Rewards and challenges of community health center practice.

BACKGROUND: More than 1100 community health centers (CHCs) in the United States provide primary care to 20 million underserved patients annually. CHCs have struggled to recruit and retain qualified physicians. OBJECTIVE: To understand physicians' work experiences in CHCs and identify major sources of satisfaction and dissatisfaction. METHODS: Using purposeful sampling, we conducted semistructured interviews with 12 family physicians practicing in CHCs. Interview questions assessed physicians' experiences in CHCs and sources of satisfaction and dissatisfaction. Interview notes were coded and analyzed by 2 investigators using a grounded theory approach to identify key themes. RESULTS: Though family physicians feel tremendous satisfaction from care of underserved patients, they are frustrated with the overwhelming workload they experience. Family physicians also report poor administrative management while working in CHCs. CONCLUSIONS: Implementation of the Affordable Care Act, which relies on expansion of CHC services, may be adversely affected by family physicians' frustrations with CHC practice. Further research to explore and potentially improve the CHC work environment may be needed.

"We have to what?": lessons learned about engaging support staff in an interprofessional intervention to implement MVA for management of spontaneous abortion.

BACKGROUND: Including support staff in practice change initiatives is a promising strategy to successfully implement new reproductive health services. The Resident Training Initiative in Miscarriage Management (RTI-MM) is an intervention designed to facilitate implementation of manual vacuum aspiration (MVA) for management of spontaneous abortion. The purpose of this study was to identify training program components that enhanced interprofessional training and provide lessons learned for engaging support staff in implementing uterine evacuation services. STUDY DESIGN: We conducted a secondary analysis of qualitative data to identify themes within three broad areas: interprofessional education, the role of support staff, and RTI-MM program components that facilitated support staff engagement in the process of implementing MVA services. RESULTS: We identified three key themes around interprofessional training and the role of support staff: "Training together is rare," "Support staff are crucial to practice change," and "Transparency, peers and champions." CONCLUSIONS: We present lessons learned that may be transferrable to other clinic sites: engage site leadership in a commitment to interprofessional training; engage support staff as teachers and learners and in shared values and building professionalism. IMPLICATIONS: This manuscript adds to what is known about how to employ interprofessional education and training to engage support staff in reproductive health services practice change initiatives. Lessons learned may provide guidance to clinical sites interested in interprofessional training, improving service delivery, or implementing new services.

"One of those areas that people avoid" a qualitative study of implementation in miscarriage management.

BACKGROUND: Miscarriage is common and often managed by specialists in the operating room despite evidence that office-based manual vacuum aspiration (MVA) is safe, effective, and saves time and money. Family Medicine residents are not routinely trained to manage miscarriages using MVA, but have the potential to increase access to this procedure. This process evaluation sought to identify barriers and facilitators to implementation of office-based MVA for miscarriage in Family Medicine residency sites in Washington State. METHODS: The Residency Training Initiative in Miscarriage Management (RTI-MM) is a theory-based, multidimensional practice change initiative. We used qualitative methods to identify barriers and facilitators to successful implementation of the RTI-MM. RESULTS: Thirty-six RTI-MM participants completed an interview. We found that the common major barriers to implementation were low volume and a perception of miscarriage as emotional and/or like abortion, while the inclusion of support staff in training and effective champions facilitated successful implementation of MVA services. CONCLUSION: Perceived characteristics of the innovation that may conflict with cultural fit must be explicitly addressed in dissemination strategies and support staff should be included in practice change initiatives. Questions remain about how to best support champions and influence perceptions of the innovation. Our study findings contribute programmatically (to improve the RTI-MM), and to broader theoretical knowledge about practice change and implementation in health service delivery.

Satisfaction of family physicians working in community health centers.

