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A group of senior leaders from the early generation of academic family medicine reflect on the meaning of being a personal physician, based on their own clinical experiences and as teachers of residents and students in academic health centers. Recognizing that changes in clinical care and education at national and local systems levels have added extraordinary demands to the role of the personal physician, the senior group offers examples of how the discipline might go forward in changing times. Differently organized care such as the Family Health Team model in Ontario, Canada; value-based payment for populations in large health systems; and federal changes in reimbursement for populations can have positive effects on physician satisfaction. These changes and examples of changes in medical student and residency education also have the potential to positively affect the primary care workforce. The authors conclude that, without substantive educational and health system reform, the ability to truly serve as a personal physician and adhere to the values of continuity, responsibility, and accountability will continue to be threatened.

The principal advantages for pioneering new territory lay in both the creativity for courageous individuals and opportunities for those who follow. The West was settled on inspiration (and perspiration) fueled by a desire for a better way, a better life, and a more hopeful future. Likewise, the development of medical family therapy (MedFT) grew from a need in healthcare for a more collaborative, relationally based, and systemic system. Today, it is finding its place. Much like pioneering settlers, MedFTs have moved from the most populated areas to those in need of more development. With each step, there is continued learning and growing appreciation for each setting’s unique population, needs, diverse cultures, and resources. In McDaniel, Hepworth, and Doherty’s (1992) early primer, primary care was described as an ideal environment for MedFT. Over the years, this scope and attention has evolved to include secondary and tertiary care settings. This book attempts to serve as a learning tool for new and experienced professionals wanting to develop as MedFTs and who wish to expand into new territories for which they were not formally trained.

Research examining the implementation and effectiveness of integrated behavioral health (BH) care in family medicine/primary care is growing. However, research identifying ways to consistently use integrated BH in busy family medicine/primary care settings with underserved populations is limited. This study describes 1 family medicine clinic's transformation into a fully integrated BH care clinic through the development of an Integrated Care Clinic (ICC) and enhanced clinical pathways to promote regular use of behavioral health clinicians (BHCs).We implemented the ICC at the Broadway Family Medicine Clinic serving a low-income ($25,000 annual income/year) and minority population (70% African American) in Minnesota. We conducted a pre- and postevaluation of the ICC during regular clinic activity.Pilot findings indicated that the creation of ICC and the use of enhanced clinical pathways (e.g., 5-2-1-0 obesity prevention messages, Transitional Care Management, postpartum depression screening visits, warm hand-offs) to facilitate regular use of integrated BH care resulted in 6 integrated care visits per BHC per clinic half-day. In addition, changes in the behavioral/mental health therapy appointment time slot (from 60 to 30 min) reduced therapy no-show rates. Transitional Care Management (TCM) visits also showed improved pre- and postchanges in patient and clinician satisfaction and reductions in patient hospital readmission rates.The transformation into a fully integrated BH family medicine clinic through the creation of ICC and enhanced clinical pathways to facilitate regular integrated BH care showed promising pilot results. Future research is needed to examine associations between ICC and patient outcomes (e.g., weight, depressive symptoms). (PsycINFO Database Record

To survive in today’s healthcare climate, stakeholders across all mental health disciplines must work to produce empirical evidence that earns their fields’ regard by educators, providers, and policy makers. As the field of Medical Family Therapy (MedFT) answers this call, it will be important for researchers to clearly define, characterize, and assess MedFT practice across clinical, operational, and financial arenas of care. In this account, we propose a common lexicon from which to do this, highlighting the following core tenets of MedFT: systems theory, biopsychosocial-spiritual sensitivity in practice, agency, communion, interdisciplinary collaboration, and the three-world model of healthcare. We conclude by offering concrete ways to advance the MedFT research agenda using qualitative, quantitative, and mixed-method approaches.

Primary care is increasingly geared toward standardized care and decision-making for common chronic conditions, combinations of medical and mental health conditions, and the behavioral aspects of care for those conditions. Yet even with well-integrated team-based care for health conditions in place, some patients do not engage or respond as well as clinicians would wish or predict. This troubles patients and clinicians alike and is often chalked up informally to "patient complexity." Indeed, every clinician has encountered complex patients and reacted with "Oh my gosh"-but not necessarily with a patterned vocabulary for exactly how the patient is complex and what to do about it. Based on work in the Netherlands, patient complexity is defined here as interference with standard care and decision-making by symptom severity or impairments, diagnostic uncertainty, difficulty engaging care, lack of social safety or participation, disorganization of care, and difficult patient-clinician relationships. A blueprint for patient-centered medical home must address patient complexity by promoting the interplay of usual care for conditions and individualized attention to patient-specific sources of complexity-across whatever diseases and conditions the patient may have.

