Harmonizing Academic Missions in Family Medicine: One Department's Experience
Background and Theory Overview: Academic practices and departments face increasing pressure to meet the Triple Aim of care experience, population health, and affordability. Although care, education, and research are conceived as mutually reinforcing, they often present challenges in practice as the missions are experienced as separate or competing. This paper presents a longitudinal case example from a large family medicine department that has harmonized its academic missions so that each complement and enhances the others, without any single mission dominating or negating the others. The goal was to highlight an example of harmonizing missions that builds a foundation for a learning health system, potentially improving faculty well-being.
What is New: The existing literature lacks specific examples and strategies for achieving a goal where missions positively reinforce each other and improve faculty well-being. The faculty within the Department of Family Medicine and Community Health at the University of Minnesota Medical School created a shared vision of harmonized missions across the operation. Instead of establishing a centralized project management plan, the department was led as a complex adaptive system. This system employed three elements: a belief in a "good enough vision," like a 2013 vision that described sections of a jazz band playing the same music, not separate bands playing their own songs, which provided a shared language from which faculty oriented themselves and engaged. They created a harmonization group that looked for opportunities to balance priorities and harmonize on projects. Lastly, they applied simple rules for harmonizing missions, such as translating innovations that spontaneously arise in any mission area to all mission areas, designing projects as tri-mission efforts from the start, using harmonization when dealing with crises, thinking "harmonize" when groups become distant, and giving department performance feedback across missions, not in isolation.
Results: Since the start of the project, the department's academic missions have increasingly been experienced as mutually beneficial rather than as parallel and competing priorities, with significant expansion of scholarly output across all faculty. Though not originally intended to improve faculty vitality, enthusiastic partnerships appeared to amplify excitement and participation.
Why It Matters: Harmonization is an example of creating a learning, adaptive health system within an academic department that has the potential to additionally improve clinician well-being. The paper presents concrete examples of cultural and operational strategies that institutions can implement to better integrate their missions and support faculty careers over the long term.
Harmonizing the Tripartite Mission in Academic Family Medicine: A Longitudinal Case Example
C.J. Peek, PhD, et al
Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Innovations in Primary Care
Team-Based Management of High-Priority Messages Shown to Reduce Feelings of Burnout Among Physicians
The messaging feature of electronic health records requires constant monitoring so that urgent messages do not get missed. This constant monitoring is a known contributor to primary care physician burnout. To address this, a group created a system to manage high-priority in-basket messages. All physicians in the group shared inbox access and shared the workload on a rotating schedule, and all reported reduced feelings of burnout.
Team-Based Management of High-Priority In-Basket Messages
John Holkeboer, BA, et al
University of Michigan, Department of Family Medicine
Ann Arbor, Michigan
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Innovations in Primary Care
Utilizing Medical Assistants to Manage Patient Portal Messages Shown to Support Practice and Physician Efficiency
Many primary care clinicians directly receive messages from patients via electronic health records' portal inboxes. The COVID-19 pandemic saw a rapid uptick in this trend. Data suggests that this additional work is linked to clinician burnout. Penn Family Care, a primary care group at Penn Medicine, instead routed incoming messages to certified medical assistants who had been taught how to distribute each message to the most appropriate physician. There was a 40% decrease in the number of messages going directly to primary care physicians, and both practice and clinician efficiency showed improvement after adopting this team-based care model.
Utilizing Medical Assistants to Manage Patient Portal Messages
Jennifer N. Lee, MD, et al
Department of Family Medicine and Community Health, University of Pennsylvania
Philadelphia, Pennsylvania
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Original Research
Study Shows Clinic Continuity Associated with Reduced Hospital and Emergency Visits
Background and Goal: Relational continuity, the ongoing relationship between a patient and a family physician, is linked to better patient care, fewer unnecessary procedures, hospitalizations, emergency department visits, and lower costs, along with higher patient satisfaction. With the rise of part-time practices, patients often see multiple family physicians within the same clinic. This study aimed to explore how continuity in a primary care clinic—separate from individual physician continuity—affects patient health outcomes in Alberta, Canada.
