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Objective: Our objective is to determine if the structure of Graduate Medical Education teaching clinics is associated with how well ophthalmology residents are prepared to meet the workload demands of independent clinical practice., Design: Resident preparedness to enter independent practice was measured by the Readiness Index. Part of the Department of Veterans Affairs' new Workload-based Resident Academic Performance measures (WRAP), resident readiness is computed from electronic health records for residents by clinic and service-date. The index compares resident productivity net of supervision and adjusted for care quality to the average productivity of non-supervising ophthalmologists. Readiness comprises a Workload component (ratio of resident gross productivity to the average productivity of non-supervising ophthalmologists) and Supervision component (ratio of resident net of supervision to gross productivity). Teaching clinic factors include resident postgraduate-year level, resident-to-physician staff ratios, patient care complexity, and program size. Covariates include time into the academic year, facility quality ranking and complexity rating, and attending physician productivity rate., Setting: Study setting is 109 ophthalmology outpatient clinics from the United States Department of Veterans Affairs and its 1,300 annual ophthalmology resident positions rotating on 84,600 ophthalmology clinic-days during academic years from July 1, 2015, through June 30, 2019., Participants: An average 2.6 residents at a second-year or higher saw 25.0 patients requiring 93.6 relative value units (RVUs) of workload., Results: Senior ophthalmology residents from clinics with higher resident-to-physician ratios had greater practice readiness than their counterparts primarily from having greater progressive autonomy from supervision. Residents from larger programs treating more complex patients had only slightly greater practice readiness than their counterparts primarily from having greater workload productivity., Conclusions: The readiness of ophthalmology residents to enter independent practice is associated with their academic level and resident-to-physician staff ratios, and to a lesser extent care complexity and program size., (Published by Elsevier Inc.)

Quite a lineup showcasing JABFM's emphasis on research and information for family medicine to improve patients' lives. Articles cover many topics: telemedicine, a clinical decision support tool, control of cardiovascular risk factors, opioid dose reduction, cancer survivorship care, patient engagement with case management/navigation, primary care physician capacity and usual source of care, marketing practices of Medicare Advantage programs, review articles (new diabetes medicine and treatment CHF with reduced ejection fraction), and more., Competing Interests: Conflict of interest: The authors are editors of the JABFM., (© Copyright 2024 by the American Board of Family Medicine.)

This issue includes articles on the lingering impact of COVID-19, often negative but occasionally positive, on patients, treatment, practices, and health care personnel. Other articles inform on prevention, such as awareness of lung cancer screening among women undergoing screening mammography; failures on sports preparticipation physicals; advance care planning as prevention; and screening for social risk factors. Another article reports on patient experiences of legal recreational cannabis in Washington State. There is a review of perinatal depression recognition and treatment. Two articles separately identify the difficulties of the congressionally created Medicare Advantage & Pharmaceutical Benefit Managers., Competing Interests: Conflict of interest: The authors are editors of the JABFM., (© Copyright by the American Board of Family Medicine.)

