Search

The learning health care system is an aspirational operational model for improving health care by learning from the care being delivered. The model, which has been endorsed by the National Academy of Medicine, aligns naturally with academic health systems, which have a mission to improve care for their communities through research and education. In this scholarly perspective, the authors define the learning health care system concept and its historical relationship to academic health systems; explore opportunities for and barriers to realizing the learning health care system; and propose actions to achieve the learning health care system at the local, regional, and national levels. The authors argue that the learning health care system model is essential to academic medicine's evolution and to achieving the foundational societal mission of academic health systems to advance health through research and education.

BackgroundCOVID-19 vaccination rates among U.S. young adults, particularly in communities of color, remain lower than other age groups. We conducted a qualitative, community-based participatory study to explore beliefs and attitudes about COVID-19 vaccines among young adults in Black/African American, Latinx, and Asian American or Pacific Islander (AAPI) communities in the San Francisco Bay Area.MethodsWe conducted six focus groups between June and August 2021. Participants were recruited by partnering with community-based organizations in the San Francisco Bay Area. Focus groups included Black/African American (N=13), Latinx (N=20), and AAPI (N=12) participants between 18 and 30 years of age. Emerging themes were identified using a modified Grounded Theory approach.ResultsProminent themes among all three racial-ethnic groups included mistrust in medical and government institutions, strong conviction about self-agency in health decision-making, and exposure to a thicket of contradictory information and misinformation in social media. Social benefit and a sense of familial and societal responsibility were often mentioned as reasons to get vaccinated. Young adult mistrust had a generational flavor fueled by anger about increasing inequity, the profit-orientation of pharmaceutical companies and health institutions, society's failure to rectify injustice, and pessimism about life prospects.ConclusionFactors influencing vaccine readiness among Black/African American, Latinx, and AAPI young adults have a distinct generational and life-course texture. Outreach efforts should appeal to young adults' interest in family and social responsibility and the social benefits of vaccination, while being cognizant of the friction mandates pose for young adults' sense of self-agency. Efforts will be most effective coming from trusted messengers with a proven commitment to communities of color and health equity.

This report by the Lancet Commission on Public Policy and Health in the Trump Era assesses the repercussions of President Donald Trump's health-related policies and examines the failures and social schisms that enabled his election Trump exploited low and middle-income white people's anger over their deteriorating life prospects to mobilise racial animus and xenophobia and enlist their support for policies that benefit high-income people and corporations and threaten health Although Trump's actions were singularly damaging, many of them represent an aggressive acceleration of neoliberal policies that date back 40 years The suffering and dislocation inflicted by COVID-19 has exposed the frailty of the US social and medical order, and the interconnectedness of society A new politics is needed, whose appeal rests on a vision of shared prosperity and a kind society Health-care workers have much to contribute in formulating and advancing that vision, and our patients, communities, and planet have much to gain from it (PsycInfo Database Record (c) 2021 APA, all rights reserved)

This Viewpoint discusses the potential of the Primary Care Extension Program to ensure access to high-quality primary care in the US.

Revitalizing the U.S. Primary Care Infrastructure Primary care is undersupported in the United States. Moving forward, an investment plan could include oversight, tools, and resources for rebuildin...

Purpose We describe the design of a longitudinal cohort study to determine SARS-CoV-2 incidence and prevalence among a population-based sample of adults living in six San Francisco Bay Area counties. Methods Using an address-based sample, we stratified households by county and by census-tract risk. Risk strata were determined by using regression models to predict infections by geographic area using census-level sociodemographic and health characteristics. We disproportionately sampled high and medium risk strata, which had smaller population sizes, to improve precision of estimates, and calculated a desired sample size of 3400. Participants were primarily recruited by mail and were followed monthly with PCR testing of nasopharyngeal swabs, testing of venous blood samples for antibodies to SARS-CoV-2 spike and nucleocapsid antigens, and testing of the presence of neutralizing antibodies, with completion of questionnaires about socio-demographics and behavior. Estimates of incidence and prevalence will be weighted by county, risk strata and sociodemographic characteristics of non-responders, and will take into account laboratory test performance. Results We enrolled 3842 adults from August to December, 2020, and completed follow-up March 31, 2021. We reached target sample sizes within most strata. Conclusions Our stratified random sampling design will allow us to recruit a robust general population cohort of adults to determine the incidence of SARS-CoV-2 infection. Identifying risk strata was unique to the design and will help ensure precise estimates, and high-performance testing for presence of virus and antibodies will enable accurate ascertainment of infections.