PURPOSE We wanted to identify risk factors for persistently high use of primary care. METHODS We analyzed outpatient office visits to practitioners in family medicine, general internal medicine, general pediatrics, and obstetrics for 1997–1999 among patients in a small Midwestern city covered by a fee-for-service insurance plan with no co-payments for physician visits and no requirement for referral to specialty care. Logistic regression was used to predict which patients with 10 or more primary care visits in 1997 would repeat high use in 1998 based on demographic and diagnostic categories (adjusted clinical groups [ACGs]). A confirmatory data set (high primary care use in 1998 persistent into 1999) was used to evaluate the model. RESULTS Two percent of the 54,074 patients had 10 or more primary care visits in 1997, and of these, almost 19% had 10 or more visits in the next year. Among adults, 4 ambulatory diagnosis groups (ADGs) were simultaneously positive predictors of repeated high primary care visits: unstable chronic medical conditions, see and reassure conditions, minor time-limited psychosocial conditions, and minor signs and symptoms. Meanwhile, pregnancy was negatively associated. The area under the receiver operating characteristic (ROC) curve was 0.794 for adults in the developmental data set and 0.752 in the confirmatory data set, indicating a moderately accurate assessment. A satisfactory model was not developed for pediatric patients. CONCLUSIONS Many persistently high primary care users appear to be overserviced but underserved, with underlying problems not addressed by a medical approach. Some may benefit from psychosocial support, whereas others may be good candidates for disease management interventions.

An Institute of Medicine committee was convened to explore the links between biological, psychosocial, and behavioral factors and health and to review effective applications of behavioral interventions. Based on the evidence about interactions of the physiological responses to stress, behavioral choices, and social influences, the committee encouraged additional research efforts to explore the integration of these variables and to evaluate their mechanisms. An understanding of the social factors influencing behavior is growing and should be considered in programs and policies for public health, in addition to individual behavior and physiological status. Interventions to change behaviors have been directed toward individuals, communities, and society. Many intervention trials have documented the capacity of interventions to modify risk factors. However, more trials that include measures of morbidity and mortality to determine if the strategy has the desired health effects are needed. Behavior can be changed and new behaviors can be taught. Maintaining behavior changes is a greater challenge. Although short-term changes in behavior following interventions are encouraging, long-duration efforts are needed to improve health outcomes and to provide long-term assessments of effectiveness. Interventions aimed at any level can influence behavior change; however, existing research suggests that concurrent interventions at multiple levels are most likely to sustain behavior change and should be encouraged.

I am a full supporter of the patient-centered medical home as an organizational model for practice, and I am hopeful this model will provide an enduring change for better primary care. I have seen evidence that some physicians enjoy this new model but are also describing rather easily the flaws of

Following are excerpts from the closing panel discussion of the session “Shaping the Future of Academic Health Centers: A Reconnaissance from the Front Lines of Medicine,” held during the 2005 annual meeting of the Association of American Medical Colleges (AAMC). ### J. Lloyd Michener, MD: I

Improving opportunities for primary care are evident in the evolving health care marketplace. Yet a secure and meaningfully scaled role in the future for family medicine and primary care is not assured. Family medicine can help lead the primary care movement now-from both clinical and policy perspectives-by energetically embracing newly emerging care options rather than becoming complacent or defensive. Avoiding complacency means: (1) improving assessment and intervention for social and health system complexity (our complex patients), (2) regarding primary care as a way of operating, not as a geographical place-even with the name medical home in place, (3) coordinating with dedicated mobile teams for our most complex and costly patients, and (4) improving leadership competence at a level required for transformation, not just maintenance.

To survive in today’s healthcare climate, stakeholders across all behavioral health disciplines must work to produce empirical evidence that earns their fields’ regard by educators, providers, and policy makers. As the field of medical family therapy (MedFT) answers this call, it will be important for researchers to clearly define, characterize, and assess MedFT practice across clinical, operational, and financial arenas of care. In this chapter, the authors propose a common lexicon from which to do this, highlighting the following core tenets of MedFT: systems theory, biopsychosocial–spiritual sensitivity in practice, agency, communion, interdisciplinary collaboration, and the three-world model of healthcare. We conclude by offering concrete ways to advance the MedFT research agenda using qualitative, quantitative, and mixed-method approaches.