Background: Depressive symptoms and sleep disturbances disproportionately affect midlife women. While there may be a bidirectional association, few studies have examined whether depressive symptoms are longitudinally associated with subsequent sleep. Sleep is typically considered unidimensional, despite emerging evidence that multidimensional sleep health provides novel information on the sleep-health link., Purpose: The current study examined whether higher depressive symptoms were longitudinally associated with poorer multidimensional sleep health., Method: Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale across six to nine annual assessments in 302 midlife women from the Study of Women's Health Across the Nation. Six months after their last assessment, actigraphy (mean ± standard deviation = 29.3 ± 6.9 days) and self-report were used to assess sleep health components: efficiency, duration, mid-sleep timing, regularity, alertness, and satisfaction, which were dichotomized and summed to create a composite multidimensional sleep health score. Mixed-effects models were used to evaluate the longitudinal associations between depressive symptoms and multidimensional sleep health, as well as individual sleep health components, adjusting for covariates. Exploratory analyses stratified models by race/ethnicity., Results: Higher depressive symptoms were associated with subsequent poorer multidimensional sleep health (p < .0.001) and lower alertness (p < .0001) and satisfaction with sleep (p < .0001)., Conclusions: Our finding that higher average depressive symptoms were associated longitudinally with actigraphy-measured poorer sleep health in midlife women is novel and converges with the larger body of evidence that these two common symptoms are strongly associated. The bidirectional relationship between these two prevalent symptoms needs to be studied in prospective longitudinal studies., (© Society of Behavioral Medicine 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: The association between sleep and adiposity (indexed by body mass index or waist-to-hip ratio) has typically been evaluated using a single dimension of self-reported sleep. However, other dimensions and behavioral measures of sleep may also be associated with adiposity. This study evaluated whether multidimensional sleep health calculated from actigraphy and self-report was longitudinally associated with adiposity in a sample of midlife women who have a high prevalence of sleep disturbances and adiposity., Design: Longitudinal study with 11-14 years of follow-up time between the sleep health assessment and body mass index / waist-to-hip ratio measurements., Participants: Two hundred and twenty-one midlife women enrolled in the Study of Women's Health Across the Nation Sleep Study., Measurements: Multidimensional sleep health was quantified using actigraphy (M[SD] = 29.1[7.2] nights) measures of sleep efficiency, midpoint, duration, regularity, and self-report measures of alertness and satisfaction. Each component was dichotomized and summed; higher values indicated better sleep health. Height, body weight, and waist and hip circumference were measured at the sleep study and at follow-up. Linear regression models were used to assess associations between sleep health and adiposity, adjusting for demographic and menopausal covariates., Results: There was no substantial within-person change in adiposity over time. Better sleep health was cross-sectionally and longitudinally associated with lower adiposity in unadjusted, but not in adjusted, models. Individual sleep health components were not associated with adiposity after adjustment., Conclusion: We did not observe cross-sectional or longitudinal associations between multidimensional sleep health and adiposity. The sleep-adiposity link may be weaker in midlife adults than in other age groups., (Copyright © 2020 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

From the United States and Netherlands, we have 2 articles on back pain, with findings that indicate significant treatment differences between the countries, and a high likelihood of persistence. The Inflammatory Diet is now shown to be related to diabetes. Multiple perspectives on palliative care for the homeless. Could pharmacists assist in preventing suicide? There are changes in the practice of family medicine. Social determinants of health substantially influence health and medical care. Moreover, care for patients from deprived communities is under-reimbursed. Patient pre-existing conditions increased after the Affordable Care Act, suggesting that repealing pre-existing condition protections would likely exacerbate disparities in health and health care., Competing Interests: Conflict of interest: The authors are editors of the JABFM., (© Copyright 2019 by the American Board of Family Medicine.)

Protecting personally identifiable information is important in clinical research. The authors, two faculty members involved in developing and implementing research infrastructure for a medical school, observed challenges novice researchers encountered in recognizing, collecting, and managing Protected Health Information (PHI) for clinical research. However, we had difficulty finding resources that provide practical strategies for novice clinical researchers for this topic. Common issues for beginners were: 1. Recognition of PHI, e.g. lack of recognition of 'indirect' PHI, i.e., that the combination of two or more non-PHI data types or other specific information could result in identifiable data requiring protection; 2. Collection of PHI, e.g., proposed collection of data not necessary for fulfillment of the project's objectives or potential inadvertent collection of PHI in free text response items; and 3. Management of PHI, e.g., proposed use of coding systems that directly included PHI, or proposed data collection techniques, electronic data storage, or software with inadequate protections. From these observations, the authors provide the following in this paper: 1. A brief review of the elements of PHI, particularly 'indirect' PHI; 2. Sample data management plans for common project types relevant to novice clinical researchers to ensure planning for data security; 3. Basic techniques for avoiding issues related to the collection of PHI, securing and limiting access to collected PHI, and management of released PHI; and 4. Methods for implementing these techniques in the Research Electronic Data Capture (REDCap) system, a commonly used and readily available research data management software system., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Some aspects of the health of Americans are declining, and family medicine is addressing these ailments. Obesity is one factor, and family physicians provide nutrition counseling. Despite new models such as direct primary care, we have not found an ideal method for providing primary care to everyone in our health system. Not all family physicians report burnout: what is their secret? Scribes: some positives and negatives from one group. Rural America is in need of more family physicians who provide prenatal and natal care, and the proof is in the infant mortality rate. We also have 2 articles on improving pediatric care, and research on the relationship of thrush to mode of infant delivery. We have reviews of new cancer and cholesterol drugs, raising awareness of important knowledge for the primary care clinicians seeing the patients who take these drugs. In addition: tick bites and delayed anaphylaxis-when and how, culture-related skin findings, and helping male perpetrators of domestic violence., Competing Interests: Conflict of interest: The authors are editors of the JABFM., (© Copyright 2018 by the American Board of Family Medicine.)