Introduction: The delivery of team-based care relies on team structure and teamwork. Little is known about the landscape of team configurations in family medicine practices in the United States. Teamwork between diverse team members likely impacts both performance and physician well-being. We examined team configuration and teamwork and whether they are associated with family physician (FP) well-being. Methods: We used data from practice demographic questionnaires completed by FPs who registered for the American Board of Family Medicine Family Medicine Certification Examination in 2017 and 2018. We grouped 14 types of health care professionals into medical assistant (MA)/nurse, nurse practitioner (NP)/physician assistant (PA), and specialist, and we characterized 3 common team configurations. We used FPs9 subjective ratings to measure perceived teamwork efficiency and a validated single-item measure to identify FPs who were burned out. Results: Among 2575 FPs in our sample, 22% worked collaboratively with MA/nurse only; 40% with MA/nurse and NP/PA or specialist; and 38% with MA/nurse, NP/PA, and specialist. The distribution of perceived teamwork efficiency was not statistically different across team configurations. In teams with greater perceived teamwork efficiency, FPs were less likely to be burned out. For FPs working with expansive teams, optimal perceived teamwork efficiency was associated with significantly reduced odds of burnout after controlling for practice and physician characteristics. Conclusion: Most FPs practice in multidisciplinary teams. Regardless of the team structure, FPs who perceived their teams as having greater efficiency were less likely to be burned out. We found that optimal perceived teamwork efficiency was associated with significantly reduced odds of burnout for FPs in all types of team configurations. Improving teamwork efficiency may be an effective strategy for practice organizations to support not only team functioning but also physician well-being.

Background COVID-19 vaccination rates are lower among historically marginalized populations, including Black/African American and Latinx populations, threatening to contribute to already high COVID-19 morbidity and mortality disparities for these groups. We conducted a community-based participatory research study using qualitative methods to explore knowledge and beliefs about COVID-19 vaccination among Black/African American, Latinx, and Chinese American residents of the San Francisco Bay Area and assess their views on vaccination outreach and delivery strategies. Methods and findings Data were collected from January 14, 2021, to February 24, 2021, with adult residents (N = 109 [Female: N = 76; 70%]) in San Francisco. Focus groups (N = 10) and in-depth interviews (N = 25) were conducted among Black/African Americans (N = 35), Latinx (N = 40), and Chinese Americans (n = 34) in English, Spanish, Cantonese, or Mandarin. Themes were identified using grounded field theory, and included misinformation, mistrust of government and health institutions, and linguistic and other barriers to vaccine access. All three racial/ethnic groups had experiences with vaccine misinformation and information overload. Many African American and Latinx participants cited structural and interpersonal racism, and anti-immigrant discrimination, as factors reducing their trust in government and public health disseminated information and their willingness to be vaccinated. Participants expressed trust in community-based organizations, including faith-based organizations and community-run clinics. Participants often experienced barriers to vaccine access, such as transportation to drive-in sites, with Latinx and Chinese American groups also frequently citing language barriers. Conclusions Vaccine outreach strategies must acknowledge how longstanding systemic, institutional, and structural racism contributes to mistrust in government and health institutions and engage with and support trusted messengers from the community to eliminate cultural, linguistic, and other barriers to vaccine access.

Efforts to move community engagement in research from marginalized to mainstream include the NIH requiring community engagement programs in all Clinical and Translational Science Awards (CTSAs). However, the COVID-19 pandemic has exposed how little these efforts have changed the dominant culture of clinical research. When faced with the urgent need to generate knowledge about prevention and treatment of the novel coronavirus, researchers largely neglected to involve community stakeholders early in the research process. This failure cannot be divorced from the broader context of systemic racism in the US that has contributed to Black, Indigenous, and People of Color (BIPOC) communities bearing a disproportionate toll from COVID-19, being underrepresented in COVID-19 clinical trials, and expressing greater hesitancy about COVID-19 vaccination. We call on research funders and research institutions to take decisive action to make community engagement obligatory, not optional, in all clinical and translational research and to center BIPOC communities in this process. Recommended actions include funding agencies requiring all research proposals involving human participants to include a community engagement plan, providing adequate funding to support ongoing community engagement, including community stakeholders in agency governance and proposal reviews, promoting racial and ethnic diversity in the research workforce, and making a course in community engaged research a requirement for Masters of Clinical Research curricula.

PURPOSE The quadruple aim of primary care transformation includes promoting well-being among the primary care workforce. We longitudinally assessed burnout among clinicians and staff in 2 health delivery organizations engaged in primary care redesign guided by a shared transformation model. METHODS We conducted a descriptive longitudinal study, using repeated cross-sectional measures from 6 waves of surveys of employed primary care clinicians (physicians, nurse practitioners, physician assistants) and staff conducted between 2012 to 2018 in the San Francisco Health Network and in UCSF Health. The 2018 wave had 613 respondents (response rate 88%). Outcome measures were scores on the Maslach Burnout Inventory emotional exhaustion and cynicism subscales. We used regression models to test for time trends in mean scores. RESULTS Trends in burnout differed by system and occupation. In one system, mean clinician scores steadily improved for emotional exhaustion (P = .04) and cynicism (P = .07). In the other system, clinician burnout scores initially worsened and then returned to baseline levels. In both systems, burnout trends among staff tended to move in the opposite direction from trends among clinicians. CONCLUSIONS The divergent trends of steady reduction in clinician burnout in one system and clinician burnout getting worse before getting better in the other system suggest that the effects of primary care transformation are influenced by the organizational context. Moreover, practice changes that reduce clinician burnout may not decrease—and may potentially even worsen—burnout among staff. Primary care transformation requires continuing efforts to promote meaningful work and sustainable workloads among all members of the primary care team.