BACKGROUND: Community health centers (CHCs) receive $2.9 billion in federal funding to provide primary care to 20 million people annually, and these numbers are increasing. Understanding of physician satisfaction in CHCs may help guide recruitment and retention efforts aimed at expanding CHC programs. The objective of this study was to contrast the satisfaction of family physicians working in CHCs with the satisfaction of family physicians working in other practice settings. METHODS: Analysis of 4 cross-sectional surveys of recent residency graduates from the Washington, Wyoming, Alaska, Montana, and Idaho Family Medicine Residency Network. Surveys were conducted approximately every 3 years from 2000 to 2010. Main outcome measures included self-reported satisfaction with residency training, practice, and specialty on a 1 (low) to 5 (high) scale. RESULTS: Eight hundred ninety-three family physician responded (response rate, 61%), of whom 129 were CHC physicians and 764 were non-CHC physicians. Compared with non-CHC physicians, higher proportions of CHC physicians reported being highly satisfied with their residency training (79% vs 61%; P < .01) and choice of specialty (74% vs 60%; P < .01). In contrast, lower proportions of CHC physicians were highly satisfied with their employers (62% vs 72%; P = .05). [corrected]. There were no differences in satisfaction with practice partners, income, practice location, or work hours. After adjustment for physician, practice, and community characteristics, CHC physicians were more likely to be highly satisfied with their residency training (odds ratio, 2.6; P = .001) and their choice of specialty (odds ratio, 1.7; P = .03). CHC physicians were less likely to be highly satisfied with their employers (odds ratio, 0.5; P < .01). CONCLUSIONS: The lower level of satisfaction reported by CHC physicians has implications for workforce recruitment and retention in CHC settings. In an era of CHC growth, efforts to improve physician relationships with employers may be a potential target for enhancing the physician workforce in CHCs.

A general framework for approaching residents in difficulty.

The general framework for approaching residents in difficulty that we present here includes (1) explicit criteria that separate suggestions for improvement from formal remedial action, (2) categorization of the problem into three areas with different approaches (competence, laws and professional standards, and performance and disability), and (3) a method for clarifying faculty roles in the remediation efforts. This framework, along with clear written policies and procedures, helps to organize and streamline a response to residents with difficulties.

Prepared but not practicing: declining pregnancy care among recent family medicine residency graduates.

BACKGROUND AND OBJECTIVES: Pregnancy care has been an important component of family medicine in the Pacific Northwest. This paper describes a sudden decline in the provision of pregnancy care by recent family medicine residency graduates in the region. METHODS: Two cohorts of graduates from the University of Washington Family Medicine Residency Network were surveyed about their current pregnancy care practice patterns. A total of 205 graduates from 1997-1999 (surveyed in 2000) and 223 graduates from 2000-2002 (surveyed in 2003) completed the surveys (69% and 65% response rates). RESULTS: From 2000 to 2003, there was a 20% decline in the proportion of recent family medicine residency graduates performing deliveries in their practice (78% versus 58%). The proportion performing prenatal care declined from 81% to 64%. Graduates from all the programs across the region rated their preparation for the practice of pregnancy care highly, regardless of whether or not they currently provided such care. In addition to graduation cohort, the provision of pregnancy care was also related to practicing in the Washington, Alaska, Montana, and Idaho (WAMI) region, providing hospital care, and feeling well prepared to provide pregnancy care. (Wyoming residency programs became affiliated with the WAMI network in 2003 and are not included in this analysis.) CONCLUSIONS: Fewer new family physicians are providing pregnancy care in the Pacific Northwest. This decline does not appear to be related to training but threatens access to service for patients.

Randomized trial of pharmacist interventions to improve depression care and outcomes in primary care.

PURPOSE: The impact of pharmacist interventions on the care and outcomes of patients with depression in a primary care setting was evaluated. METHODS: Patients diagnosed with a new episode of depression and started on anti-depressant medications were randomized to enhanced care (EC) or usual care (UC) for one year. EC consisted of a pharmacist collaborating with primary care providers to facilitate patient education, the initiation and adjustment of antidepressant dosages, the monitoring of patient adherence to the regimen, the management of adverse reactions, and the prevention of relapse. The patients in the UC group served as controls. Outcomes were measured by the Hopkins Symptom Checklist, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depression, health-related quality of life, medication adherence, patient satisfaction, and use of depression-related health care services. An intent-to-treat analysis was used. RESULTS: Seventy-four patients were randomized to EC or UC. At baseline, the EC group included more patients diagnosed with major depression than did the UC group (p = 0.04). All analyses were adjusted for this difference. In both groups, mean scores significantly improved from baseline for symptoms of depression and quality of life at three months and were maintained for one year. There were no statistically significant differences between treatment groups in depression symptoms, quality of life, medication adherence, provider visits, or patient satisfaction. CONCLUSION: Frequent telephone contacts and interventions by pharmacists and UC in a primary care setting resulted in similar rates of adherence to antidepressant regimens and improvements in the outcomes of depression at one year.

