Journal of the American Board of Family Medicine最新文献

Point-of-care ultrasound (POCUS) has seen growing integration into family medicine over the past decade, to the point that POCUS competency is now moving toward inclusion in board eligibility. In parallel, excitement and interest around POCUS are growing at the medical student and residency levels. With its wide array of practical applications in the outpatient setting, POCUS invites us to imagine what family medicine could look like if ultrasound truly became "the new stethoscope" and a routine part of care. This commentary highlights how POCUS can be used accurately and efficiently for abdominal aortic aneurysm (AAA) screening, avoid unnecessary emergency department visits by ruling out deep vein thrombosis (DVT), and change management of soft tissue infections by detecting abscesses. Together, these examples illustrate how POCUS can enhance care in the family medicine clinic.

If available in one's practice area, augmenting current medication therapy with esketamine results in greater rates of remission for treatment resistant depression as compared with quetiapine¹.

Point-of-care ultrasound (POCUS) is flourishing in family medicine. This issue presents a collection of POCUS articles exploring its use among family physicians, including specific applications and barriers to implementation. In addition, 4 articles present screening considerations for common problems - anxiety, social determinants of health, cervical cancer, and prostate cancer. Common practice management issues include urine drug screening in the care of patients with opioid use disorder, improving Human Papilloma Virus vaccination rates, and enhancing patient portal use in low resource settings. A series of articles comments on family medicine workforce issues, discussing ongoing challenges facing the discipline. Two helpful clinical reviews round out the issue - well water safety and combination medications for hypertension.

In family medicine (FM), point-of-care ultrasound (POCUS) usage is rising. Clinically, acute outpatient concerns often lends itself to more opportunities to use POCUS. Common scans utilized in the acute, outpatient setting include soft tissue masses, foreign body assessments, preprocedural guidance for incision and drainage and soft tissue mass excisions, deep vein thrombosis (DVT) ultrasound (US), joint effusions, right upper quadrant (RUQ) US assessments to check for gallstones, lung US for respiratory infections (especially in children), shoulder rotator cuff assessments, bladder US, and US assisted/guided procedures such as Baker's cyst aspirations, Carpal tunnel injections, and DeQuervain tenosynovitis injections. The goal of this commentary is to share clinical scenarios that can be helpful to use POCUS in the outpatient setting. With the advent of handheld US, recent Accreditation Council for Graduate Medical Education FM updates to recommend residents to learn POCUS³, and nationwide efforts spreading POCUS into residencies and primary care departments; I am optimistic that this will inspire and empower primary care physicians to learn and use POCUS effectively to benefit patients where and when they need care the most.

Point-of-care ultrasound (POCUS) is increasingly recognized as an important and useful improvement for bedside clinical care. Its wide adoption is slowed by the time it takes to perform, and the time it takes to learn. This commentary discusses this dilemma, and needed directions in education, technical advancements, and financial workflows for family medicine clinicians to better incorporate POCUS into clinical practice.

Background: The Centers for Medicare & Medicaid Services (CMS) has launched multiple alternative payment models (APMs) to address limitations with fee-for-service payments in traditional Medicare (TM), including challenges of TM in supporting high-quality primary care.

Methods: Using Medicare claims, CMS data on APM participation, and publicly available data, we examined the association between primary care physician (PCP) participation in TM APMs between 2017 and 2022 and the essential primary care features of accessibility, comprehensiveness, continuity, and coordination.

Results: 38.1% of PCPs in our analysis participated in at least 1 of 14 APMs during the study period. Based on a difference-in-differences analysis, we found that participation in APMs was significantly associated with improved outcomes on various key primary care dimensions. Of TM APMs assessed, hybrid payment models with no financial risk showed a significant association with improvement in all measures of the 4 essential features of primary care, both on measures that passed the parallel trends test as well as those that did not.

Conclusions: Overall participation in APMs is significantly associated with improved PCP outcomes on measures of various essential features of primary care. Of TM APMs assessed, only hybrid payment models with no financial risk showed a significant association with PCP improvement on all essential features of primary care. While methodological limitations preclude asserting a causal relationship, these findings support continued efforts to improve primary care for Medicare beneficiaries through hybrid payments to practices without imposing downside financial risk on PCPs.