Study Approach: The study analyzed linked health administrative data from Alberta from 2015 to 2018. It examined the relationship between both physician and clinic continuity and the rates of emergency department visits and hospitalizations, considering various levels of patient complexity. Continuity was measured by the percentage of visits a patient made to their regular family physician compared to all primary care visits. Patients were included if they had at least three visits in a three-year period, with continuity categorized into low (0-40%), moderate (41-80%), and high (81-100%) groups. Patient complexity was assessed using the clinical risk grouper (CRG) methodology, which assigns one of nine complexity levels based on health history.
Main Results: 44% of patients were male and 56% female. Researchers found that known clinician continuity is associated with reduced emergency room visits and hospitalizations, especially in complex patients. Most patients had moderate to high continuity with their family physician. Patients who frequently visited the same clinic group also had fewer hospital and emergency department visits, indicating that larger group practices might facilitate better care continuity. Additionally, continuity within clinics was associated with improved outcomes, but the effect of clinic continuity was less pronounced than the effect of known clinician continuity. Group continuity was more important for complex patients than for less complex patients.
Why It Matters: Consistently seeing the same family physician, or at least staying within the same clinic group, is associated with improved health outcomes. These findings highlight the importance of clinic continuity in community primary care and suggest areas for further research, especially regarding why patients receiving low levels of group care face slight disadvantages. This study provides valuable insights for future primary care design and investment. Rather than investing in urgent care, the authors suggest that investing in collaborative primary care clinics may result in better outcomes for patients.
The Impact of Primary Care Clinic and Family Physician Continuity on Patient Health Outcomes: A Retrospective Analysis From Alberta, Canada
Terrence McDonald, MD, MSc, et al
Department of Family Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Essay
Recognizing the Range of Experiences Among Individuals of Latino, Hispanic, and/or Spanish Origin is an Essential Step Toward Health Equity
Background: Currently, people of Latiné/e/x/o/a, Hispanic, and/or Spanish (LHS) origin make up 19.1% of the population of the U.S. There is great variation in the personal experiences and family backgrounds of LHS individuals, including differences in country of origin, time in the U.S., colonization histories and immigration experiences.
Key Argument: This essay considers the importance of recognizing the heterogeneity of lived experiences among LHS populations in the U.S. in a health care context.
Why It Matters: Race is a sociopolitical construct that is often conflated with ethnicity. Both use broadly defined categories to identify one's biological and cultural background. One's race and/or ethnicity (self-identified and/or perceived), however, can have a profound impact on health risks as well as health care and outcomes. Aggregating patients by broad racial or ethnic groups creates risks for clinical care and research, even when clinicians and/or researchers are sensitive to diversity issues. As we work toward more equitable health care for minoritized populations, including for LHS communities as an aggregate group, it is important to recognize both the use and limits of racial/ethnic categorization and consider more nuanced aspects of biological and cultural heritage.
Optional Quote: "There is power in unity when advocating for community, social, and political change, especially as it pertains to Equity, Diversity, and Inclusion (EDI) efforts in academic institutions. Yet, there is also a critical need to disaggregate the LHS diaspora and its conceptualization based on differing experiences so that we may improve our understanding of the sociopolitical attributes that impact health."
We Are Not All the Same: Implications of Heterogeneity Among Latiné/e/x/o/a, Hispanic, and Spanish Origin People
Diana N. Carvajal, MD, MPH, et al
Department of Family & Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Original Research
Study Reveals Decline in Reported Medicare Outpatient Procedures by Family Physicians Amid an Aging Population
Background and Goal: Family physicians perform a wide range of procedures outside the hospital and tend to be office based. Examples may include surgical procedures such as excisions, suturing, and joint injections. Since the training can vary substantially, the Council of Academic Family Medicine (CAFM) issued a statement on which procedures they recommend physicians be able to perform competently upon completion of a family medicine residency. The aim of this study was to determine the extent to which family physicians perform CAFM-recommended procedures for Medicare Part B, the outpatient portion of Medicare. By documenting the procedural clinical activity of family physicians, the researchers set out to better understand their impact on U.S. primary care.
Study Approach: Using a publicly available dataset that contains use, payments, and submitted charges for Medicare activities, researchers matched Medicare patient encounter codes with CAFM-recommended procedures to analyze how often family physicians reported CAFM-recommended procedures in an outpatient setting from 2014 to 2021. The researchers classified procedure codes by organ system.
Main Results: In 2021, 9,410 family physicians filed 904,278 CAFM procedure claims for 444,309 patients.
