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Conducting research in primary care during the COVID-19 pandemic is hard, due to baseline stresses on primary care, which have been compounded by the pandemic. We acknowledge and validate primary care researchers' frustrations. Using our experience on over 15 individual projects during the pandemic we identify 3 key challenges to conducting primary care research: (1) practice delivery trickle-down effects, (2) limited/changing resources and procedures for research, and (3) a generally tense milieu in US society during the pandemic. We present strategies, informed by a set of questions, to help researchers decide how to address these challenges observed during our studies. In order to overcome and grow from these challenging times we encourage normalization and self-compassion, and encourage researchers and funders to embrace pragmatic and adaptive research designs as the circumstances with COVID-19 evolve over time., (© 2022 Annals of Family Medicine, Inc.)

Background: Interventions are often adapted; some adaptations may provoke more favorable outcomes, whereas some may not. A better understanding of the adaptations and their intended goals may elucidate which adaptations produce better outcomes. Improved methods are needed to better capture and characterize the impact of intervention adaptations., Methods: We used multiple data collection and analytic methods to characterize adaptations made by practices participating in a hybrid effectiveness-implementation study of a complex, multicomponent diabetes intervention. Data collection methods to identify adaptations included interviews, observations, and facilitator sessions resulting in transcripts, templated notes, and field notes. Adaptations gleaned from these sources were reduced and combined; then, their components were cataloged according to the framework for reporting adaptations and modifications to evidence-based interventions (FRAME). Analytic methods to characterize adaptations included a co-occurrence table, statistically based k-means clustering, and a taxonomic analysis., Results: We found that (1) different data collection methods elicited more overall adaptations, (2) multiple data collection methods provided understanding of the components of and reasons for adaptation, and (3) analytic methods revealed ways that adaptation components cluster together in unique patterns producing adaptation "types." These types may be useful for understanding how the "who, what, how, and why" of adaptations may fit together and for analyzing with outcome data to determine if the adaptations produce more favorable outcomes rather than by adaptation components individually., Conclusion: Adaptations were prevalent and discoverable through different methods. Enhancing methods to describe adaptations may better illuminate what works in providing improved intervention fit within context., Trial Registration: This trial is registered on clinicaltrials.gov under Trial number NCT03590041 , posted July 18, 2018., (© 2022. The Author(s).)

Context: Shared Medical Appointments for diabetes (SMAs) are an evidence-based strategy improve health outcomes. However, which elements of SMAs are important remain unknown. Invested in Diabetes studied two implementation approaches (standardized [STD] vs. patient-driven [PTD]), using a curriculum focused on mental health and skill building in addition to diabetes self-management. Objective: To understand patient experiences and preferences, including care team and peer mentor involvement, and how teaching style affected satisfaction. Those completing SMAs after the COVID pandemic began discussed their experience with virtual SMAs. Study Design: Semi-structured interviews, conducted between 2019-21. Setting: 21 primary care practices in Colorado and Kansas. Population: Patients with type 2 diabetes who attended SMAs at participating sites. Outcome Measures: Transcripts were analyzed using qualitative thematic analysis (data triangulation and a constant comparative technique). Results: Forty-one patients from 14 participating clinics agreed to participate (25 STD, 16 PTD). All patients completed their 6-class cohort. Both newly diagnosed patients and those living with diabetes for longer found classes useful. Patients generally enjoyed the content, with nutrition favored most. Opinion on mental health topics and skill building varied, but overall deemed valuable. The social aspect of SMAs was seen as the biggest benefit. However, the peer mentor role (PTD only) was not always appreciated. Patient topic order selection and behavioral health as part of the care team (PTD only) were viewed as helpful but not necessary, though guest lecturers were supported by all. Facilitators were mostly seen as supportive and their teaching style agreeable, which contributed considerably to positive experiences. Those who did virtual SMAs had mostly positive views. The format allowed continuation of care that may have been halted due to the pandemic, let people with busy schedules to participate, and in some instances made sharing easier to do. Some would still have preferred an in-person class. Conclusions: Patients found SMAs beneficial, favoring classic diabetes self-management topics over mental health and skill building. The peer mentor role was not always well received, likely due to variations in the peer mentor. Teaching style was very important to satisfaction, and all patients wanted guest speakers with varied expertise. A virtual format was acceptable. ., Competing Interests: Authors report none., (© 2021 Annals of Family Medicine, Inc.)