This implementation and comparative effectiveness study compared an automated call system (ACS)-assisted method to enhance staff efficiency in panel management cancer screening outreach compared with standard outreach using manual calls. One panel manager assisted by the ACS at the intervention primary care practice completed outreach workflows for 43% more patients than 2 unassisted panel managers at comparison practices, with 78% more patients in the ACS-assisted panel management program ultimately having a preventive screening gap closed. Outreach cost per completion of 1 or more cancer screenings was $45.39 under standard procedures and $15.85 using the ACS-assisted method.

As America’s health care system continues to transform, the foundational importance of primary care becomes more clear. The Joint Principles of the Patient Centered Medical Home are now more than a decade old. As delivery reform continues, the importance of seven essential shared principles have emerged from a dynamic, collaborative, and iterative process of consensus building across multiple stakeholders. These seven principles will help the public, policy makers, payers, physicians, and other clinical providers speak with a unified voice about these core principles that define the enduring essence and value of primary care. The seven shared principles of primary care consist of: (1) person and family centered, (2) continuous, (3) comprehensive and equitable, (4) team based and collaborative, (5) coordinated and integrated, (6) accessible, and (7) high value. When used together, these shared principles provide a solid platform on which to build all further health care reform.

Importance Surveys in the US have found that Black and Latinx individuals have more reservations than their white counterparts about COVID-19 vaccination. However, little is known about the degree to which racial-ethnic differences in COVID-19 vaccination intentions are explained by differences in beliefs or perceptions about COVID-19 vaccines. Objective To compare intention to receive COVID-19 vaccination by race-ethnicity, to identify perceptional factors that may mediate the association between race-ethnicity and intention to receive the vaccine, and to identify the demographic and perceptional factors most strongly predictive of intention to receive a vaccine. Design Cross-sectional survey conducted from November, 2020 to January, 2021, nested within two longitudinal cohort studies of prevalence and incidence of SARS CoV-2 among the general population and healthcare workers. Setting Six San Francisco Bay Area counties. Study Cohort 3,161 participants in the Track COVID cohort (a population-based sample of adults) and 1,803 participants in the CHART Study cohort (a cohort of employees at three large medical centers). Results Rates of high vaccine willingness were significantly lower among Black (45.3%), Latinx (62.5%), Asian (65%), multi-racial (67.2%), and other race (61.0%) respondents than among white respondents (77.6%). Black, Latinx, and Asian respondents were significantly more likely than white respondents to endorse reasons to not get vaccinated, especially lack of trust. Participants’ motivations and concerns about COVID-19 vaccination only partially explained racial-ethnic differences in vaccination willingness. Being a health worker in the CHART cohort and concern about a rushed government vaccine approval process were the two most important factors predicting vaccination intention. Conclusions and Relevance Special efforts are required to reach historically marginalized racial-ethnic communities to support informed decision-making about COVID-19 vaccination. These campaigns must acknowledge the history of racism in biomedical research and health care delivery that has degraded the trustworthiness of health and medical science institutions among non-white population and may continue to undermine confidence in COVID-19 vaccines. Highlights Black, Latinx, Asian, Multi-racial, and Other race respondents were significantly less likely than white respondents to have high willingness to receive COVID-19 vaccination when surveyed around the time that the first COVID-19 vaccines received Emergency Use Authorization in the US. Racial-ethnic differences in vaccination intention were present for both health workers and the general population. Motivations and concerns about COVID-19 vaccination only partially explained racial-ethnic differences in COVID-19 vaccine willingness. The most important factors explaining COVID-19 vaccination intention were being a health worker, concern about government rushing the vaccine process, concern about having a bad reaction to the vaccine, motivation to protecting one’s self and family from COVID-19, and concern about getting COVID from the vaccine

This cross-sectional survey study investigates COVID-19 vaccine intentions among racially and ethnically diverse samples of health workers and the general population.

