Jerry Kruse

Health is primary: Family medicine for America's health.

PURPOSE More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to “renew the specialty to meet the needs of people and society,” some of which bore important fruit. Family Medicine for America’s Health was launched in 2013 to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim). METHODS Family Medicine for America’s Health was preceded and guided by the development of a family physician role definition. A consulting group facilitated systematic strategic plan development over 9 months that included key informant interviews, formal stakeholder surveys, future scenario testing, a retreat for family medicine organizations and stakeholder representatives to review strategy options, further strategy refinement, and finally a formal strategic plan with draft tactics and design for an implementation plan. A second communications consulting group surveyed diverse stakeholders in coordination with strategic planning to develop a communication plan. The American College of Osteopathic Family Physicians joined the effort, and students, residents, and young physicians were included. RESULTS The core strategies identified include working to ensure broad access to sustained, primary care relationships; accountability for increasing primary care value in terms of cost and quality; a commitment to helping reduce health care disparities; moving to comprehensive payment and away from fee-for-service; transformation of training; technology to support effective care; improving research underpinning primary care; and actively engaging patients, policy makers, and payers to develop an understanding of the value of primary care. The communications plan, called Health is Primary, will complement these strategies. Eight family medicine organizations have pledged nearly

Meconium Aspiration Syndrome: Pathophysiology and Prevention

20 million and committed representatives to a multiyear implementation team that will coordinate these plans in a much more systematic way than occurred with FFM. CONCLUSIONS Family Medicine for America’s Health is a new commitment by 8 family medicine organizations to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim. It is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.

Research support infrastructure and productivity in U.S. family practice residency programs.

Background: Despite the common occurrence of intrauterine meconium passage and resultant meconium aspiration syndrome (MAS), controversies regarding the pathophysiology and use of appropriate preventive strategies abound. Methods: Databases from MEDLINE, MD Consult, and the Science Citation Index were searched from 1964 to the present to find relevant sources of information. Results and Conclusions: Meconium passage occurs by three distinct mechanisms: (1) as a physiologic maturational event, (2) as a response to acute hypoxic events, and (3) as a response to chronic intrauterine hypoxia. Meconium passage might merely be a marker of chronic intrauterine hypoxia or can predispose to aspiration of meconium and resultant inflammatory pneumonitis, surfactant inactivation, and mechanical airway obstruction. Aspiration can occur in utero with fetal gasping, or after birth with the first breaths of life. Many cases of MAS can be prevented by the strategies addressed in this article, but some will occur despite appropriate preventive techniques. There is not enough evidence to support the use of amnioinfusion as a standard of care for all pregnancies complicated by meconium. Pharyngeal suctioning before delivery of the shoulders is an effective preventive intervention, as is the combination of pharyngeal suctioning followed by intubation and tracheal suctioning. Suctioning of the trachea may be done on a selective basis depending on fetal vigor and consistency of meconium.

The four pillars for primary care physician workforce reform: A blueprint for future activity

Purpose To examine the associations between 11 research support infrastructural characteristics and measures of research productivity. Method A questionnaire was mailed to 462 directors of non-military family practice residency programs in the United States. A total of 11 research support infrastructural characteristics and six research productivity measures were coded. Initial analyses indicated a skewness in responses given by larger versus smaller programs. Respondents were divided into those from programs with eight or fewer full-time faculty and those from programs with nine or more. Separate analyses were run for each. Logistic regression was employed to determine which research support characteristics would best predict productivity in the top quartile. Results Of the 461 recipients of deliverable questionnaires, 351 (76.1%) responded. A large proportion of programs reported no research productivity for the preceding 12 months. Separate stepwise logistic regression analyses were run for small and large programs; the ability of the 11 characteristics to predict research-productive programs varied with size. Employment of full-time research professionals was the only characteristic positively associated with research productivity for both groups. For small programs, research productivity was positively associated with the requirement of faculty members to do research. For large programs, it was positively associated with both the presence of fellowship programs and the presence of a specific, written research strategic plan. Conclusion This study demonstrated a positive association between several elements of research infrastructure and research productivity but that such infrastructure is inconsistent across programs and seemingly insufficient to develop the necessary research culture and socialization.

Allies in family medicine advocacy: the patient-centered primary care collaborative.

82 Max has been a member of the Governing Board of the Student Outreach Resource Center (SOURCE) at Johns Hopkins for 3 years. He is a co-leader of his medical school’s Urban Health Interest Group and Family Medicine Interest Group, he sat on the board of the Maryland Academy of Family Physicians Foundation, and he served as a Student Delegate to the National Congress of Student Members of the American Academy of Family Physicians (AAFP). Recently, Max was appointed to a 1-year term on the AAFP’s Commission on Health of the Public and Science and was named a Sommer Scholar at the Johns Hopkins Bloomberg School of Public Health. As a future family physician, Max looks forward to practicing community-based primary care and preventive medicine. He wants to bring innovative models of primary care delivery to underserved communities and provide coordinated, comprehensive, and compassionate care to his patients.

