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Storylines of Family Medicine is a 12-part series of thematically linked essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'V: ways of thinking-honing the therapeutic self', authors present the following sections: 'Reflective practice in action', 'The doctor as drug-Balint groups', 'Cultivating compassion', 'Towards a humanistic approach to doctoring', 'Intimacy in family medicine', 'The many faces of suffering', 'Transcending suffering' and 'The power of listening to stories.' May readers feel a deeper sense of their own therapeutic agency by reflecting on these essays.

Abstract: The behavioral mechanisms by which urban wildlife adapt to urban landscapes and disturbances within these environments are poorly understood. Such understanding can be important for wildlife managers, especially if the species is of concern to human and pet safety, such as the coyote (Canis latrans). Here, we evaluate coyote tolerance to the presence of humans, pets, and anthropogenic landscapes, to better understand how coyotes are conditioned to live in urbanizing landscapes. Using continuous focal follow and instantaneous scan sampling, we collected data on metrics of anthropogenic development and coyote flight response. We used cumulative link mixed models to determine that intensity of behavioral response to observation was impacted by habitat, human visitation to sites, and coyote group composition. These data may be useful to managers for profiling potentially problematic individual animals and identifying strategies for human–coyote coexistence.

Abstract Background Children and adolescents with complex health complaints are often referred to several different healthcare specialists for assessments and treatment. This may result in fragmented care, higher risks of medical errors, and sub-optimal health outcomes. The aim of this non-controlled open label trial was to evaluate the feasibility of implementing a new interdisciplinary intervention for children and adolescents with multiple referrals and complex health complaints and to gather experiences from participating children, adolescents and parents. Methods In all, 47 children and adolescents aged 6–16 years with multiple referrals at a tertiary hospital were invited to participate. The intervention was a half-day consultation based on a biopsychosocial model. The aim of the intervention was to clarify the child/adolescent’s condition(s) and provide a joint understanding and treatment plan in collaboration with the family. A team consisting of a pediatrician, a physiotherapist and a psychologist delivered the intervention. Acceptance and completion rate was recorded, and child- and parent-experience measures were collected; the children and adolescents completed the Visual Consultation and Relational Empathy Scale (CARE) five questions and parents completed two de novo created measures about their experiences. Results Almost all invited families consented to participate (96%) and ultimately received the interdisciplinary intervention (92%). Mean age of the children and adolescents was 12 years, and under half were boys (40%). Before the intervention, 39 (91%) parents completed a questionnaire about previous experiences with healthcare. After the consultation 39 children and adolescents (91%) and 40 (93%) parents completed the questionnaire regarding their experience with the interdisciplinary intervention. Of the children and adolescents, 18–30 (47–77%) rated relational empathy in the intervention as “Very good” or “Excellent”. Of the parents, 35–39 (92–100%) rated their experience with the consultation using the more positive response options. The parents were significantly more content with the intervention compared to previously received healthcare (p

Abstract Introduction Chronic pain is a common, multifactorial condition and pharmacological treatments have limited benefits. Mindfulness is a holistic approach that might be of value in the management of chronic pain. However, attrition rates from mindfulness‐based interventions are high and factors affecting engagement are unknown. The aim of this study was to inform the design of a mindfulness programme that would be accessible and acceptable for people with chronic pain. Methods Interpretative phenomenological analysis of interview data from people with chronic pain who had taken part in an 8‐week mindfulness programme based on mindfulness‐based stress reduction revealed factors affecting engagement with and suggestions for tailoring the programme. Factors were grouped into physical, psychological and social domains. Further suggestions for tailoring the programme to address these factors were generated through a nominal group of healthcare professionals and a focus group with service users who had chronic pain. Findings Physical factors included disability and discomfort with some practices; psychological factors included expectations of the mindfulness programme and understanding the relationship between mindfulness and pain; and social factors included loneliness and support from others. The proposed modifications to the mindfulness programme supported by healthcare professionals and/or service users to address these are described in this paper. Public Contribution This study involved public contributions at a number of stages. The University of Aberdeen Division of Applied Health Sciences Service User Group (who were members of the public with chronic pain) was involved in the design of the study. Patients with chronic pain recruited from general medical practice who took part in the mindfulness programme were interviewed on their experience of the programme. Patients with chronic pain who attended the mindfulness programme, and healthcare professionals with expertise in chronic pain and/or mindfulness, attended meetings to design a tailored mindfulness programme for people with chronic pain.