BackgroundHealthcare personnel (HCP) are prioritized for earliest SARS-CoV-2 vaccine administration, yet relatively few data exist on HCP’s knowledge, motivations, concerns, and intentions regarding COVID-19 vaccines.MethodsWe conducted a cross-sectional survey Nov.16-Dec.8, 2020 among HCP enrolled in a cohort study at three Northern California medical centers serving diverse roles including COVID-19 patient care. Eligible HCP were adult (age≥18) on-site employees of the University of California, San Francisco, San Francisco General Hospital, and Stanford Healthcare. A one-time electronically-administered survey was sent to cohort HCP on November 16, 2020 and responses analyzed.ResultsOverall, among 2,448 HCP invited, 2,135 completed the COVID-19 vaccine survey (87.2% response rate). HCPs had mean age 41 years, were 73% female, and had diverse jobs including COVID-19 patient contact. Enthusiasm for vaccination was overall strong, and more HCP (1,453, 69%) said they would definitely/likely receive vaccine if formally FDA-approved versus if approved via emergency use authorization only (785, 35%). While 541 (25%) respondents wanted to be among the earliest to receive vaccine, more desired vaccination after the first round (777, 36%) or >2 months after vaccinations began (389, 18%). Top factors increasing motivation for vaccination included perceiving risk from COVID-19 to self (1,382, 65%) or to family/friends (1355, 63%). Top concerns were vaccine side effects, cited by 596 (28%), and concerns about political involvement in FDA’s approval process (249, 12%).ConclusionsHCP were enthusiastic about COVID-19 vaccination for individual protection and protecting others, but harbored concerns about vaccine side effects. Our data may inform emerging vaccine education campaigns.Key PointsAmong 2,135 healthcare personnel surveyed, we found enthusiasm for COVID-19 vaccination both for individual benefit and protecting others. However, healthcare personnel rated their knowledge of COVID-19 vaccines as only moderate and harbored concerns about vaccine side effects. Education raising awareness of vaccine efficacy and side effects may help maximize vaccine uptake.

Background: Burnout and engagement are commonly conceptualized as opposite ends of a spectrum, and there is concern that high clinician burnout and lack of engagement may adversely impact patient care. Methods: We matched self-reported data on burnout and engagement for 182 primary care clinicians with data on clinical quality (cancer screenings, hypertension and diabetes control) and patient experience (Clinician and Group Survey-Consumer Assessment of Healthcare Providers and Systems [CG-CAHPS] communication scores, overall rating, and likelihood to recommend the clinic). Multivariable linear regression models examined burnout, engagement, or burnout-engagement phenotype (eg, high burnout-low engagement) as predictors of quality and patient experience. Results: One-third of clinicians in this sample did not fall along the spectrum of low burnout-high engagement to high burnout-low engagement. Neither burnout nor engagement on their own was associated with quality or patient experience measures. However, clinicians with high burnout who also were highly engaged had the highest average ratings for all 3 patient experience domains: clinician communication, overall rating of the clinician, and overall rating of the clinic. Discussion: The results of our study challenge the assumptions that burnout and engagement are opposite ends of a spectrum and that burnout or low engagement adversely impact quality of care and patient experience. Greater understanding is needed of how best to support dedicated clinicians who may provide quality care at the expense of their personal well-being.

Background and Objectives: Graduate medical education (GME) determines the composition and distribution of the physician workforce in the United States. Federal and state governments heavily subsidize GME but in most cases do not tie subsidies to national or state physician workforce goals. As a result, GME sponsoring institutions (eg, teaching hospitals, schools of medicine, federally qualified health centers) decide how many and what type of physicians to train. The objective of this study was to better understand the factors that influence decision-making by sponsoring institutions. Methods: Between May and December 2018, we interviewed 35 national or state GME policy leaders and an additional 26 GME leaders from a purposive sample of four sponsoring institutions. We analyzed interviews following a conventional content analysis approach to identify emergent themes. Results: When considering investing in GME, we found that sponsoring institutions do not consider national or statewide workforce recommendations. Instead, they weigh multiple factors of concern to their institution, including public GME subsidies, market competition, potential clinical revenues, academic stature, local workforce demands, as well as their own organization’s mission/culture, staffing, financial reserves, educational leadership, teaching resources, and size. Conclusions: Unless and until the incentives for sponsoring institutions are strongly aligned with national and state physician workforce priorities based on public need, progress on creating a more balanced physician workforce will not occur.