Background: Despite the overwhelming prevalence and health implications of obesity, it is rarely adequately addressed in a health care setting. PATHWEIGH is a pragmatic approach to weight management that uses tools built into the electronic medical record to overcome barriers and guide care. Implementation strategies are employed to facilitate adoption and use of the PATHWEIGH tools and processes. The current study will compare the effectiveness of PATHWEIGH versus standard of care (SOC) on patient weight loss in primary care and explore factors for its successful implementation., Methods: A stepped wedge cluster randomized trial design will be used within an effectiveness-implementation hybrid study. Adult patient weight loss and weight loss maintenance will be compared in PATHWEIGH versus SOC in 57 family and internal medicine clinics in a large health system in Colorado, USA. Effectiveness will be evaluated using generalized linear mixed models to determine statistical differences in weight loss and weight loss maintenance at 6, 12, and 18 months. Patient-, provider-, and clinic-level predictors will be identified using mediator and moderator analyses. Conceptually guided by the Practical, Robust, Implementation and Sustainability Model (PRISM), a mixed methods approach including quantitative (practice surveys, use tracking) and qualitative (interviews, observations) data collection will be used to determine factors impeding and facilitating adoption, implementation, and maintenance of PATHWEIGH and evaluate specified implementation strategies. A cost analysis of the practice and system costs and resources required by PATHWEIGH relative to the reimbursement collected will be performed., Discussion: The effectiveness and implementation of PATHWEIGH, and their interrelatedness, for patient weight loss are collectively the focus of the current trial. Findings from this study are expected to serve as a blueprint for available and effective weight management in primary care medical practice., Trial Registration: ClinicalTrials.gov NCT04678752 . Registered on December 21, 2020., (© 2022. The Author(s).)

Purpose: Evidence supports treatment for opioid use disorder (OUD) with buprenorphine in primary care practices (PCPs). Barriers that slow implementation of this treatment include inadequately trained staff. This study aimed to increase the number of rural PCPs providing OUD treatment with buprenorphine. This evaluation describes the impact of a practice team training on the implementation and delivery of OUD treatment with buprenorphine in PCPs of rural Colorado., Methods: Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado (IT MATTTRs) was a multilevel implementation study that included a practice-focused intervention to improve awareness, adoption, and use of buprenorphine treatment for OUD. Participating PCP teams received the IT MATTTRs Practice Team Training and support. Practices' implementation of treatment components was assessed before and after training. Practice-reported and population-level data from the Prescription Drug Monitoring Program were obtained to describe changes in delivery of treatment after training., Results: Forty-two practices received team training. Practices reported an average of 4.7 treatment-related components in place at baseline compared with 13.0 at 12-month follow-up (F[2,56] = 31.17, P <.001). The proportion of participating practices providing or referring patients for treatment increased from 18.8% to 74.4%. The increase in number of people with a prescription for buprenorphine was significantly greater in the study region over a 4-year period compared with the rest of the state (Wald χ 2 = 15.73, P <.001)., Conclusions: The IT MATTTRs training for PCP teams in OUD treatment with buprenorphine addressed elements beyond clinician waiver training to make implementation feasible and effectively increased implementation and delivery of this treatment in rural Colorado., (© 2022 Annals of Family Medicine, Inc.)

Medication assisted treatment (MAT) is an evidence-based solution to combatting opioid use disorder (OUD); however, MAT is largely unavailable in rural areas. This study investigated clinician and staff perceptions related to OUD and MAT, in particular, buprenorphine treatment, in rural primary care practices. In this qualitative study, we interviewed staff members from 42 practices and analyzed the data using a grounded hermeneutic editing approach. Four key themes emerged: 1) policies and procedures to reduce opioid prescribing were already in place, 2) there was an emotional toll to treating "those types" of patients, 3) there is a lack of local resources for help with chronic pain and buprenorphine treatment, and 4) there is a strong desire to help local patients and community members but hesitancy to engage in buprenorphine treatment. Although there was almost no provision of MAT, many practices were interested in learning more to help their communities.

