The Practice Is the Curriculum.

The training family medicine residents receive will have a lasting impact on how they deliver care in the future. Evidence demonstrates an imprinting effect based on the training environment itself. Thus, residency training represents a critical time for establishing clinical experiences that embody core primary care principles and ensure excellent care delivery. This paper focuses on the clinical experience in the family medicine practice setting. We have used Starfield's four C's of primary care and added two more: cost and community, as the tools to achieve the triple aim. In reviewing the current state of residency programs across the country, we noted that there was a lack of measurement on how programs were performing when it came to the six C's. We will briefly describe some recent innovative collaboratives among residencies. Next, we examine the six C's of primary care in context of current care. These six C's inform our recommendations for residency training standards to create the family physicians of the future. The overarching theme of these recommendations is the need to measure and report on what we want to ultimately improve.

The Evolving Role of Medical Assistants in Primary Care Practice: Divergent and Concordant Perspectives from MAs and Family Physicians.

Medical assistants (MAs) are a flexible and low-cost resource for primary care practices and their roles are swiftly transforming. We surveyed MAs and family physicians in primary care practices in North Carolina to assess concordance in their perspectives about MA roles, training, and confidence in performing activities related to visit planning; direct patient care; documentation; patient education, coaching or counseling; quality improvement; population health and communication. For most activities, we did not find evidence of role confusion between MAs and physicians, physician resistance to delegate tasks to properly trained MAs, or MA reluctance to pursue training to take on new roles. Three areas emerged where the gap between the potential and actual implementation of MA role transformation could be narrowed-population health and panel management; patient education, coaching, and counseling; and scribing. Closing these gaps will become increasingly important as our health care system moves toward value-based models of care.

Improving Patient Care Through Workspace Renovation and Redesign: A Lean Approach.

BACKGROUND AND OBJECTIVES: At a time when the US health care system needs greater access to comprehensive, on-demand primary care, the University of North Carolina Family Medicine Center found itself struggling to meet patient demands within the confines of an outdated facility. Clinic leadership sought to redesign the physical space to expand capacity, integrate other members of the care team, support extended hours of operation, and improve patient experience. METHODS: Clinic leadership employed experienced lean coaches to train our entire department in lean methodology, to implement a comprehensive approach to redesigning our workflows, and to use those perfected workflows to redesign and renovate our new clinical workspace. RESULTS: Upon completion of the renovation and redesign, the clinic experienced significant growth in patient volumes (24%) and unprecedented improvement in patient satisfaction (89th to 92nd percentile). CONCLUSIONS: Lean methodology proved to be an effective strategy for analyzing our current workflows and use of physical space. Moreover, lean strategies proved vital for redesigning and renovating our clinic.

The Financial Cost of Medical Assistant Turnover in an Academic Family Medicine Center.

INTRODUCTION: Primary care clinics increasingly hire medical assistants (MAs) to perform a variety of clinical and administrative tasks. Anecdotal reports suggest that MA turnover is high, but no studies to date have calculated the rate or cost of MA turnover. The purpose of this study was to calculate the rate of MA turnover and associated costs in a single, large academic Family Medicine clinic. METHODS: Retrospective data were collected from clinic administrators regarding MA turnover, overtime worked, salaries and benefits as well as administrator salaries and benefits and the amount of administrator time spent in MA hiring, training, and termination in 2017. RESULTS: During 2017, MA turnover rate was 59%. The total estimated cost of MA turnover was $213,000. The per-MA cost of turnover was $14,200, or approximately 40% of the average annual salary of MAs. CONCLUSION: Turnover rate in this practice was similar to other estimates of primary care clinic staff and allied health professionals. The estimated cost of MA turnover relative to annual salary was significantly greater than that in other fields, likely reflecting the costs of training MAs. Establishing a method for calculating the turnover rate and costs can allow other healthcare systems to better describe turnover and evaluate retention strategies.

PURLs: Does fish oil during pregnancy help prevent asthma in kids?

A 24-year-old G2P1 at 24 weeks' gestation presents to your clinic for a routine prenatal visit. Her older daughter has asthma and she is inquiring as to whether there is anything she can do to lower the risk of her second child developing asthma in the future. What do you recommend?

Clinical Evaluation of Bleeding and Bruising in Primary Care.

Bleeding and bruising are common symptoms in the primary care setting. The patient history can help determine whether the bruising or bleeding is abnormal. The International Society on Thrombosis and Hemostasis has developed a bleeding assessment tool that can be used to indicate possible pathology. A family history of bleeding problems may suggest a hereditary coagulation defect. Such a history is especially important in children who may not have experienced a major bleeding episode. Medication review can identify pharmacologic causes of the bleeding or bruising. Physical examination findings such as mucocutaneous bleeding suggest that the underlying condition is caused by platelet dysfunction, whereas hemarthroses or hematomas are more common in coagulopathy. If the history and physical examination findings suggest a bleeding diathesis, initial laboratory testing includes a complete blood count, peripheral blood smear, prothrombin time (PT), and partial thromboplastin time (PTT). A normal PT and PTT indicate a platelet disorder, the most common of which is von Willebrand disease. A normal PT and prolonged PTT signal a deficit in the intrinsic pathway, and a mixing study should be performed. A vitamin K challenge is indicated in patients with an abnormal PT and normal PTT. A workup for liver failure is warranted in patients with prolonged PT and PTT. If initial testing does not reveal an etiology in a patient with a high suspicion for a bleeding disorder, the patient should be referred to a hematologist for additional evaluation.