- All (99.92%) of the mCAFM procedures reported in 2021 fell into the following five procedure clusters: skin (51%), musculoskeletal (36%), eyes, ears, nose, and throat (EENT) (9%), pulmonary (2%), and anesthesia (2%)
- Despite a slight uptick (2% to 6%) in skin, musculoskeletal, and anesthesia procedures between 2018 and 2019, there was a 33% decline in outpatient procedures filed and a 36% decline in the number of family physicians filing them between 2014 and 2021
- Only 12% of family physicians reported CAFM outpatient procedure claims in 2021. These claims represent less than 1% of all patient encounter codes submitted that year
Why It Matters: Fewer and fewer family physicians are billing for CAFM-recommended procedures. This trend is concerning as the U.S. population is aging. While procedures may increasingly be performed by physician assistants, nurse practitioners, or specialists after referral, this trend is still troublesome because it is likely to reduce access and convenience while increasing cost.
Family Physicians as Proceduralists for Medicare Recipients
Robert McKenna, DMSc, MPH, PA-C, et al
Marshall B. Ketchum University, Fullerton, California
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Original Research
Stratified Care Significantly Improves Disability and Quality of Life in Primary Care Patients With Low Back Pain
Background and Goal: Low back pain, or LBP, challenges health systems worldwide. To mitigate persistent disabling LBP, the implementation of a stratified approach in primary care has been suggested. This strategy involves aligning specific treatments with distinct patient subgroups. The StarT Back trial demonstrates the effectiveness and cost effectiveness of the stratified approach for LBP using the StarT Back Screening Tool (SBST), which categorizes patients into low, medium, and high risk of developing persistent disabling pain. This approach suggests matched physical therapy treatments of increasing dosages and complexity according to risk subgroups. The goal of this study was to determine the effects of a stratified approach (SPLIT program) in reducing back-related disability of patients with LBP in primary care.
Study Approach: Conducted with the Regional Health Administration of Lisbon and Tagus Valley, the study involved 7 health units of the Arrábida health center group. It enlisted 447 participants, using a before-and-after design with two sequential, independent patient groups. From February to September 2018, family physicians managed the initial group of 115 patients according to usual care, unaware of the SPLIT program. The second phase involved training and mentoring primary care–based physical therapists (PT) in a structured program to potentiate the implementation of a stratified care approach, the SPLIT program. This phase included training PTs in assessing patients' disability risk, matching treatments to risk levels, and tracking outcomes. Family physicians were presented with the SPLIT program, including the latest recommendations for managing LBP to enhance recruitment and referrals to PTs. In phase three, from November 2018 to October 2021, usual care continued but added referrals of eligible patients to primary care–based physical therapists for the SPLIT group, comprising 332 participants. Health outcomes for both groups were assessed via telephone at two and six months, focusing on back-related disability, pain intensity, quality of life, and perceived effect of treatment.
Main Results: The average age of the participants was about 46 years old. Most of them were women and the majority were employed. The SPLIT group was slightly younger. LBP symptoms were generally less severe in the SPLIT group.
- Over six months, significant improvements in back-related disability, pain, and health-related quality of life were observed in the SPLIT group compared to the usual care group.
- The first group of patients were mainly treated by family physicians with pharmacological treatment (85.3%). Nonsteroidal anti-inflammatory drugs (81.4%) and muscle relaxants (60.8%) were the most frequent, followed by weak opioids (19.6%). Only 8.3% of patients were referred for physical therapy.
- In the SPLIT group, an average of 3.76 physical therapy sessions were provided: 1.11 for patients with low risk, 4.48 for medium risk, and 9.98 for high risk.
Why It Matters: The SPLIT program can significantly improve outcomes in patients with low back pain. The SPLIT program's success indicates that tailored care strategies can benefit a broad spectrum of patients, not just those at the highest risk. Further research should assess the cost effectiveness of the SPLIT program.
A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study
Luís Antunes Gomes, MSc, et al
Comprehensive Health Research Centre, EpiDoC Unit, NOVA Medical School, Universidade NOVA de
Lisboa, Lisbon, Portugal
Departamento de Fisioterapia, Escola Superior de Saúde, Instituto Politécnico de Setúbal,
Setubal, Portugal
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
PERMANENT LINK
Original Research
COVID-19 Pandemic Leads to Drop in Breast Cancer Screenings, Especially Among Older and Racial Minority Women
Background and Goal: Breast cancer is the second most common cancer among women in the U.S.. Early detection of the disease through screening can greatly improve the chances of successful treatment and is an essential preventive service in primary care. The COVID-19 pandemic interrupted breast cancer screening as many screening programs were temporarily suspended due to personal concerns about exposure to the virus and the burden on the health care system. The goal of this study was to use real-world electronic health records (EHR) across the U.S. to examine the changes in breast cancer screening utilization since the COVID-19 pandemic and how the follow-up screening rates were impacted by the pandemic.