Objective: To fill the gap in knowledge on systematic differences between primary care practices (PCP) that do or do not provide intensive behavioral therapy (IBT) for obese Medicare patients., Methods: A mixed modality survey (paper and online) of primary care practices obtained from a random sample of Medicare databases and a convenience sample of practice-based research network practices., Key Results: A total of 287 practices responded to the survey, including 140 (7.4% response rate) from the random sample and 147 (response rate not estimable) from the convenience sample. We found differences between the IBT-using and non-using practices in practice ownership, patient populations, and participation in Accountable Care Organizations. The non-IBT-using practices, though not billing for IBT, did offer some other assistance with obesity for their patients. Among those who had billed for IBT, but stopped billing, the most commonly cited reason was billing difficulties. Many providers experienced denied claims due to billing complexities., Conclusions: Although the Centers for Medicare and Medicaid Services established payment codes for PCPs to deliver IBT for obesity in 2011, very few providers submitted fee-for-service claims for these services after almost 10 years. A survey completed by both a random and convenience sample of practices using and not using IBT for obesity payment codes revealed that billing for these services was problematic, and many providers that began using the codes discontinued using them over the past 7 years., (© 2021. Society of General Internal Medicine.)

Background: Obesity is of epidemic proportion in the USA but most people with obesity do not receive treatment., Objective: To explore the experience of providing obesity management among primary care clinicians and their team members involved with weight loss in primary care practices. The study's focus was on examining the use of the Medicare payment code for intensive behavioral therapy for obesity (IBT), but other obesity management services and payment mechanisms were also studied., Design/participants: We conducted 85 interviews of clinicians (physician, advanced practice clinicians, registered dietitian, or other) practicing in primary care practices. Interviews gathered information about treatment approach to obesity, barriers, and facilitators to providing obesity care including the handling of billing and reimbursement (especially use of the IBT code), personal beliefs about the appropriateness of primary care providing weight loss services, and recommendations for improving weight management in primary care practice. The analysis was conducted using a grounded theory hermeneutic editing approach and the constant comparative method., Key Results: Seventy-five interviews were included in this analysis. We identified three primary themes: (1) clinicians and staff involved in obesity management in primary care believe that addressing obesity is an essential part of primary care services, (2) because providing obesity care can be challenging, many practices opt out of treatment, and (3) despite the challenges, many clinicians and others find treating obesity feasible, satisfying, and worthwhile., Conclusions: Treating obesity in primary care settings poses several challenges but can also be very satisfying and rewarding. To improve the ability of clinicians and practice members to treat obesity, important changes in payment, education, and work processes are necessary., (© 2021. Society of General Internal Medicine.)

The field of dissemination and implementation (D&I) science is rapidly growing, with many scientists seeking to apply D&I science to enhance and expand the impact of their work. As the D&I field grows and collaborations of implementation scientists with other fields flourish, a description for the roles for D&I scientists as they collaborate with researchers from other fields could be beneficial. This paper exemplifies how the D&I scientist/researcher collaborative process might work and important elements to consider in doing so, as well as provide an outline on how collaborations might progress for different project needs. This is discussed through example scenarios to consider an implementation scientists' engagement in a research project and describe potential roles for implementation scientists in supporting research teams. We then discuss characteristics to consider when incorporating a D&I expert into a team and considerations in navigating the scenarios.