This issue provides many articles reporting on research pertinent to patient-centered care, with great richness in the variety of methods and settings. Topics include disparities in the availability of care and the type of care provided (including a randomized trial), effecting elective hospitalizations on future patient satisfaction, the effect of the specific content of the after visit summary, 2 articles related to aspects of shared decision making, 2 articles considering the effects of practice culture, plus a report on divergent views on how to integrate behavioral and primary health care. Differences between academic and nonacademic family medicine practice are finally documented, with important dissimilarities in patient-centered care. Family physicians are highly involved with dementia care. An exciting report documents a high negative predictive value for a new genomic expression test for coronary artery disease in family medicine that uses combinations of gene expression instead of individual gene testing.

As our readership continues to expand dramatically, we are pleased to have an issue with broad range of articles all about common issues or illnesses seen daily, providing much information that will inform patient care and aid the practice of medicine. Included are articles addressing the effect of shared decision making about PSA testing and weight loss management, capitated payments to patient education, physician language related to adherence, and various factors of provider-patient continuity. We also have articles comparing outcomes of Cesarean sections by family physicians and obstetricians, articles about the natural history of symptoms (dangerous or otherwise) in childhood febrile illnesses, and articles providing a different look at sample medications, the evolving use of narcotics for chronic pain, a risk estimation score for male osteoporosis, a simple test for detecting cognitive impairment in people with low literacy, reproductive health care for adolescent women, and the overlap syndrome between asthma and chronic obstructive pulmonary disease. In addition, we note that scores on the American Board of Family Medicine certification examination vary substantially across the country and by various residency factors.

In this diverse issue, we have a report on the high cost of diabetes quality improvement programs. Two studies using health information technology, including one that embedded a questionnaire and tool for bipolar disorder into an electronic health record to improve diagnosis, and another that collected information about anxiety and depression for adolescents with a personal digital assistant. Other articles considered sources of disparities in screening for colorectal cancer in rural Georgia, and the characteristics of sepsis in HIV patients. Clinicians will likely find interesting how patients interpret and report provider reactions to interpersonal violence situations. We also have a review of the symptoms patients report in a community practice sample; breast cancer survivors' perspectives on acupuncture for treating hot flashes; clinical reviews about Alzheimer disease and prasugrel; and several interesting brief case reports.

Purpose: Research suggests that expectancy may modulate the response to medical interventions, including acupuncture. However, the paucity of validated tools to measure expectancy limits rigorous evaluation. We sought to validate a previously developed Acupuncture Expectancy Scale (AES) as an instrument to measure patients' expected responses to acupuncture., Purpose: Participants were patients with stage I to III cancers seen in outpatient medical and radiation oncology clinics. They were drawn from three study cohorts that included 404 participants. We examined the reliability, validity, and responsiveness of the AES., Results: The scores on the AES had internal consistency (Cronbach's alpha coefficient) of 0.95 and test-retest reliability of 0.62 over 4 weeks without acupuncture treatment. Those who had previously used acupuncture had higher AES scores compared to those who were acupuncture naive (12.4 vs 9.5, P = .002). AES scores were higher in those who reported willingness to participate in an acupuncture trial compared to those who did not want to participate in an acupuncture trial (11.5 vs 8.1, P < .001). Patients who enrolled in a pilot trial of acupuncture had higher AES scores than the general outpatient population (13.0 vs 9.8, P = .02), and expectancy increased during the course of acupuncture treatment (13.0 to 16.5, P < .017)., Conclusion: The AES is reliable and valid, and scores appear to increase during or after prior therapy. Incorporation of AES in clinical trials and outcome studies can evaluate the role of expectancy on acupuncture outcomes.

Background: Previous research among specific cancer populations has shown high but variable symptom burden; however, very little is known about its extent and pattern among the entire population of US cancer survivors, which is more clinically relevant to primary care physicians., Methods: To determine the prevalence of ongoing symptom burden among cancer survivors and compare it with the general population without cancer, we analyzed data from the 2002 National Health Interview Survey, which included 1,904 cancer survivors and 29,092 controls. Main outcome measures included self-reported ongoing pain, psychological distress, and insomnia. Multivariate logistic regression models were used to adjust for confounders and test for interactions., Results: The rates of ongoing pain, psychological distress, and insomnia among cancer survivors were 34%, 26%, and 30%, respectively, and were significantly higher (all P<.001) than controls without a history of cancer (18%, 16%, and 17%). Compared with controls in the same age groups, younger survivors (younger than 50) were much more likely to report ongoing symptoms than older survivors (older than 64); adjusted odds ratios were 2.96 and 1.36 for pain in the respective age groups (P<.001). Comorbidities also interact with cancer status and contribute to a marked increase in reports of ongoing symptom burden among cancer survivors, with a greater number of comorbidities leading to greater degree of symptom burden in a dose-dependent manner (P<.001)., Conclusions: The symptom burden among cancer survivors on a population level is substantial and can be impacted by other comorbidities. Thus, engaging primary care physicians in the design, testing, and implementation of effective interventions is important to reduce the symptom burden among cancer survivors.