As ambassadors for Medical Family Therapy (MedFT), training in leadership skills should start when we are students. Then, throughout our training and as we grow in our careers, we should be continuously building competency in research, training, policy, and practice. Through confidence and competence, leaders emerge and are able to offer innovative ways to serve diverse populations and improve systems of care. Leaders in MedFT have many roles and have been recognized in academic, community-based, and healthcare environments for their systemic lens. This chapter highlights ways to prepare for leadership roles as well as stories of challenges and triumphs experienced by leaders.

This chapter provides a practical approach for understanding and dealing with patient “complexity” in a health care context. Complexity is defined as the interaction of patient, provider, and care delivery variables, which intermingle to create situations where usual treatments are not working—or not working as well as patients and clinicians are expecting. These situations can only be understood by looking at the complex interaction of those variables and adopting new models of understanding and implementing new care-giving strategies. The chapter begins with a review of different approaches to dealing with complexity within the USA and in Europe. A particular method and clinical checklist is described in detail. A “real world” application, the Complex Continuity Clinic, using this and other methods of engaging patients in complex situations, is outlined, with clinical examples. Finally, the important implications of a complexity approach to emerging health care reform is described, shedding light on how effective approaches that embrace complex biopsychosocial health issues can result in greater quality and reduced costs.

Such problems as sexually transmitted diseases, alcohol and other drug use, and acquaintance rape require college health professionals to function in primary and secondary preventive roles. In this article, the authors draw upon counseling literature and college health practice to identify the central elements of preventive programs, highlight specific intervention formats used in preventive work, and describe how interventions are assembled into coherent programs of prevention. To illustrate the structure and process of long-range, institutionalized preventive efforts, the authors describe an initiative addressing the primary, secondary, and tertiary prevention of substance use at a health sciences campus.

Three years ago ADFM reported the need to develop an effective pipeline for family medicine department chairs.1 Prompting this report were results from our 2008 survey, in which nearly one-half (47%) of chairs reported a possible or probable change in departmental leadership in the next 3 years. One year later, our 2009 data indicated a more imminent turnover in chair positions with 52% chairs reporting plans to leave their positions within 2 to 5 years and 20% planning to leave within 2 years or less. Turnover in chair positions is not a new phenomenon. Since 2005, our data show that 10 to 15 new chairs (interim and permanent) have come into ADFM each year, and the trend has accelerated this past year as 19 new family medicine chairs joined ADFM between February 2011 and February 2012. In response to the chair pipeline concern raised in 2008, ADFM launched the ADFM fellowship program. The ADFM fellowship is a 1-year program designed for family physicians who aspire to become a chair in the near future. Since 2009 13 fellows have completed the ADFM fellowship, 6 of whom (46%) have assumed chair positions. There are 3 additional fellows in our current 2012–2013 class, and we will be recruiting for a new class of fellows in the fall of 2012 for the 2013–2014 fellowship class. Below is a description of the program and application process. Curriculum components of the ADFM fellowship include: Attendance at 2 consecutive ADFM Annual Winter Meetings. Annual ADFM Winter meetings are in February and run from the opening reception on Wednesday evening through Saturday at noon. The 2013 winter meeting is scheduled for February 20–23, 2013 in New Orleans, Louisiana. The 2014 winter meeting has not been scheduled yet but the time-frame will be similar. Attendance at 1 ADFM Fall Meeting in conjunction with the AAMC annual meeting. In 2013, this meeting will be in early November in Philadelphia, Pennsylvania. Assignment to a faculty advisor who will work one-on-one with each fellow to help guide them through the fellowship. Participation on the ADFM Chairs’ list-serve for the duration of the fellowship. List-serve participation allows fellows to learn about potential chair opportunities and about the many issues facing chairs in their everyday jobs. Meetings with other fellows and assigned advisors (as scheduled) during the ADFM Annual Winter Meeting to review together all fellows’ learning needs (including but not limited to the CV review) and educational plans for the year Fellowship projects. In consultation with her/his department chair, the fellow will select a project aimed at increasing the fellow’s skills in an area of interest that also benefits the department. A fellowship application must include: Current curriculum vitae Title of your fellowship project Letter from the chair of your department supporting your aspirations of becoming a department chair and including a statement of: (1) willingness to support the cost of your participation in the fellowship; (2) support of the fellow’s year-long participation on the ADFM List-serve; and (3) support of your fellowship project. If you are not from an ADFM member department, a letter from a current ADFM member chair is required. Personal statement regarding aspirations to become a chair (suggested length is 1 to 2 pages). In the personal statement provide an anecdote or describe an event that illustrates your ability to successfully lead a department of family medicine. If you already have a mentor who is a chair of a family medicine department (other than your own department chair) and would like to have that person continue to mentor you in the ADFM fellowship, please provide the name of that mentor. The cost of the program is registration for and travel to the 2 ADFM winter meetings and travel to the ADFM fall meeting held in conjunction with the annual meeting of the Association of American Medical Colleges. Applications will be reviewed by the ADFM executive committee and the ADFM fellowship co-directors. Applicants are notified by late November regarding acceptance into the 2013–2014 ADFM fellowship program. Criteria which are considered in reviewing applications include: Complete application packet Associate Professor or higher rank Involvement in each mission: education, clinical, research/scholarship (and administration) Evidence of being prepared for leadership role within dept/institution and outside institution MD, DO, or PhD with clinical practice in family medicine If you have any questions, please do not hesitate to contact either of us or Ardis Davis, MSW, Executive Director, ADFM (moc.loa@3827dsidra; 425-423-0922).