No longer are prolonged sadness and despondency, with their effects on day-to-day functioning, conceived of as a response to someone's internal world or external environment. Instead, the syndrome has been elevated to a medical disorder-depression-explained as a chemical imbalance in the nervous system that requires medication to rebalance these chemicals. How did we arrive at this modern state of affairs? While the answer to this question is complex and has been hotly debated, one thing is certain: This relatively new explanation of depression as a neurochemical imbalance leads to the current privileging of pharmacotherapy over other approaches to treatment. However, the pharmacologic effect of these treatments is still speculative. Numerous studies have failed to show a benefit to active treatment greater than that seen with placebo, and most patients will not achieve remission of symptoms despite treatment. This overreliance on medication may reflect a "medicine is awesome" stance that biases clinicians toward medical interventions. A more expansive understanding of depressed mood, one that can and should be discussed with patients, is to understand it as a reaction to one's psychosocial, political, economic, and physical environment. This more expansive understanding includes the neurobiological basis of mood, but it also allows for discussions of non-pharmaceutical treatments, ones that can be aligned with each patient's agenda. Medications may be an eventual option after a thorough explanation of limited benefit and possible harms. However, this reframing of depression facilitates a valuable, satisfying means of developing trust and helping people with depressed mood.

Background: Healthcare access disparities persist, particularly among Medicaid patients in regions like the Inland Empire, California. These patients often face prolonged wait times for primary and specialty care, compounded by difficulties in scheduling with providers. Leveraging eConsult platforms offers a potential solution to improve specialist care accessibility. This study examines the impact of the Inland Empire Health Plan's (IEHP) eConsult services on enhancing interactions between primary care providers (PCPs) and specialists and improving patient care.

Methods: We analyzed 2,505 eConsults conducted between January and June 2022 within the IEHP, focusing on dermatology, pulmonology, and urology. Each eConsult was categorized based on closure outcomes, advice provided, and authorization status. We cross-referenced eConsult data with claims and authorization records to determine encounter completion, particularly whether a face-to-face specialist visit occurred.

Results: Only a fraction of eConsults (27% dermatology, 25% pulmonology, 37% urology) resulted in specialist advice. In cases where eConsults did not suffice, specialists recommended in-person follow-up; however, a significant portion of patients (57% dermatology, 71% pulmonology, 53% urology) did not receive in-person specialty care.

Conclusion: This study highlights the potential of eConsults in improving specialty care access for Medicaid patients in underserved regions. While eConsults show promise in expediting specialist access, challenges such as varying PCP utilization and the need for in-person visits persist. Addressing these issues with standardized protocols and better triaging can significantly reduce healthcare disparities and improve patient outcomes.

Diagnostic errors are a significant challenge in health care, often resulting from gaps in physicians' knowledge and misalignment between confidence and diagnostic accuracy. Traditional educational methods have not sufficiently addressed these issues. This commentary explores how large language models (LLMs), a subset of artificial intelligence, can enhance diagnostic education by improving learning transfer and physicians' diagnostic accuracy. The American Board of Family Medicine (ABFM) is integrating LLMs into its Continuous Knowledge Self-Assessment (CKSA) platform to generate high-quality cloned diagnostic questions, implement effective spaced repetition strategies, and provide personalized feedback. By leveraging LLMs for efficient question generation and individualized learning, the initiative aims to transform continuous certification and lifelong learning, ultimately enhancing diagnostic accuracy and patient care.

Purpose: Increasingly emphasized by leaders in family medicine and primary care research, team science is an approach to research that requires clear documentation for replicability. Here, we report the approach to documenting team science in 2 US family medicine research journals.

Methods: Our interdisciplinary team, composed of MDs and PhDs from family medicine and other disciplines, established a definition of the "team science" construct, which included the utilization of interdisciplinary partnerships and/or collaboration with community-based organizations. Two team members reviewed every original research article published in 2023 in the Annals of Family Medicine (AFM) and the Journal of the American Board of Family Medicine (JABFM). Data extraction identified the use of the term "team science" or the presence of elements of the construct as defined by the team, as well as the funding source(s).

Results: Of the 107 articles reviewed, none explicitly mentioned the term "team science." However, 19 (17.8%) described interdisciplinary partnerships. Seventeen (15.9%) described the disciplines of the contributors, and 5 (4.7%) described community collaborators. Most articles (80.4%) were funded studies, with 70.9% supported by national governmental or nongovernmental entities.

Conclusions: In this sample of articles, team science was either not reported at all or it was described in a limited way. The authors recommend that editors encourage discussions of interdisciplinarity and team science research practices in manuscripts, including descriptions of the strengths each disciplinary representative brings to the team.