Objectives The study sought to determine whether objective measures of electronic health record (EHR) use—related to time, volume of work, and proficiency—are associated with either or both components of clinician burnout: exhaustion and cynicism. Materials and Methods We combined Maslach Burnout Inventory survey measures (94% response rate; 122 of 130 clinicians) with objective, vendor-defined EHR use measures from log files (time after hours on clinic days; time on nonclinic days; message volume; composite measures of efficiency and proficiency). Data were collected in early 2018 from all primary care clinics of a large, urban, academic medical center. Multivariate regression models measured the association between each burnout component and each EHR use measure. Results One-third (34%) of clinicians had high cynicism and 51% had high emotional exhaustion. Clinicians in the top 2 quartiles of EHR time after hours on scheduled clinic days (those above the sample median of 68 minutes per clinical full-time equivalent per week) had 4.78 (95% confidence interval [CI], 1.1-20.1; P = .04) and 12.52 (95% CI, 2.6-61; P = .002) greater odds of high exhaustion. Clinicians in the top quartile of message volume (>307 messages per clinical full-time equivalent per week) had 6.17 greater odds of high exhaustion (95% CI, 1.1-41; P = .04). No measures were associated with high cynicism. Discussion EHRs have been cited as a contributor to clinician burnout, and self-reported data suggest a relationship between EHR use and burnout. As organizations increasingly rely on objective, vendor-defined EHR measures to design and evaluate interventions to reduce burnout, our findings point to the measures that should be targeted. Conclusions Two specific EHR use measures were associated with exhaustion.

PURPOSE We investigated whether physician race and ethnicity were associated with burnout among a nationally representative sample of family physicians. METHODS We undertook a cross-sectional observational study using survey data from 1,510 American Board of Family Medicine recertification applicants in 2017 and 1,586 respondents to the 2017 National Graduate Survey. Of the 3,096 total family physicians, 450 (15%) were from racial and ethnic groups underrepresented in medicine. We used structural equation models to test the effects of underrepresented status on single-item measures of emotional exhaustion and depersonalization. RESULTS Family physicians underrepresented in medicine were significantly less likely than their non-underrepresented counterparts to report emotional exhaustion (adjusted odds ratio = 0.82; 95% CI, 0.69-0.99; total effect) and depersonalization (adjusted odds ratio = 0.54; 95% CI, 0.41-0.71; total effect). The underrepresented physicians were more likely than non-underrepresented peers to practice in more racially and ethnically diverse counties and less likely to practice obstetrics, both of which partly mediated the protective effect of underrepresented status on depersonalization. CONCLUSIONS Although factors such as racism might be expected to adversely affect the well-being of underrepresented clinicians, underrepresented family physicians reported a lower frequency of emotional exhaustion and depersonalization. The mediating protective effect of working in more racially and ethnically diverse counties is consistent with evidence of the beneficial effect of cultural diversity on health outcomes for minorities. Because physician burnout is a known predictor of job turnover and may also be associated with poorer quality of care, the lower burnout observed among underrepresented family physicians may be an asset for the health care system as a whole.

This chapter looks at the role of primary health care in community health. Primary care, it argues, has built on its historical roots of holistic family-centered care to embrace the broader concept of population health. The chapter looks at the evolution of care models from patient/family-centered to panel management (the sum of patients being cared for by a primary care practice), to community health management. This broader concept of health necessitates collaboration with partners outside the clinical practice, including public health professionals, policymakers, schools, housing, parks and recreation, law enforcement, transportation, and food systems. The chapter describes the population and community framework and its historical role in the development of primary care, and then turns to the proposal of pragmatic approaches that busy primary care clinicians and care teams can use to integrate population health approaches into their practices.

This chapter examines global budgets and competition as cost control strategies. It discusses the use of global budgeting in other nations, evaluating its advantages and potential problems. The chapter focuses on the United States, with its own set of problems and opportunities, and contrast the global budget approach with the most prominent contemporary pro-competitive strategy, managed competition. It also discusses the ways in which the Clinton plan attempts to broker a compromise between global budgeting and market competition and highlights some of the unsettled questions about health care reform model. The initial budgets for hospitals at the inception of public insurance in Canada were based on each individual hospital's historical operating costs. The main attraction of global budgets is that they erect a firm fence around expenditures. The regulatory process may fail to register accurately public willingness to increase resources for health care, resulting in excessively austere global budgets.

PURPOSE Levels of burnout among primary care clinicians and staff are alarmingly high, and there is widespread belief that burnout and lack of employee engagement contribute to high turnover of the workforce. Scant research evidence exists to support this assertion, however. METHODS We conducted a longitudinal cohort study using survey data on burnout and employee engagement collected in 2013 and 2014 from 740 primary care clinicians and staff in 2 San Francisco health systems, matched to employment roster data from 2016. RESULTS Prevalence of burnout, low engagement, and turnover were high, with 53% of both clinicians and staff reporting burnout, only 32% of clinicians and 35% of staff reporting high engagement, and 30% of clinicians and 41% of staff no longer working in primary care in the same system 2 to 3 years later. Burnout predicted clinician turnover (adjusted odds ratio = 1.57; 95% CI, 1.02-2.40); there was also a strong trend whereby low engagement predicted clinician turnover (adjusted odds ratio with high engagement = 0.58; 95% CI, 0.33-1.04). Neither measure significantly predicted turnover for staff. CONCLUSIONS High rates of burnout and turnover in primary care are compelling problems. Our findings provide evidence that burnout contributes to turnover among primary care clinicians, but not among staff. Although reducing clinician burnout may help to decrease rates of turnover, health care organizations and policymakers concerned about employee turnover in primary care need to understand the multifactorial causes of turnover to develop effective retention strategies for clinicians and staff.