Addressing disparities in children's oral health: a dental-medical partnership to train family practice residents.

Providing oral health care to rural populations in the United States is a major challenge. Lack of community water fluoridation, dental workforce shortages, and geographical barriers all aggravate oral health and access problems in the largely rural Northwest. Children from low-income and minority families and children with special needs are at particular risk. Family-centered disease prevention strategies are needed to reduce oral health disparities in children. Oral health promotion can take place in a primary care practitioner's office, but medical providers often lack relevant training. In this project, dental, medical, and educational faculty at a large academic health center partnered to provide evidence-based, culturally competent pediatric oral health training to family medicine residents in five community-based training programs. The curriculum targets children birth to five years and covers dental development, the caries process, dental emergencies, and oral health in children with special needs. Outcome measures include changes in knowledge, attitudes, and self-efficacy; preliminary results are presented. The program also partnered with local dentists to ensure a referral network for children with identified disease at the family medicine training sites. Pediatric dentistry residents assisted in didactic and hands-on training of family medicine residents. Future topics for oral health training of family physicians are suggested.

Family practice training over the first 26 years: a cross-sectional survey of graduates of the University of Washington Family Practice Residency Network.

PURPOSE: To describe the current practice setting, scope of practice, and adequacy of residency training of a large cohort of family practice (FP) residency graduates. METHOD: In February 2000, questionnaires containing 120 demographic, practice, and training items were mailed to 1,498 graduates (1973-1999) of the University of Washington Family Practice Residency Network. RESULTS: A total of 983 (71%) graduates completed the survey. Of the 870 who were currently practicing family physicians, 38% were women, 73% worked full-time, 45% practiced in FP groups, and 97% were board certified in FP. A total of 37% practiced in communities of fewer than 25,000 residents, and 29% practiced in federally designated health provider shortage sites. Most cared for their patients in the hospital: 79% for adult medical patients, 54% for adult ICU/CCU patients, and 71% for children. Most provided maternity care: 63% delivered babies and 58% assisted at cesarean sections (12% as primary surgeon). Even in cities of over 100,000, 58% delivered babies. Large numbers of responders performed colposcopy, flexible sigmoidoscopy, vasectomy, and minor surgery. A higher proportion of the most recent graduates provided maternity care and performed colposcopy. Most graduates reported that residency training prepared them well. CONCLUSIONS: FP residency training is modeled to prepare primary care physicians to meet the needs of all patients in all communities. These data document the success of this model in producing and sustaining family physicians to fulfill these roles in practice.

Collaborative care model to improve outcomes in major depression.

OBJECTIVE: To develop a pharmacist intervention to improve depression care and outcomes within a primary care setting. METHODS: Pragmatic, randomized trial of a clinical pharmacist collaborative care intervention versus usual care in a busy, academic family practice clinic. RESULTS: Seventy-four patients diagnosed with a new episode of major depression and started on antidepressant medications were randomized to enhanced care (EC) or usual care (UC) groups. EC consists of a clinical pharmacist collaborating with primary care providers (PCPs) to facilitate education, initiation, and titration of acute-phase antidepressant treatment to monitor treatment adherence and to prevent relapse. Control patients receive UC by their PCP. The main end point is reduction of depression symptoms over time as measured by the Hopkins Symptom Checklist (SCL-20). Other outcomes include the Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV) criteria for major depression, health-related quality of life measured by the Medical Outcomes Study Short Form 12 (SF-12), medication adherence, patient satisfaction, and healthcare utilization. The main end point and the cost of treating major depression will be used to estimate the cost-effectiveness of the collaborative care model. CONCLUSIONS: The study is a unique, ongoing trial that may have important implications for the treatment of depression in primary care settings as well as new roles for clinical pharmacists.