Human-wildlife interactions, including human-wildlife conflict, are increasingly common as expanding urbanization worldwide creates more opportunities for people to encounter wildlife. Wildlife-vehicle collisions, zoonotic disease transmission, property damage, and physical attacks to people or their pets have negative consequences for both people and wildlife, underscoring the need for comprehensive strategies that mitigate and prevent conflict altogether. Management techniques often aim to deter, relocate, or remove individual organisms, all of which may present a significant selective force in both urban and nonurban systems. Management-induced selection may significantly affect the adaptive or nonadaptive evolutionary processes of urban populations, yet few studies explicate the links among conflict, wildlife management, and urban evolution. Moreover, the intensity of conflict management can vary considerably by taxon, public perception, policy, religious and cultural beliefs, and geographic region, which underscores the complexity of developing flexible tools to reduce conflict. Here, we present a cross-disciplinary perspective that integrates human-wildlife conflict, wildlife management, and urban evolution to address how social-ecological processes drive wildlife adaptation in cities. We emphasize that variance in implemented management actions shapes the strength and rate of phenotypic and evolutionary change. We also consider how specific management strategies either promote genetic or plastic changes, and how leveraging those biological inferences could help optimize management actions while minimizing conflict. Investigating human-wildlife conflict as an evolutionary phenomenon may provide insights into how conflict arises and how management plays a critical role in shaping urban wildlife phenotypes.

Abstract Background Multimorbidity (the co‐existence of two or more long‐term conditions within an individual) is a complex management challenge, with a very limited evidence base. Theories can help in the design and operationalization of complex interventions. Objective This article proposes self‐determination theory (SDT) as a candidate theory for the development and evaluation of interventions in multimorbidity. Methods We provide an overview of SDT, its use in research to date, and its potential utility in complex interventions for patients with multimorbidity based on the new MRC framework. Results SDT‐based interventions have mainly focused on health behaviour change in the primary prevention of disease, with limited use in primary care and chronic conditions management. However, SDT may be a useful candidate theory in informing complex intervention development and evaluation, both in randomized controlled trials and in evaluations of ‘natural experiments’. We illustrate how it could be used multimorbidity interventions in primary care by drawing on the example of CARE Plus (a primary care‐based complex intervention for patients with multimorbidity in deprived areas of Scotland). Conclusions SDT may have utility in both the design and evaluation of complex interventions for multimorbidity. Further research is required to establish its usefulness, and limitations, compared with other candidate theories. Patient or Public Contribution Our funded research programme, of which this paper is an early output, has a newly embedded patient and public involvement group of four members with lived experience of long‐term conditions and/or of being informal carers. They read and commented on the draft manuscript and made useful suggestions on the text. They will be fully involved at all stages in the rest of the programme of research.

Abstract The co-occurrence of mental and physical chronic conditions is a growing concern and a largely unaddressed challenge in low-and-middle-income countries. This study aimed to investigate the independent and multiplicative effects of depression and physical chronic conditions on health-related quality of life (HRQoL) in China, and how it varies by age and gender. We used two waves of the China Health and Retirement Longitudinal Study (2011, 2015), including 9227 participants aged ≥ 45 years, 12 physical chronic conditions and depressive symptoms. We used mixed-effects linear regression to assess the effects of depression and physical multimorbidity on HRQoL, which was measured using a proxy measure of Physical Component Scores (PCS) and Mental Component Scores (MCS) of the matched SF-36 measure. We found that each increased number of physical chronic conditions, and the presence of depression were independently associated with lower proxy PCS and MCS scores. There were multiplicative effects of depression and physical chronic conditions on PCS (− 0.83 points, 95% CI − 1.06, − 0.60) and MCS scores (− 0.50 points, 95% CI − 0.73, − 0.27). The results showed that HRQoL decreased markedly with multimorbidity and was exacerbated by the presence of co-existing physical and mental chronic conditions.

Characterising associations between the methylome, proteome and phenome may provide insight into biological pathways governing brain health. Here, blood protein markers of brain health are integrated with omics data to reveal DNA methylation differences that associate with these protein markers.