Background: Type 2 diabetes affects 9.4% of US adults with higher rates among racial and ethnic minorities and individuals of low socioeconomic status. The National Diabetes Prevention Program (NDPP) is an evidence-based and widely disseminated behavioral intervention to reduce diabetes incidence through modest weight loss. However, retention in the yearlong NDPP is problematic and leads to suboptimal weight loss, especially among diverse, underserved populations. Strategies to improve NDPP engagement and weight loss are needed urgently. Pilot results of the pre-NDPP, a novel enhancement to enrollment in the NDPP based on the Health Belief Model, were highly successful in a nonrandomized cohort study among 1140 racially diverse, predominately low-income participants. A total of 75 presession participants had doubled attendance and weight loss as compared with earlier participants who did not receive presessions. On the basis of these promising results, we are conducting a randomized controlled trial (RCT) to determine whether pre-NDPP reliably improves NDPP outcomes, as reported on ClinicalTrials.gov., Objective: This study aims to (1) conduct an RCT comparing NDPP attendance and weight loss outcomes between participants who receive pre-NDPP versus direct enrollment into the NDPP (usual care), (2) examine potential effect mediators (perceived risk for developing diabetes and self-efficacy and readiness for weight control) and moderators (race and ethnicity; income level), and (3) evaluate implementation factors, including cost and projected return on investment., Methods: This two-arm RCT will compare outcomes among diverse, predominately low-income participants who receive pre-NDPP versus direct enrollment into the NDPP (usual care). This is a type 1 hybrid effectiveness-implementation design to determine clinical effectiveness through an RCT, while assessing factors that may impact future pre-NDPP dissemination and implementation, including cost. Our primary research question is whether pre-NDPP improves NDPP attendance and weight loss compared with standard NDPP delivery., Results: This project was funded in April 2019. Recruitment is underway as of July 2019. Initial participants began the intervention in October 2019. Data analysis and results reporting are expected to be completed in 2024., Conclusions: This RCT of pre-NDPP may lead to future dissemination of a scalable, evidence-based strategy to improve success of the NDPP, reduce disparities in NDPP effectiveness, and help prevent type 2 diabetes across the country., Trial Registration: ClinicalTrials.gov NCT04022499; https://clinicaltrials.gov/ct2/show/NCT04022499., International Registered Report Identifier (irrid): PRR1-10.2196/15499., (©Natalie D Ritchie, Jodi Summers Holtrop, R Mark Gritz, Katherine Ann Sauder, Michael Josh Durfee, L Miriam Dickinson, Peter G Kaufmann. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 01.06.2020.)

Background: Shared medical appointments (SMAs) have been shown to be an efficient and effective strategy for providing diabetes self-management education and self-management support. SMA features vary and it is not known which features are most effective for different patients and practice settings. The Invested in Diabetes study tests the comparative effectiveness of SMAs with and without multidisciplinary care teams and patient topic choice for improving patient-centered and clinical outcomes related to diabetes., Methods: This study compares the effectiveness of two SMA approaches using the Targeted Training for Illness Management (TTIM) curriculum. Standardized SMAs are led by a health educator with a set order of TTIM topics. Patient-driven SMAs are delivered collaboratively by a multidisciplinary care team (health educator, medical provider, behavioral health provider, and a peer mentor); patients select the order and emphasis on TTIM topics. Invested in Diabetes is a cluster randomized pragmatic trial involving approximately 1440 adult patients with type 2 diabetes. Twenty primary care practices will be randomly assigned to either standardized or patient-driven SMAs. A mixed-methods evaluation will include quantitative (practice- and patient-level data) and qualitative (practice and patient interviews, observation) components. The primary patient-centered outcome is diabetes distress. Secondary outcomes include autonomy support, self-management behaviors, clinical outcomes, patient reach, and practice-level value and sustainability., Discussion: Practice and patient stakeholder input guided protocol development for this pragmatic trial comparing SMA approaches. Implementation strategies from the enhanced Replicating Effective Programs framework will help ensure practices maintain fidelity to intervention protocols while tailoring workflows to their settings. Invested in Diabetes will contribute to the literature on chronic illness management and implementation science using the RE-AIM model., Trial Registration: ClinicalTrials.gov, NCT03590041. Registered on 5 July 2018.

Background: Care management and care managers are becoming increasingly prevalent in primary care medical practice as a means of improving population health and reducing unnecessary care. Care managers are often involved in chronic disease management and associated transitional care. In this study, we examined the communication regarding chronic disease care within 24 primary care practices in Michigan and Colorado. We sought to answer the following questions: Do care managers play a key role in chronic disease management in the practice? Does the prominence of the care manager's connectivity within the practice's communication network vary by the type of care management structure implemented?, Methods: Individual written surveys were given to all practice members in the participating practices. Survey questions assessed demographics as well as practice culture, quality improvement, care management activities, and communication regarding chronic disease care. Using social network analysis and other statistical methods, we analyzed the communication dynamics related to chronic disease care for each practice., Results: The structure of chronic disease communication varies greatly from practice to practice. Care managers who were embedded in the practice or co-located were more likely to be in the core of the communication network than were off-site care managers. These care managers also had higher in-degree centrality, indicating that they acted as a hub for communication with team members in many other roles., Discussion: Social network analysis provided a useful means of examining chronic disease communication in practice, and highlighted the central role of care managers in this communication when their role structure supported such communication. Structuring care managers as embedded team members within the practice has important implications for their role in chronic disease communication within primary care.