Study Approach: Using the TriNetX Research Network, a global platform that connects health care organizations and researchers, offering real-time access to anonymized clinical data, the researchers retrospectively analyzed a group of 1,186,669 women eligible for breast cancer screening from Jan. 1, 2017, to Feb. 28, 2022. The researchers looked at how frequently screenings occurred each month within the study period and observed any patterns or changes in frequency. They paid particular attention to how these patterns varied before and during the COVID-19 pandemic, especially regarding how often individuals returned for a follow-up screening within 24 months of their previous screening.
Main Results:
- The monthly screening volume temporarily decreased by 80.57% from February to April 2020 but rebounded to close to pre-pandemic levels after June 2020.
- Even after the rebound, there was still a decrease in the rate of follow-up breast cancer screenings. On average, COVID-19 led to a 2.47% decrease in follow up screening rates among all women participants, with a 95% confidence interval of -2.60 to -2.34. This indicates a significant number of missed screenings given the large population scale.
- Women were generally less likely to return for follow-up screenings during the pandemic, especially women over 65 years old and women from racial minority groups who are not Hispanic.
Why It Matters: The slight decrease in follow-up screening rates translates to many missed opportunities for early detection and treatment of breast cancer, which can result in late-stage diagnoses and poorer health outcomes. The disparities in adherence to follow-up screenings among older and racial minority women are concerning as they suggest a risk of increased late-stage diagnoses and mortality among these groups. Innovative strategies, such as the use of technology and community-based interventions, are needed to ensure that all women, especially those from vulnerable groups, have access to screenings.
"Understanding the medical comorbidities and social determinants that impact screening adherence in the COVID period and how that drives current gaps and disparities is crucial for family physicians and health systems to provide the best care for their patient population," the author wrote.
Breast Cancer Screening During the COVID-19 Pandemic in the United States: Results From Real-World Health Records Data
Qiushi Chen, PhD, et al
The Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, The Pennsylvania State University, University Park, Pennsylvania
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Special Report
Translating the Surgeon General's Framework on Social Isolation and Loneliness to Actionable Steps in Primary Care
Background & Goal: Prior to the COVID-19 pandemic, 20% of adult primary care patients identified as lonely, representing a higher prevalence than many diseases commonly seen in primary care such as diabetes. Social isolation and loneliness are increasing over time, which is not only associated with increased health care utilization in primary care patients, but also with increased risk of chronic health conditions. Social isolation is reported to be equivalent to smoking 15 cigarettes per day in terms of premature death. The U.S. Surgeon General recently released an advisory entitled, "Our Epidemic of Loneliness and Isolation," presenting a framework for action that includes three main pillars for the health care sector: 1) train health care clinicians, 2) assess and support patients, and 3) expand public health surveillance and interventions. In this paper, the authors summarize the Surgeon General's framework and present actionable steps for implementing the framework in primary care.
Why This Matters: All health care professionals will encounter social isolation and loneliness in clinical settings. While social isolation and loneliness were historically not considered within the scope of clinical care—and hence, few systematic attempts have been made to address social isolation and loneliness—we are now at a critical juncture where the health care workforce must recognize this as a medical issue. Infrastructural support is needed, and the primary care sector can be instrumental in addressing this epidemic through prevention, early identification, education, and intervention.
The Role of Primary Care in the Social Isolation and Loneliness Epidemic
Sebastian T. Tong, MD, MPH, et al
Department of Family Medicine, University of Washington, Seattle, Washington
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Point/Counterpoint
Point/Counterpoint: Is Prediabetes Overdiagnosed?
Background: Prediabetes, a diagnosis intended to identify high-risk persons and prevent progression to diabetes, has been a topic of ongoing debate, and experts continue to disagree about its screening criteria, interpretation, and implications.