Patient care outcomes of a tobacco use registry in an academic family practice.

PURPOSE: While the potential benefit of a chronic disease registry for tobacco use is great, outcome reports have not been generated. We examined the effect of implementing a tobacco use registry, including a decision support tool, on treatment outcomes within an academic family medicine clinic. METHODS: A chart review of 200 patients who smoked and attended the clinic before and after registry implementation assessed the number of patients with clinic notes documenting (1) counseling for tobacco use, (2) recommendations for cessation medication, (3) a set quit date, (4) referrals to the on-site Nicotine Dependence Program (NDP) and/or QuitlineNC, and (5) pneumococcal vaccine. Data from the NDP, QuitlineNC, and clinic billing records before and after implementation compared the number of clinic-generated QuitlineNC fax referrals, new scheduled appointments for the NDP, and visits coded for tobacco counseling reimbursement. RESULTS: Significant increases in documentation occurred across most chart review variables. Significant increases in the number of clinic-generated fax referrals to QuitlineNC (from 27 to 96), initial scheduled appointments for the NDP (from 84 to 148), and coding for tobacco counseling (from 101 to 287) also occurred when compared with total patient visits during the same time periods. Patient attendance at the NDP (52%) and acceptance of QuitlineNC services (31%) remained constant. CONCLUSIONS: The tobacco use registry's decision support tool increased evidenced-based tobacco use treatment (referrals, medications, and counseling) for patients at an academic family medicine clinic. This novel tool offers standardized care for all patients who use tobacco, ensuring improved access to effective tobacco use counseling and medication treatments.

The implementation of a tobacco use registry in an academic family practice.

PURPOSE: Patients who use tobacco often are not provided evidence-based interventions because of barriers such as lack of time or expertise. Using a chronic disease model, we sought to improve delivery of care with an innovative decision support tool and a tobacco use registry. METHODS: We designed and implemented a decision support tool in an academic family medicine clinic. To assess barriers, we measured duration of visit and provider confidence (scale of 0-10) in prescribing cessation medications before and after the introduction of the tool. We examined fidelity through daily counts of returned forms. RESULTS: No significant differences in mean office visit cycle times occurred for tobacco users (64.7 vs 63.1 minutes; P = .90) or between tobacco users and nontobacco users (63.1 vs 62.5 minutes; P = 1.00) before or after implementation of the decision support tool. Mean provider confidence in prescribing cessation medications increased significantly for nicotine inhalers (4.8 vs 6.4; P = .01), nicotine nasal spray (3.9 vs 5.5; P = .03) and combination nicotine replacement therapy (5.5 vs 6.2; P = .05). Two years after implementation, 88% of forms were filled out and returned daily, and >2200 tobacco users have been entered into the registry. CONCLUSIONS: The tobacco use decision support tool resulted in an increase in provider confidence in prescribing cessation medications without lengthening the duration of patients' visits, and the tool continues to be used routinely in the practice 2 years after introduction, indicating sustainability. The use of a tobacco use registry and decision support tool aids in standardizing care and overcoming barriers to cessation counseling.

An obesity remedy for diabetes.

For obese patients with type 2 diabetes, surgery may be the best bet.

Diagnosis of secondary hypertension: an age-based approach.

Secondary hypertension is a type of hypertension with an underlying, potentially correctable cause. A secondary etiology may be suggested by symptoms (e.g., flushing and sweating suggestive of pheochromocytoma), examina- tion findings (e.g., a renal bruit suggestive of renal artery stenosis), or laboratory abnormalities (e.g., hypokalemia suggestive of aldosteronism). Secondary hypertension also should be considered in patients with resistant hyper- tension, and early or late onset of hypertension. The prevalence of secondary hypertension and the most common etiologies vary by age group. Approximately 5 to 10 percent of adults with hypertension have a secondary cause. In young adults, particu- larly women, renal artery stenosis caused by fibromuscular dyspla- sia is one of the most common secondary etiologies. Fibromuscular dysplasia can be detected by abdominal magnetic resonance imag- ing or computed tomography. These same imaging modalities can be used to detect atherosclerotic renal artery stenosis, a major cause of secondary hypertension in older adults. In middle-aged adults, aldosteronism is the most common secondary cause of hyperten- sion, and the recommended initial diagnostic test is an aldosterone/ renin ratio. Up to 85 percent of children with hypertension have an identifiable cause, most often renal parenchymal disease. Therefore, all children with confirmed hypertension should have an evaluation for an underlying etiology that includes renal ultrasonography.