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

The U.S. Preventive Services Task Force (USPTF) recognizes that behaviors have a major impact on health and well-being. Currently, the USPSTF has 11 behavioral counseling intervention (BCI) recommendations. These BCIs can be delivered in a primary care setting or patients can be referred to other clinical or community programs. Unfortunately, many recommended BCIs are infrequently and ineffectually delivered, suggesting that more evidence is needed to understand which BCIs are feasible and referable. In response, the USPSTF convened an expert forum in 2013 to inform the evaluation of BCI feasibility. This manuscript reports on findings from the forum and proposes that researchers use several frameworks to help clinicians and the USPSTF evaluate which BCIs work under usual conditions. A key recommendation for BCI researchers is to use frameworks whose components can support dissemination and implementation efforts. These frameworks include the Template for Intervention Description and Replication (TIDieR), which helps describe the essential components of an intervention, and pragmatic frameworks like Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) or Pragmatic-Explanatory Continuum Indicator Summary (PRECIS), which help to report study design elements and outcomes. These frameworks can both guide the design of more-feasible BCIs and produce clearer feasibility evidence. Critical evidence gaps include a better understanding of which patients will benefit from a BCI, how flexible interventions can be without compromising effectiveness, required clinician expertise, necessary intervention intensity and follow-up, impact of patient and clinician intervention adherence, optimal conditions for BCI delivery, and how new care models will influence BCI feasibility., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: We aimed to describe and contrast the targeting methods and engagement outcomes for health plan-delivered disease management with those of a provider-delivered care management program., Study Design: Health plan epidemiologists partnered with university health services researchers to conduct a quasi-experimental, mixed-methods study of a 2-year pilot. We used semi-structured interviews to assess the characteristics of program-targeting strategies, and calculated target and engagement rates from clinical encounter data., Methods: Five physician organizations (POs) with 51 participating practices implemented care management. Health plan member lists were sent monthly to the practices to accept patients, and then the practices sent back data reports regarding targeting and engagement in care management. Among patients accepted by the POs, we compared those who were targeted and engaged by POs with those who met health plan targeting criteria., Results: The health plan's targeting process combined claims algorithms and employer group preferences to identify candidates for disease management; on the other hand, several different factors influenced PO practices' targeting approaches, including clinical and personal knowledge of the patients, health assessment information, and availability of disease-relevant programs. Practices targeted a higher percentage of patients for care management than the health plan (38% vs 16%), where only 7% of these patients met the targeting criteria of both. Practices engaged a higher percentage of their targeted patients than the health plan (50% vs 13%)., Conclusions: The health plan's claims-driven targeting approach and the clinically based strategies of practices both provide advantages; an optimal model may be to combine the strengths of each approach to maximize benefits in care management.