Author Stance: An epidemiologist and health services researcher argues that prediabetes is overdiagnosed. A prediabetes diagnosis for patients like herself who are at low risk of developing type 2 diabetes can cause more harm than good. They may experience undue distress, undergo unnecessary consultations and tests, and pay additional health care costs. It may be implied—incorrectly—that prediabetes will inevitably develop into diabetes. Ultimately, the author feels, clinicians should focus on identifying and treating patients at high risk or with diabetes: "Let's put out fires, not fan flames."
Conversely, a family physician argues that a prediabetes diagnosis "represents a crucial stage for intervention in primary care." Prediabetes can signal an individual has metabolic syndrome, which increases the risk of all-cause mortality, cardiovascular disease, risks of common cancers, and neurocognitive disorders. To provide a comprehensive health assessment—and to avoid causing patients anxiety—physicians shouldn't over-rely on a single biomarker. He presents three hypothetical case studies to illustrate the complexities of diagnosing and managing prediabetes. He concludes, "By recognizing the early signs and adopting a holistic view of patient health, family physicians play a pivotal role in preventing the long-term risks associated with prediabetes and metabolic syndrome, and ultimately improving patient outcomes and quality of life."
Why It Matters: We now know that type 2 diabetes is a preventable disease. There is disagreement about who is at higher risk and who would be a good candidate for preventive interventions. Balancing potential harms of overdiagnosing prediabetes with opportunities for early intervention to prevent progression is complex. Patient-centered counseling and patient preferences matter in these discussions.
Is Prediabetes Overdiagnosed? Yes: A Patient-Epidemiologis's Experience
Rani Marx, PhD, MPH
Initiative for Slow Medicine, Berkeley, California
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Is Prediabetes Overdiagnosed? No: A Clinician's Perspective
Jonathan G. Gabison, MD
University of Michigan Family Medicine, Ann Arbor, Michigan
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Innovations in Primary Care
Primary Care Clinics Can Help Low-Income Families Receive Nutritional Support Benefits
A research team designed a standardized process for helping low-income families navigate applications for federal nutrition support programs. Within a brief tablet-based nutrition screener completed at pediatric primary care visits, families were asked if they would like help applying for Women, Infants, and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP) benefits. If they did, clinic staff followed up by telephone with application assistance. One limitation of this innovation is that some families were not able to be reached by telephone.
Connecting Families to Benefit Programs Through a Standardized Nutrition Screener
Aditi Vasan, MD, MSHP, et al
Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
The Possibilities Project and Clinical Futures, Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Editorial
The Wall of Evidence for Continuity of Care
Background: A long-term relationship between a patient and their doctor, known as continuity of care, has seen a decline in recent decades in both the UK and the U.S. This decline has negatively impacted patient and physician health outcomes and well-being.
Editorial Stance: Building on Terrence McDonald and colleagues' research, which distinguishes between the continuity contributions of a practice and an individual clinician, increased physician continuity has been linked to reduced emergency department usage for all patients and lower hospitalization for those with higher patient complexity. Notably, patients consistently seeing their regular family physician or a partner at the same practice had the best health outcomes. The author notes that this evidence is crucial and points to practical solutions that increase physician awareness of continuity's benefits and underscore the relationship between continuity and key health outcomes.
Why It Matters: Gradual benefits of improved continuity suggest that solutions don't have to be all-or-nothing but can come from various strategies that together enhance overall care. Possible improvements include 'buddy' systems among doctors, the use of e-health options, and focused training for family physician trainees on delivering continuity of care. These methods represent stepwise changes that can collectively improve continuity of care.
The Wall of Evidence for Continuity of Care: How Many More Bricks Do We Need?
Otto R. Maarsingh, MD, PhD
Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health, Amsterdam, The Netherlands
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Original Research
Parents of Children With Serious Illness From Somali, Hmong, and Latin American Communities Desire Better Communication and Support in Pediatric Health Care
Background and Goal: Nearly 500,000 children in the U.S. live with serious or life-threatening illnesses. Family caregivers, especially parents, face the challenges of managing complex medical needs, navigating the health system, and advocating for their children. This often leads to psychological distress, depression, and anxiety for caregivers. Understanding the experiences of parents of children with serious illnesses, especially those who are racially and ethnically diverse, remains limited. This study examined the experiences of Somali, Hmong, and Latin American parents in pediatric serious illness care, aiming to identify improvements and reduce disparities in pediatric health care.