Background: Formation of GP clusters began in Scotland in April 2016 as part of a new Scottish GP contract. They aim to improve the care quality for local populations (intrinsic role) and the integration of health and social care (extrinsic role). Aim: To compare predicted challenges of cluster implementation in 2016 with reported challenges in 2021. Design & setting: Qualitative study of senior national stakeholders in primary care in Scotland. Method: Qualitative analysis of semi-structured interviews with 12 senior primary care national stakeholders in 2016 (n = 6) and 2021 (n = 6). Results: Predicted challenges in 2016 included balancing intrinsic and extrinsic roles, providing sufficient support, maintaining motivation and direction, and avoiding variation between clusters. Progress of clusters in 2021 was perceived as suboptimal and was reported to vary significantly across the country, reflecting differences in local infrastructure. Practical facilitation (data, administrative support, training, project improvement support, and funded time) and strategic guidance from the Scottish Government was felt to be lacking. GP engagement with clusters was felt to be hindered by the significant time and workforce pressures facing primary care. These barriers were considered as collectively contributing to cluster lead ‘burnout’ and loss of momentum, exacerbated by inadequate opportunities for shared learning between clusters across Scotland. Such barriers preceded, but were perpetuated by, the impact of the COVID-19 pandemic. Conclusion: Apart from the COVID-19 pandemic, many of the challenges reported by stakeholders in 2021 were predicted in 2016. Accelerating progress in cluster working will require renewed investment and support applied consistently across the country.

Background: Pilot 'new models' of primary care have been funded across the UK since 2015, through various national transformation funds. Reflections and syntheses of evaluation findings provide an additional layer of insight into 'what works' in transforming primary care. Aim: To identify good practice in policy design, implementation, and evaluation for primary care transformation. Design & setting: A thematic analysis of existing pilot evaluations in England, Wales, and Scotland. Method: Ten studies presenting evaluations of three national pilot studies — the Vanguard programme in England, the Pacesetter programme in Wales, and the National Evaluation of New Models of Primary Care in Scotland — were thematically analysed, and findings synthesised in order to identify lessons learnt and good practice. Results: Common themes emerged across studies in all three countries at project and policy level, which can support or inhibit new models of care. At project level, these included the following: working with all stakeholders, including communities and front-line staff; providing the time, space, and support necessary for the project to succeed; agreeing on clear objectives from the outset; and support for data collection, evaluation, and shared learning. At policy level, more fundamental challenges related to the parameters for pilot projects, in particular, the typically short-term nature of funding, with an expectation of results within 2–3 years. Changing expectations about outcome measures or project guidance part-way through project implementation was also identified as a key challenge. Conclusion: Primary care transformation requires coproduction and a rich, contextual understanding of local needs and complexities. However, a mismatch between policy objectives (care redesign to better meet patient needs) and policy parameters (short timeframes) is often a significant challenge to success.

BackgroundPrimary care patients, especially those with an older age, are one of the most vulnerable populations for post-COVID-19 symptoms. Identifying predictors of post-COVID symptoms can help identify high-risk individuals for preventive care.MethodsOut of 977 primary care patients aged 55 years or above with comorbid physical and psychosocial conditions in a prospective cohort in Hong Kong, 207 patients infected in the previous 5–24 weeks were included. The three most common post-COVID-19 symptoms (breathlessness, fatigue, cognitive difficulty), which lasted beyond the 4-week acute infection period, were assessed using items from the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS), together with other self-reported symptoms. Multivariable analyses were conducted to identify predictors of post-acute and long COVID-19 symptoms (5–24 weeks after infection).ResultsThe 207 participants had a mean age of 70.8 ± 5.7 years, 76.3% were female, and 78.7% had ≥2 chronic conditions. In total, 81.2% reported at least one post-COVID symptom (mean: 1.9 ± 1.3); 60.9, 56.5 and 30.0% reported fatigue, cognitive difficulty, and breathlessness respectively; 46.1% reported at least one other new symptom (such as other respiratory-related symptoms (14.0%), insomnia or poor sleep quality (14.0%), and ear/nose/throat symptoms (e.g., sore throat) (10.1%), etc.). Depression predicted post-COVID-19 fatigue. The female sex predicted cognitive difficulty. Receiving fewer vaccine doses (2 doses vs. 3 doses) was associated with breathlessness. Anxiety predicted a higher overall symptom severity level of the three common symptoms.ConclusionDepression, the female sex, and fewer vaccine doses predicted post-COVID symptoms. Promoting vaccination and providing intervention to those at high-risk for post-COVID symptoms are warranted.