Objective: Report lessons learned in an RCT of Stop My Smoking (SMS) USA, a mHealth smoking cessation program for young adult smokers., Methods: 164 18-24-year-olds were recruited nationally, online in 2011. Program evaluation data were provided at 12-week post-Quit Day., Results: (1) Inviting participants to complete a brief text messaging survey and then asking them to complete a longer online survey resulted in the highest response rate (89%). (2) The positive tone of program messages was the most commonly noted program strength. (3) Suggested improvements included more social connectivity and additional assistance overcoming stressful situations. (4) Half of intervention participants moved through the program linearly and half went through various paths that reflected multiple relapses. Suggestions to use pharmacotherapy resulted in 22% of heavy smokers to utilize it., Conclusion: Participant feedback provided concrete ways in which this and other young adult-focused interventions can improve messaging and program features to be even more salient., Practice Implications: Future young adult mHealth interventions could: Integrate models that are flexible to different "paths" of behavior change; address stressful life events directly and comprehensively; integrate proactive messaging that promotes pharmacotherapy options; and use text messaging as a gateway to longer online surveys., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Cell phone text messaging is gaining increasing recognition as an important tool that can be harnessed for prevention and intervention programs across a wide variety of health research applications. Despite the growing body of literature reporting positive outcomes, very little is available about the design decisions that scaffold the development of text messaging-based health interventions. What seems to be missing is documentation of the thought process of investigators in the initial stages of protocol and content development. This omission is of particular concern because many researchers seem to view text messaging as the intervention itself instead of simply a delivery mechanism. Certainly, aspects of this technology may increase participant engagement. Like other interventions, however, the content is a central driver of the behavior change., Objective: To address this noted gap in the literature, we discuss the protocol decisions and content development for SMS Turkey (or Cebiniz birakin diyor in Turkish), a smoking cessation text messaging program for adult smokers in Turkey., Methods: Content was developed in English and translated into Turkish. Efforts were made to ensure that the protocol and content were grounded in evidence-based smoking cessation theory, while also reflective of the cultural aspects of smoking and quitting in Turkey., Results: Methodological considerations included whether to provide cell phones and whether to reimburse participants for texting costs; whether to include supplementary intervention resources (eg, personal contact); and whether to utilize unidirectional versus bidirectional messaging. Program design considerations included how messages were tailored to the quitting curve and one's smoking status after one's quit date, the number of messages participants received per day, and over what period of time the intervention lasted., Conclusion: The content and methods of effective smoking cessation quitline programs were a useful guide in developing SMS Turkey. Proposed guidelines in developing text messaging-based behavior change programs are offered.

Background: Smokers receiving pharmacotherapy and individualized smoking cessation counseling through telephone quitlines have been found to have higher quit rates than smokers receiving pharmacotherapy alone. Health plans are often positioned to encourage their members to use quitline services in addition to pharmacotherapy., Objective: To determine if healthcare members who were receiving pharmacotherapy increased their participation in smoking quitline services after receiving proactive telephone calls or postcards., Study Design: Randomized controlled trial., Methods: Health plan members filing pharmacotherapy claims were identified weekly from health plan pharmacy claims data and randomized to 1 of the following 3 conditions: control, recruitment postcard, or recruitment telephone call by a nurse quitline counselor. Enrollment of study members into the quitline program was tracked for 1 month after randomization., Results: During 5 months, 625 individuals were identified for participation in the study, with the following enrollment into the program: 0% to the control group, 1.3% to the postcard group, and 20.6% to the telephone call group (P < .001 for significance by group). Although costs for the telephone intervention were the most expensive, it was also the most cost effective, given its success in enrolling members into the program., Conclusions: Proactive telephone calling by smoking cessation nurse counselors to smokers receiving pharmacotherapy may be an effective method of enrolling smokers into a cessation quitline. Health plans should consider proactive telephone recruitment to improve use of quitline services.

Background and Objectives: Mergers of residency training programs have become more common, but little has been published about their educational impact. Following our own merger, we sought to understand this process and its aftermath by conducting focus groups., Methods: Three 1-hour focus groups were conducted-one with third-year residents, one with first- and second-year residents, and one with core faculty members. The interview script was based on a five-factor transitional model where each factor represented a potential fracture point that could result in organizational conflict. The five factors were curriculum, corporate culture, day-to-day operations, teaching environment, and financial resources. Focus group audiotapes were transcribed, and the investigators independently identified themes using an immersion and crystallization approach. Feedback from participants was obtained., Results: Themes identified included unmet potential of the combined curriculum, a blending of two disparate cultures resulting in feelings of loss and displacement for some, and a sense of rapid policy change and lack of resident and faculty accountability. Faculty recommendations for other programs involved in mergers include creating frequent facilitated retreats, acknowledging loss, and establishing new rituals for the combined program., Conclusions: The transition through a merger of two residency programs is difficult and has direct educational and emotional impact. Such difficulties can, in part, be predicted, and improved communication and planning may facilitate this process.