 pandemic on their engagement and productivity in clinical care, teaching and research, and on the effect of departmental efforts on well-being. RESULTS: Most respondents reported decreased engagement and productivity across clinical, teaching, and research domains. Older age and male gender were associated with higher clinical engagement. Most respondents were satisfied with their departments' virtual community but reported that social distancing had a negative impact on departmental ability to problem-solve and on personal emotional well-being. Higher engagement and productivity in all three domains of effort (clinical, teaching, and research) were associated with respondents' well-being and with positive perceptions of their department's efforts. CONCLUSIONS: Clinical, teaching, and research engagement and productivity for academic family physicians decreased during the COVID-19 pandemic. Faculty well-being and departmental interventions lessened the impact of diminished productivity and research engagement.

Promotion of Clinical Educators: A Critical Need in Academic Family Medicine.

BACKGROUND AND OBJECTIVES: Academic family medicine departments have traditionally promoted faculty using research and scholarship criteria augmented by teaching, clinical care, and service. Clinic-focused faculty who spend significant time in direct patient care may not have enough time to meet promotion criteria, although they are critical for training future family physicians and for rebalancing the system of academic promotion. METHODS: We surveyed family medicine department chairs on the effects of protected time for scholarship, presence of promotion and tenure (P and T) committees, salary increase, and special promotion tracks on promotion of physician faculty. RESULTS: Promotion rates to both associate and full professor were higher for faculty with 25% time for scholarship than for clinic-focused faculty. For clinic-focused faculty, promotion rates to associate professor were higher than they were to full professor. No differences were found for promotion to associate professor and full professor for faculty with 25% protected time for scholarship. No differences were found in promotion rates for either rank between departments that had P and T committees and those that didn't, whether promotion came with a salary increase, or if departments had a special track for physician faculty whose job is patient care. CONCLUSIONS: Promotion rates are higher for faculty with protected time for scholarship than for clinic-focused faculty for promotion to both associate and full professor. Clinic demands on faculty may reduce the likelihood of engaging in scholarship or research that in many academic family medicine departments is necessary for promotion.

Prescribing Patterns and Use of Risk-Reduction Tools After Implementing an Opioid-Prescribing Protocol.

BACKGROUND: The literature on results from primary care-based opioid-prescribing protocols is small and results have been mixed. To advance this field, we evaluated whether opioid prescribing changed after a comprehensive protocol was implemented and whether change was associated with the number and type of risk reduction tools adopted. METHODS: Electronic medical record data were obtained for 2607 patients. Demographics, Patient Health Questionnaire-9 scores, body mass index, and utilization levels of protocol elements were measured for 24 months prior and 18 months post implementation of an opioid-prescribing protocol within a federally qualified health center. χ2 and t-tests were computed to estimate change in opioid prescribing, morphine-equivalent dose, comedication prescribing, and number and type of protocol elements utilized. RESULTS: The opioid protocol was associated with an increase in urine drug screens from 18.3% to 26.8% from pre to postimplementation (P < .0001). There was no significant increase in opioid treatment agreements. Tramadol (21.4% to 16.8%, P = .0006) and antidepressant (56.0% to 51.6%, P = .012) prescribing significantly decreased. Total opioid prescriptions and maximum morphine-equivalent doses were similar from pre to postimplementation. Protocol elements were more often used when patients had a higher opioid dose and were receiving benzodiazepines. CONCLUSIONS: Implementing a multi-faceted opioid-prescribing protocol was not associated with change in number or dose of opioid prescriptions but was associated with greater use of urine drug screens, and risk reduction tools were used more often in high-risk patients. Implementation research is needed to identify barriers to maximizing adherence to opioid protocols.

Gender-Stratified Prevalence of Psychiatric and Pain Diagnoses in a Primary Care Patient Sample with Fibromyalgia.

OBJECTIVE: Comorbid psychiatric and pain-related conditions are common in patients with fibromyalgia. Most studies in this area have used data from patients in specialty care and may not represent the characteristics of fibromyalgia in primary care patients. We sought to fill gaps in the literature by determining if the association between psychiatric diagnoses, conditions associated with chronic pain, and fibromyalgia differed by gender in a primary care patient population. DESIGN: Retrospective cohort. SETTING AND SUBJECTS: Medical record data obtained from 38,976 patients, ≥18 years of age with a primary care encounter between July 1, 2008, to June 30, 2016. METHODS: International Classification of Diseases-9 codes were used to define fibromyalgia, psychiatric diagnoses, and conditions associated with chronic pain. Unadjusted associations between patient demographics, comorbid conditions, and fibromyalgia were computed using binary logistic regression for the entire cohort and separately by gender. RESULTS: Overall, 4.6% of the sample had a fibromyalgia diagnosis, of whom 76.1% were women. Comorbid conditions were more prevalent among patients with vs without fibromyalgia. Depression and arthritis were more strongly related to fibromyalgia among women (odds ratio [OR] = 2.80, 95% confidence interval [CI] = 2.50-3.13; and OR = 5.19, 95% CI = 4.62-5.84) compared with men (OR = 2.16, 95% CI = 1.71-2.71; and (OR = 3.91, 95% CI = 3.22-4.75). The relationship of fibromyalgia and other diagnoses did not significantly differ by gender. CONCLUSIONS: Except for depression and arthritis, the burden of comorbid conditions in patients with fibromyalgia is similar in women and men treated in primary care. Fibromyalgia comorbidities in primary care are similar to those found in specialty care.

Clinical inquiries. Sleep apnea in adults: how accurate is clinical prediction?

Moderately accurate, depending on which tool you use. Questionnaires, physical examination, and clinical prediction rules estimate the pretest probability of obstructive sleep apnea hypopnea syndrome (OSAHS), but are not specific enough to make the diagnosis. The Epworth Sleepiness Scale is a reliable measure of daytime sleepiness. The Berlin Questionnaire, Mallampati score, and truncal obesity can be used to assess pretest probability of OSAHS.