Abstract Background No validated tool is available to assess patients’ perception of physician empathy in Korea. The objective of this study was to establish a Korean version of the Consultation and Relational Empathy (CARE) measure—originally developed in English and widely used internationally—and to examine its reliability and validity. Methods The CARE measure was translated into Korean and tested on 240 patients from one secondary care hospital and one tertiary care hospital in Korea. Internal consistency by Cronbach’s alpha, exploratory analysis, and confirmatory factor analysis were conducted to verify the 10 items of the Korean CARE measure. Results The Korean CARE measure demonstrated high acceptability and face validity, excellent internal reliability (Cronbach’s alpha = 0.97) and moderate test-retest reliability (Pearson correlation coefficient = 0.53; Spearman correlation coefficient = 0.51). Distribution of scores showed negative skewedness. Corrected item-total correlations ranged from 0.77–0.92, indicating homogeneity. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.949, and Bartlett’s test of sphericity was good (χ2 = 3157.11, P

The consequences of intraguild predation on vulnerable subordinate species are an important consideration in the recovery of endangered species. In prairie ecosystems, coyotes (Canis latrans) are the primary predator of endangered black-footed ferrets (Mustela nigripes ; hereafter, ferrets) and presumably compete for prairie dog (Cynomys spp.) prey. Coyote predation of ferrets is thought to occur at night when ferrets are active aboveground; however, the apparent source of competition, diurnal prairie dogs, are belowground and inaccessible to coyotes at this time, presenting a perplexing temporal mismatch between actual and expected times that coyotes and ferrets come into conflict. Our study used remote wildlife cameras, occupancy models, and overlap of circadian activity patterns to investigate how landscape features, prairie dog colony attributes, and attraction to sympatric species, i.e. American badgers (Taxidea taxus ; hereafter, badgers) and lagomorphs (cottontail rabbits and jackrabbits) influence Coyote use of prairie dog colonies and potential Coyote–ferret interactions. We first evaluated Coyote use (i.e. occupancy) between prairie dog colonies and surrounding available grasslands, finding that coyotes whose home ranges include prairie dog colonies used colonies nearly twice as much as surrounding grasslands. Next, we investigated biotic and abiotic factors that may influence Coyote use and frequency of use (i.e. detection probability) on prairie dog colonies. We found high Coyote use across all areas on prairie dog colonies; however, their frequency of use increased in areas that were also used by badgers. High overlap between Coyote and badger activity patterns (81%) further supports the spatial use patterns revealed by our occupancy analysis, and badgers and coyotes are known to form hunting associations. Interspecific competition and overlapping patterns of resource use between badgers and ferrets have been documented in previous studies; our study supports these findings and suggests that Coyote attraction to badger activity may influence Coyote–ferret interactions. [ABSTRACT FROM AUTHOR]

Aims: Prescribing of antidepressant and antipsychotic drugs in general populations has increased in the United Kingdom, but prescribing trends in people with type 2 diabetes (T2D) have not previously been investigated. The aim of this study was to describe time trends in annual prevalence of antidepressant and antipsychotic drug prescribing in adult patients with T2D. Methods: We conducted repeated annual cross‐sectional analysesof a population‐based diabetes registry with 99% coverage, derived from primary and secondary care data in Scotland, from 2004 to 2021. For each cross‐sectional calendar year time period, we calculated the prevalence of antidepressant and antipsychotic drug prescribing, overall and by sociodemographic characteristics and drug subtype. Results: The number of patients with a T2D diagnosis in Scotland increased from 161 915 in 2004 to 309 288 in 2021. Prevalence of antidepressant and antipsychotic prescribing in patients with T2D increased markedly between 2004 and 2021 (from 20.0 per 100 person‐years to 33.3 per 100 person‐years and from 2.8 per 100 person‐years to 4.7 per 100 person‐years, respectively). We observed this pattern for all drug subtypes except for first‐generation antipsychotics, prescribing of which remained largely stable. The degree of increase, as well as the overall prevalence of prescribing, differed by age, sex, socioeconomic status and subtype of drug class. Conclusions: There has been a marked increase in the prevalence of antidepressant and antipsychotic prescribing in patients with T2D in Scotland. Further research should identify the reasons for this increase, including indication for use and the extent to which this reflects increases in incident prescribing rather than increased duration. [ABSTRACT FROM AUTHOR]