Study Approach: Researchers formed a team in partnership with a community advisory board consisting of Somali, Hmong, and Latin American community leaders and parents, who provided input on study design, analysis, and recommendations. Participants, including caregivers and parents, were recruited through provider referrals, flyers, social media, and community networks in the Minneapolis-St. Paul, Minnesota, metropolitan area. They completed demographic surveys and participated in either a 1.5- to 2-hour community-specific focus group or individual Zoom or telephone interviews, guided by a structured interview guide developed from literature, professional and community insights, and advisory board feedback. The interviews were transcribed and analyzed to identify common aspects of the parents' experiences across all three communities.
Main Results: Twenty-six parents participated. All but one were mothers. Their children, ranging from infants to adults, suffered from serious illnesses, some requiring intensive medical support like feeding tubes or ventilators. Researchers found that professional interpreters were important to improve communication and trust. Other key findings include a strong desire for respectful, trusting relationships with medical staff, highlighted by three main themes:
- Informed understanding helps parents prepare for their children's medical needs
- Compassionate staff interactions make parents feel their children are well cared for
- Respected parental advocacy ensures parents' insights are valued
Challenges included language barriers, systemic mistrust, and experiences of racism.
Why It Matters: Fostering caring and compassionate dialogue that involves both parent and medical staff point of view is essential for building trust and providing quality care. Active listening by clinicians, collaboration, and shared decision making are particularly important for parents from diverse communities. Addressing patients' religious, spiritual, and cultural needs also helps build trust that their children are well cared for. The study advocates for interventions at both individual and systemic levels, driven by community voices like those of the parents in this study.
"We Feel Alone and Not Listened To": Parents' Perspectives on Pediatric Serious Illness Care in Somali, Hmong, and Latin American Communities
Jennifer Needle, MD, MPH, HEC-C, et al
University of Minnesota, Minneapolis, Minnesota
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Research Brief
Primary Care Can Improve Hygienic Practices While Reducing Waste
Background & Goal: Exam table paper is perceived as necessary for hygienic care; however, there is limited evidence for its efficacy. It may not stop disease transmission, and it may create a false sense of cleanliness. The Ontario Guidelines for Prevention & Control of Infection in Healthcare Settings do not endorse exam table paper, but rather recommend cleaning with specific low-level disinfectants (for example, 0.5% accelerated hydrogen peroxide). Additionally, there are negative economic and climate change impacts of using exam table paper. The average clinic seeing ~100 patients per day spends ~$75-$90 CAD (~$55.40-$66.50 USD) per week on exam table paper. Exam table paper contributes to the environmental impact and carbon footprint of the health care industry.
Study Approach: Exam tables were covered with exam table paper according to usual practices, which leaves about 25% uncovered. Study participants in the 'patient' role spread the liquid form of the fluorescent product Glo GermTM across both of their palms. They then received one of three common exams seen in family medicine clinics—knee/hip, cardiorespiratory, or abdominal—by a resident physician in the 'doctor' role. Black UV light was used to identify areas of the exam table with Glo GermTM. These steps were then repeated with exam tables that were not covered with exam table paper.
Results: Whether or not exam table paper was present, patient-role volunteers more frequently touched the areas of the table that are not typically covered with exam table paper (i.e. the sides).
Why It Matters: The economic and environmental costs of exam table paper cannot be overlooked. A reduction in exam table paper use may mitigate this field's environmental impact, carbon footprint, and unnecessary clinic spending. Additionally, hygienic maintenance of exam tables can shift from reliance on exam table paper to low-level disinfectants. Exam table paper may still be beneficial in certain sensitive exams (rectal/genital/pelvic) and vulnerable populations (newborns and the elderly). The study has limitations, in that it did not consider the economic and climate costs of using low-level disinfectants.
Does Examination Table Paper Use Mitigate the Risk of Disease Transmission in a Family Medicine Clinic?
Nathan Chiarlitti, MD, et al
Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Research Brief
Variations in Medical Assistant to Primary Care Clinician Staffing Ratios May Reflect Differences in Practice Ownership and Organizational Culture
Background and goal: Medical assistants (MAs) are among the fastest growing occupations within the U.S. primary care workforce, and many practices have expanded the roles and caregiving responsibilities of primary care MAs. However, little is known about organizational factors associated with MA support levels for primary care clinicians (PCCs).