Hippocrates noted that the patient must be attended in light of “his†diet, work, home, and community setting. Since that time, we have struggled with the dilemma of how to put the patient’s presenting problems in the context of the patient’s life circumstances. That goal has proven elusive. So how do we sort out where to put the emphasis with our healing arts?

National Institutes of Health consensus and state-of-the science statements are prepared by independent panels of health professionals and public representatives on the basis of 1) the results of a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality (AHRQ); 2) presentations by investigators working in areas relevant to the conference questions during a 2-day public session; 3) questions and statements from conference attendees during open discussion periods that are part of the public session; and 4) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the panel and is not a policy statement of the National Institutes of Health or the U.S. government. The statement reflects the panel's assessment of medical knowledge available at the time the statement was written. Thus, it provides a "snapshot in time" of the state of knowledge on the conference topic. When reading the statement, keep in mind that new knowledge is inevitably accumulating through medical research.

This pilot study was conducted to determine the effect of an innovative reflecting interview on the health care utilization, physical health, mental function, and health care satisfaction of high-utilizing primary care patients with medically unexplained physical symptoms. Twenty-four high-utilizing patients met study selection criteria and were randomly assigned to a no-intervention control group or a reflecting interview intervention group. Outcomes were measured at 4 weeks, 6 months, and 1 year after the date of study enrollment. Results indicated that high-utilizing patients with medically unexplained physical symptoms who participated in a reflecting interview had reduced total health care costs, primarily through the reduction of hospitalization or inpatient expenses, despite a modest increase in outpatient primary care clinic visits. These data suggest that participation in a reflecting interview and regular visits with a primary care clinician can decrease health care utilization without adversely affecting patient satisfaction.

As a part of an on-going effort to assess the prevalence of alcoholism among hospitalized patients, a structured technique was devised to document the prevalence of alcoholism in a large teaching hospital. A system of inpatient chart audit classification was developed to assess direct evidence of patient alcoholism. In addition, the reported prevalence of alcoholism as a discharge diagnosis was determined. An assessment of the degree of alcoholism was used to classify patients into severity levels. A determination was made of the relationship of hospital chart data classification level to other medical problems or treatments directly addressed by the physician(s) that would indicate that the alcohol abuse, if present, was considered. A retrospective chart audit was conducted for 809 consecutive adult admissions to a 350-bed urban university teaching hospital using a specific classification scheme for determining evidence of alcoholism. This technique revealed a reported prevalence of alcoholism in 4.3% of all nonobstetric admissions to this university hospital. However, a chart review technique using specific criteria for the diagnosis of probable alcoholism raised the estimated prevalence to 15.9%. When the chart contained a primary diagnosis of alcoholism, physicians' responses reflected treatment plans that addressed acute management of alcohol related medical complications but often did not document efforts to assist the patient with the underlying alcoholism/substance abuse.