Shortage or Surplus of Physicians in the United States

In the quest for better health care for all Americans, the discipline of family medicine needs influential, aggressive allies. For decades, academic and organized medicine, the government, insurers, and consumers of health care have shown little interest in the development of an effective, efficient

Family Medicine Advocacy—It Depends on All of Us!

(safety population), described within the medical review. Next, we used Thomson Reuters’ Incidence and Prevalence Database,3 primary epidemiology literature, and summary reports to estimate the number of US patients who were potentially eligible for treatment (target population). We then calculated the ratio of safety population to the target population, categorizing therapeutics as having a ratio in the top quartile (ie, larger safety population relative to target population) or below the 75th percentile. The threshold ratio for categorization in the top quartile was 0.005, implying that the equivalent (or more) of 0.5% of the total number of US patients who were potentially eligible for treatment were used for the FDA’s therapeutic safety analysis. We repeated our original multivariable model, including the 7 novel therapeutic characteristics and features of their regulatory approval, as well as expected length of treatment and safety population:target population ratio. Neither characteristic was statistically associated with increased risk of postmarket safety events. For expected length of treatment, using short-term treatment as the reference, the incidence rate ratio (IRR) for intermediate treatment was 0.67 (95% CI, 0.35-1.29), whereas the IRR for long-term treatment was 0.88 (95% CI, 0.34-2.29). For the safety population:target population ratio, using the top quartile as the reference, the IRR for therapeutics below the 75th percentile was 1.17 (95% CI, 0.632.16). Further research should consider additional novel therapeutic characteristics or features of their regulatory approval that may be potential predictors of an increased risk of postmarket safety events.

At STFM, Advocacy is a Verb

Advocating for our members and promoting the value of family medicine to legislators and policymakers is an important priority for STFM. To do this, STFM gets involved in legislative and regulatory issues that affect our members and family medicine. We also strive to keep our members informed about

DEAR MR. PRESIDENT: REFORM HEALTH CARE, AND KEEP IT SIMPLE

The prospect of dramatic health care reform has spurred increased interest in governmental advocacy by STFM members. For some, the potential strain of primary health care needed by millions of newly insured Americans has struck a chord of anxiety and sparked an interest in advocacy. Most STFM members, however, welcome the opportunity to be participants in health system change that promotes primary care and its corollary benefits to society. Since the first draft of this article, the loss of a 60-vote Democratic majority in the Senate has made immediate passage of reform legislation less likely. Regardless, our work is cut out for us. New legislation would bring a myriad of opportunities and challenges, and STFM and its members must stand ready to think creatively, respond rapidly, and influence effectively. Should health care reform fail, our work is to assure that another generation doesn’t pass before Congress addresses reform again. It is our hope that the enthusiasm engendered this year will be harnessed and used for even more effective advocacy efforts. Each family medicine educator and primary healthcare professional should carefully assess his or her role in advocacy in the new healthcare construct. These questions are essential: What items for health care reform are most important for an effective, efficient, equitable system? What items are most important to impact the medical education system to train the workforce needed for such a system? What should I do if I haven’t participated in advocacy efforts yet? Do those currently active in advocacy efforts really need my help? A loud, unified voice from family medicine is needed, and STFM provides the organizational structure for you to be an effective advocate.

Community-Oriented Primary Care: Historical Perspective

Dear Mr. President, Congratulations on your election. We, the nation’s departments of family medicine, look forward to giving you a hand with health care reform. Compared to other rich nations, we know that our health outcomes fall far short, our health care costs are very high, and access to care is altogether inequitable. Rectifying these problems seems a daunting task, but when attention is paid to the abundant evidence, the solution boils down to 2 simple essentials—universal access to healthcare for all Americans, and much more emphasis on primary care, preventive medicine, and public health. You may ask: “How will we pay for greater access and for more primary care?” Solid evidence shows that the initial cost for this type of reform is recouped within 2 years and then there are substantial savings. Just ask Senator Richard Burr of North Carolina. He can tell you about his state’s great Community Care of North Carolina program.1 Like oil companies, we in academic family medicine are concerned about pipelines. For the best health care system, we need to train more family physicians. Ask Senator Edward Kennedy of Massachusetts. His state introduced a program of universal health care coverage in 2006, but it failed to flourish because there were not enough primary care physicians to care for all of the people suddenly insured.2 And guess what? It’s going to get worse. Currently, 32% of US physicians practice primary care. Over the last 3 years, the number of medical school graduates who will practice primary care is only 16%, and federal programs that will reverse the trend have been eviscerated. Here’s an example: Since 2000, the funding for Federally Qualified Health Centers (FQHCs) has nearly doubled to almost