Study Approach: This study analyzed the current ratio of medical assistants (MAs) to primary care clinicians based on responses to the second National Survey of Healthcare Organizations and Systems (NSHOS II), a 52-question survey of a nationally representative sample of adult primary care physician practices. Practice characteristics such as practice ownership (independent, group-owned, system-owned) and aspects of organizational culture (e.g., practice goals and values) associated with MA to PCC staffing ratios were taken into consideration in the analysis.
Results: Of 1,252 responding practices, most (56.6%) had ratios of 1 MA per PCC, while only 11.4% had ratios of 2 or more MAs per PCC; 27.6% had ratios of less than one-to-one, and 4.3% of practices did not employ MAs. Independent practices, medical group–owned practices, and Federally Qualified Health Centers (FQHCs) were more likely to have ratios of 2 or more MAs per PCC than practices owned by health care systems. In terms of organizational culture, innovation-oriented practices were more likely to have staffing ratios of 2 or more MAs per PCC. Low MA staffing levels were not associated with higher levels of staffing of nurses, physician assistants, and nurse practitioners.
Why It Matters: Health-system–owned practices are less likely to be adequately staffed with MAs than practices with other organizational structures. Inadequate MA staffing negatively affects patient care and may also contribute to physician burnout. Policy makers and insurance companies might consider financial incentives to promote adequate staffing.
Primary Care Practice Characteristics Associated With Medical Assistant Staffing Ratios
Hector P. Rodriguez, PhD, MPH, et al
School of Public Health, University of California, Berkeley, California
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
Original Research
Power Imbalance in Health Care Reveals Impact of Race and Role on Team Dynamics and DEI Efforts
Background and Goal: Team-based care is considered the gold standard in delivery models. It uses integrated clinical teams with diverse skills and perspectives to provide efficient, high-quality health care services. Within these teams, individuals from minoritized racial-ethnic groups, often referred to as persons of color (POC), typically occupy roles with less authority (e.g., medical assistants), while white individuals more frequently hold positions of greater power (e.g., physicians). Few studies have explored the viewpoints of staff members in lower-power roles, who are disproportionately POC and constitute the majority of a health care team. This study aims to understand the perspectives of clinic staff members across racial and role groups to inform future interventions that could improve health care teams and address race-related issues more effectively.
Study Approach: From May to July 2021, researchers conducted semi-structured, 45-minute interviews with 60 staff members at community health clinics within a large urban health care system. The team intentionally recruited participants to ensure representation of POC and support staff, including medical assistants, front desk clerks, care navigators, nurses, and others. Interviews were recorded, transcribed, and analyzed over six months using a critical ideological framework. This theoretical approach focuses on understanding and challenging power structures, ideologies, and social inequalities within society.
Main Results: Among the 60 participants, most identified as female (83%), POC (68%), and support staff (70%). Five overarching themes emerged:
- POC face hidden challenges
- Racial discrimination persists
- Power dynamics perpetuate inaction
- Interpersonal actions (such as relationship building, active recognition of staff member contributions, and tangible anti-racist steps) foster safety and equity
- System-level change is needed for cultural shifts
POC team members deal with hidden challenges related to managing an emotional burden that white team members may not perceive. Those with the least power in the clinic, namely support staff who are POC, bear the brunt of this burden and yet have the least power to effect change, resulting in diversity, equity, and inclusion (DEI) inaction. Relationship building acts as a buffer to race-related experiences and is, to some extent, reparative and protective for POC team members.
Why It Matters: Without a sense of belonging and value, diversity and equity efforts fail to last in the workplace. Interpersonal actions and system-level changes are essential for a cultural shift, undertaken by those currently in positions of power. The findings show that investing time in developing team relationships, actively recognizing staff contributions, and taking tangible antiracist actions by leadership foster safety and equity. The researchers recommend that leadership take on the responsibility of identifying and offering repeated, experiential, and interactive training. These should serve as alternatives to ineffective one-time DEI training.
Power Dynamics Perpetuate DEI Inaction: A Qualitative Study of Community Health Clinic Teams
Laura Marie Ramzy, PhD, et al
Integrated Behavioral Health, Ambulatory Care Services, Denver Health and Hospital Authority,
Denver, Colorado
Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
PRE-EMBARGO LINK (Link expires at 5 p.m. EDT May 28th, 2024)