The Association of Departments of Family Medicine (ADFM), as part of its mission, has made diversity, inclusion, and health equity priorities. This mission is being carried out with adherence to the core values that are crucial to our member departments’ teaching, research, and provision of

BACKGROUND: Clinicians and healthcare staff report high levels of burnout. Two common burnout assessments are the Maslach Burnout Inventory (MBI) and a single-item, self-defined burnout measure. Relatively little is known about how the measures compare. OBJECTIVE: To identify the sensitivity, specificity, and concurrent validity of the self-defined burnout measure compared to the more established MBI measure. DESIGN: Cross-sectional survey (November 2016–January 2017). PARTICIPANTS: Four hundred forty-four primary care clinicians and 606 staff from three San Francisco Aarea healthcare systems. MAIN MEASURES: The MBI measure, calculated from a high score on either the emotional exhaustion or cynicism subscale, and a single-item measure of self-defined burnout. Concurrent validity was assessed using a validated, 7-item team culture scale as reported by Willard-Grace et al. (J Am Board Fam Med 27(2):229–38, 2014) and a standard question about workplace atmosphere as reported by Rassolian et al. (JAMA Intern Med 177(7):1036–8, 2017) and Linzer et al. (Ann Intern Med 151(1):28–36, 2009). KEY RESULTS: Similar to other nationally representative burnout estimates, 52% of clinicians (95% CI: 47–57%) and 46% of staff (95% CI: 42–50%) reported high MBI emotional exhaustion or high MBI cynicism. In contrast, 29% of clinicians (95% CI: 25–33%) and 31% of staff (95% CI: 28–35%) reported “definitely burning out” or more severe symptoms on the self-defined burnout measure. The self-defined measure’s sensitivity to correctly identify MBI-assessed burnout was 50.4% for clinicians and 58.6% for staff; specificity was 94.7% for clinicians and 92.3% for staff. Area under the receiver operator curve was 0.82 for clinicians and 0.81 for staff. Team culture and atmosphere were significantly associated with both self-defined burnout and the MBI, confirming concurrent validity. CONCLUSIONS: Point estimates of burnout notably differ between the self-defined and MBI measures. Compared to the MBI, the self-defined burnout measure misses half of high-burnout clinicians and more than 40% of high-burnout staff. The self-defined burnout measure has a low response burden, is free to administer, and yields similar associations across two burnout predictors from prior studies. However, the self-defined burnout and MBI measures are not interchangeable. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4507-6) contains supplementary material, which is available to authorized users.

ADFM celebrated its 40th “Birthday” at our annual Winter meeting in Washington, DC with champagne, cake, singing and dancing, the return of 20 former members to help us reminisce, and reflection on where we have been and where we should be going. As incoming President Kevin Grumbach, MD

Background: A recent regional study found lower burnout among primary care clinicians who perceived that their clinic had greater capacity to meet patients9 social needs. We aimed to more comprehensively investigate the association between clinic capacity to address social needs and burnout by using national data that included a more representative sample of family physicians and a more comprehensive set of practice-level variables that are potential confounders of an association between clinic social needs capacity and burnout. Methods: We conducted a cross-sectional analysis of 1298 family physicians in ambulatory primary care settings who applied to continue certification with the American Board of Family Medicine in 2016. Logistic regression was used to test associations between physician and clinic characteristics, perceived clinic social needs capacity, and burnout. Results: A total of 27% of family physicians reported burnout. Physicians with a high perception of their clinic9s ability to meet patients9 social needs were less likely to report burnout (adjusted odds ratio [OR], 0.66; 95% confidence interval [CI], 0.47–0.91). Physicians who reported high clinic capacity to address patients9 social needs were more likely to report having a social worker (adjusted OR, 2.16; 95% CI, 1.44–3.26) or pharmacist (adjusted OR, 1.73; 95% CI, 1.18–2.53) on their care team and working in a patient-centered medical home (adjusted OR, 1.65; 95% CI, 1.24–2.21). Conclusion: Efforts to reduce primary care physician burnout may be furthered by addressing structural issues, such as improving capacity to respond to patients9 social needs in addition to targeting other modifiable burnout risks.