Background: Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment., Methods: A national research study was conducted by independent research firms. Interviews and focus groups identified key issues for diverse constituencies, including patients, payers, residents, students, family physicians, and other clinicians. Subsequently, interviews were conducted with nationally representative samples of 9 key constituencies. Based in part on these data, 5 task forces addressed key issues to meet the project goal. A Project Leadership Committee synthesized the task force reports into the report presented here., Results: The project identified core values, a New Model of practice, and a process for development, research, education, partnership, and change with great potential to transform the ability of family medicine to improve the health and health care of the nation. The proposed New Model of practice has the following characteristics: a patient-centered team approach; elimination of barriers to access; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance. A unified communications strategy will be developed to promote the New Model of family medicine to multiple audiences. The study concluded that the discipline needs to oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, competent to provide family medicine's basket of services within the New Model, and capable of adapting to varying patient needs and changing care technologies. Family medicine education must continue to include training in maternity care, the care of hospitalized patients, community and population health, and culturally effective and proficient care. A comprehensive lifelong learning program for each family physician will support continuous personal, professional, and clinical practice assessment and improvement. Ultimately, systemwide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service, advocating that every American have health care coverage for basic services and protection against extraordinary health care costs, advancing research that supports the clinical decision making of family physicians and other primary care clinicians, and developing reimbursement models to sustain family medicine and primary care practices., Conclusions: The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans.

Background and Objectives: Authorship on scientific articles is an important form of academic productivity. We examined the influence of personal and professional relationships on authorship decisions, particularly as they may conflict with stated criteria of the International Committee of Medical Journal Editors (ICMJE)., Methods: We conducted an anonymous e-mail survey of corresponding authors of original research articles in the Archives of Family Medicine, British Medical Journal, New England Journal of Medicine, and the American Journal of Psychiatry in 1999. Assessments were made of how often concerns about personal and professional relationships enter authorship decisions as well as factors affecting authorship if that person does not meet ICMJE criteria., Results: Of 578 eligible individuals, 292 participated, for a response rate of 50.5%. Personal and professional relationship concerns enter into decisions about who should be named as an author Junior faculty and individuals whose job is dependent on publications were significantly more likely to feel obligated to consider adding an author who doesn't meet ICMJE criteria when that person has administrative power over them. Current strategies to improve the veracity of authorship were endorsed as moderately effective., Conclusions: Authors arefaced with the difficult task of negotiating interpersonal relationships while allocating authorship according to ICMJE criteria. Mechanisms should be explored to provide greater protection of junior faculty from pressure by senior faculty.

Background: Journal reading is a time-tested means of continuing medical education (CME) among physicians. Asking physicians to make a written statement of commitment to change has been shown to increase the likelihood of eventual change in practice behavior when used in conjunction with CME lectures. We describe the type and medical content of articles responsible for commitment to change comments among readers of a large circulation primary care journal., Methods: Response to the question "what change(s) do you plan to make in your practice as a result of reading the articles in this issue?" were analyzed from CME response cards associated with six issues (1 year's publication) of the Archives of Family Medicine. Responses indicating a commitment to change were analyzed to characterize the type and content of articles responsible for their generation., Results: During the 1-year study period, original contributions (reports of research trials) dealing with medicine and preventive medicine content accounted for the greatest number of comments. After adjusting for the frequency of article type and content, special articles and those dealing with complementary medicine accounted for the highest number of comments on a per-article basis., Findings: Family physicians make commitment to change statements on the basis of a broad range of journal articles. Certain articles are more likely to generate statements of commitment to planned changes in practice.

Many health promotion and disease prevention recommendations are specific to adult women. Given their strategic position within families, women often hold the responsibility for the health and well-being of all family members.

Patients who seek advice from family physicians on dietary intervention and the value of estrogen replacement will benefit by several new studies. Febrile infants without evidence of bacterial infection can be watched as outpatients. By diagnosing and treating clinical depression, family physicians can lower the costs of this illness to the nation.