Purpose Primary care physicians (PCP) experience high rates of professional burnout. These symptoms may be magnified in underserved populations. This study explores relationships between clinic capacity to address patients' social needs (SN) and PCP burnout. Methods We conducted a cross-sectional survey of PCPs from three delivery systems in San Francisco. Surveys included three components of burnout, measured by the Maslach Burnout Inventory (MBI) and a four-item instrument exploring attitudes, confidence, individual skills and organizational capacity to address patients' SN. Results Provider perception of higher clinic capacity to address patients' SN was the strongest independent predictor of lower burnout. Providers who perceived high clinic capacity and resources to address SN reported significantly greater professional efficacy (p l.01), lower emotional exhaustion (p l.05), and lower cynicism (p l.05). Conclusions Provider perceptions of greater clinic capacity to address SN are significantly associated with lower burnout. Devoting organizational resources to address SN may reduce PCP burnout.

Introduction: Emerging policy consensus advocates that patient-centered care should include an active, practice-level patient role, but it is unknown how commonly these roles are implemented. We sought to understand current prevalence and predictors of practice-level patient engagement in US primary care settings. Methods: We assessed practice-level patient engagement by using 2016 American Board of Family Medicine Certification Examination registration data, restricted to ambulatory primary care site respondents randomly selected for a patient-centered medical home (PCMH) question module. Multivariate logistic regression models identified predictors of high-intensity patient engagement, defined as a patient advisory council or patient volunteers in quality improvement activities. Results: A total of 6900 examinees reported practicing in primary care sites; 1368 randomly received PCMH questions. Practice-level patient engagement included patient surveys (76.5%; 95% CI, 74.3–78.8%), patient suggestion boxes (52.9%; 95% CI, 50.2–55.5%), patient board of director memberships (18.8%; 95% CI, 16.7–20.9%), patient advisory councils (23.8%; 95% CI, 21.5–26.0%), and patient participation in quality improvement (20.5%; 95% CI, 18.3–22.6%). High-intensity patient engagement was reported by 31.1% (95% CI, 28.7–33.6%); predictors included large practice size (OR, 3.30; 95% CI, 1.96–5.57), serving more vulnerable patient populations, (OR, 1.83; 95% CI, 1.18–2.84) and PCMH certification (OR, 2.19; 95% CI, 1.62–2.97). Conclusions: Nearly one-third of physicians reported working in settings with high-intensity practice-level patient engagement. An implementation science approach should examine why high-intensity activities are more common in some practice settings and whether these activities add value through improved patient experience and health outcomes.

Every department that is a member of the Association of Departments of Family Medicine includes the term “family medicine” in its title. Fewer than one-half our member departments, however, only have family medicine in their titles. Many titles acknowledge the other major elements of work being

Context: To meet demands for evidence-based chronic and preventive services and to improve performance, primary care practices are turning toward team-based strategies such as panel management, in which nonclinicians address routine preventive and chronic disease care tasks for a group of patients. No known validated instruments have been published for measuring panel management implementation. Objective: To describe development and evaluation of the Panel Management Questionnaire (PMQ), a self-report tool measuring panel management capability in primary care. Design: Cross-sectional study for questionnaire validation. Main Outcome Measures: We developed the 12-item PMQ from a conceptual framework to measure 4 domains of panel management and tested the questionnaire for internal and external validity. Data were assembled from self-administered cross-sectional surveys that included the PMQ instrument sent from February 2012 through May 2012. We surveyed 136 staff and 204 clinicians in 9 county and 5 university adult primary care clinics. Additional data came from clinic quality measures routinely collected the quarter before the survey. Results: The PMQ scale demonstrated good internal consistency (Cronbach α = 0.92 and 0.84 for staff and clinicians, respectively). Staff and clinician PMQ scores in each clinic were correlated (Kendall τ = 0.45, p < 0.05). The cliniclevel median PMQ score was positively associated with a composite clinic quality measure (Kendall τ = 0.42 for staff, 0.28 for clinicians). Conclusions: The PMQ measures self-reported panel management capability and may be a useful assessment and research tool for panel management implementation in primary care practice.

PURPOSE The projected U.S. physician shortage will disproportionately affect underserved areas. This study examined the impact of medical school educational experiences on positive changes in and reaffirmation of students' intention to practice in underserved areas (practice intention). METHOD Medical students (n = 7,361) from 113 U.S. MD-granting medical schools who graduated in 2009-2010 and responded to both the Association of American Medical Colleges' 2006 Matriculating Student Questionnaire and 2010 Graduation Questionnaire were included. Multilevel logistic regression analyses were conducted to determine factors associated with change in and reaffirmation of practice intention. RESULTS After controlling for individual characteristics, community health field experience (adjusted odds ratio [OR]: 1.36; 95% CI: 1.18, 1.57), learning another language (OR: 1.41; 95% CI: 1.22, 1.63), cultural competence/awareness experience (OR: 1.38; 95% CI: 1.21, 1.58), becoming more aware of perspectives of individuals from different backgrounds (OR: 1.24; 95% CI: 1.04, 1.48), and attending schools with higher social mission scores (OR: 1.66; 95% CI: 1.28, 2.16) were all significantly associated with positive changes in practice intention from matriculation to graduation. Field experience in community health (OR: 1.24; 95% CI: 0.99, 1.53), learning another language (OR: 1.29; 95% CI: 1.01, 1.65), and attending schools with higher social mission scores (OR: 1.62; 95% CI: 1.09, 2.43) were all significantly associated with reaffirmation of practice intention at graduation. CONCLUSIONS Multifaceted factors are associated with practice intention. This study suggests medical schools can play active roles in alleviating the physician shortage in underserved areas through targeted curricular interventions and recruitment.

GoalsTo evaluate provider knowledge, attitudes and barriers to hepatitis B virus (HBV) care and management practices across diverse primary care settings.BackgroundFactors influencing adherence to recommended HBV screening and management guidelines are poorly defined.Materials and methodsProviders across various health care settings in San Francisco were surveyed. Multivariate analyses were used to identify factors associated with recommended HBV screening, vaccination, and disease monitoring.ResultsOf 277 (41.3%) responding providers, 42% reported performing HBV screening in >50% of at-risk patients, and 49%, HBV vaccination in >50% of eligible patients. Most reported appropriate monitoring of a majority of HBV-infected patients with alanine aminotransferase (79%) and HBV viral load (67%) every 6 to 12 months, but performed any hepatocellular carcinoma screening in 49%. Provider factors significantly associated with HBV screening were speaking an Asian language [odds ratio (OR), 3.27], offering HBV treatment (OR, 3.00), having >25% of Asian patients in practice (OR, 2.10), practicing in safety net settings (OR, 7.51) and having higher barrier score (OR, 0.74). Appropriate HBV monitoring was associated with provider speaking an Asian language (OR, 3.43) and provider age (OR, 0.68/decade). Hepatocellular carcinoma screening was associated with having >25% of patients speaking English as a second language (OR, 4.26) and practicing in safety net settings (OR, 0.14).ConclusionsRates of adherence to HBV guidelines were suboptimal irrespective of practice setting and were influenced by certain provider, patient and practice factors. This study reinforces the importance of engaging primary care providers in development, dissemination, and implementation of evidence-based HBV practice guidelines.

Background Shared decision making (SDM) is a potentially valuable but underexplored approach to contraceptive counseling. Methods We determined the correlation between patient report of SDM and of whether their provider had a method preference with measures of satisfaction. Results Women reporting SDM were more likely to be satisfied with counseling than those reporting a provider-driven decision and were more likely to be satisfied with their method than those reporting a patient-driven decision. Patients who felt that the provider had a method preference were less likely to be satisfied with their method. Conclusions SDM in contraceptive counseling is associated with patient satisfaction.

Author(s): Grumbach, Kevin; Vargas, Roberto A; Fleisher, Paula; Aragon, Tomas J; Chung, Lisa; Chawla, Colleen; Yant, Abbie; Garcia, Estela R; Santiago, Amor; Lang, Perry L; Jones, Paula; Liu, Wylie; Schmidt, Laura A | Abstract: BackgroundThe San Francisco Health Improvement Partnership (SFHIP) promotes health equity by using a novel collective impact model that blends community engagement with evidence-to-policy translational science. The model involves diverse stakeholders, including ethnic-based community health equity coalitions, the local public health department, hospitals and health systems, a health sciences university, a school district, the faith community, and others sectors.Community contextWe report on 3 SFHIP prevention initiatives: reducing consumption of sugar sweetened beverages (SSBs), regulating retail alcohol sales, and eliminating disparities in children's oral health.MethodsSFHIP is governed by a steering committee. Partnership working groups for each initiative collaborate to 1) develop and implement action plans emphasizing feasible, scalable, translational-science-informed interventions and 2) consider sustainability early in the planning process by including policy and structural interventions.OutcomeThrough SFHIP's efforts, San Francisco enacted ordinances regulating sale and advertising of SSBs and a ballot measure establishing a soda tax. Most San Francisco hospitals implemented or committed to implementing healthy-beverage policies that prohibited serving or selling SSBs. SFHIP helped prevent Starbucks and Taco Bell from receiving alcohol licenses in San Francisco and helped prevent state authorization of sale of powdered alcohol. SFHIP increased the number of primary care clinics providing fluoride varnish at routine well-child visits from 3 to 14 and acquired a state waiver to allow dental clinics to be paid for dental services delivered in schools.InterpretationThe SFHIP model of collective impact emphasizing community engagement and policy change accomplished many of its intermediate goals to create an environment promoting health and health equity.

On November 8, 2016, family physicians went to work across the United States caring for patients. Some patients wore caps emblazoned “Make America Great Again” and others had buttons declaring “I’m With Her.” As on any other day, the task was to care for each patient with respect and