Annals of Family Medicine最新文献

For many years I cared for Joe, following him through diagnoses of strokes, end-stage renal disease, and metastatic prostate cancer. Gaining his trust, coordinating his care across specialist visits and hospitalizations, and helping him and his family clarify goals of care took an investment of time and relationship-building. I was able to spend this time with Joe, and all of my medically complex patients, because I had taken a job in a Program of All-Inclusive Care for the Elderly (PACE), a fully capitated model of care. With care organized around the patient instead of the visit, this payment model transformed my work life. As I reflect on the care that I provided for Joe over the years, I consider how health care organization and finance can either help or hinder our ability to provide patient-centered, coordinated, continuous care for our patients. Evolving payment models can help make space for family physicians to provide the robust primary care we are trained to deliver.

Purpose: Although a large proportion of males in the United States become sexually active during high school, condom use is decreasing and contributing to negative sexual health outcomes. Fathers are influential in promoting adolescent male sexual health; however, factors that shape fathers' decisions about when to discuss condom use with their sons remain understudied. We examined paternal perceptions of adolescent males' readiness for sex relative to fathers providing guidance for condom use in Latino and Black families.

Methods: We recruited 191 Latino and Black males aged 15-19 years and their fathers in the South Bronx, New York City. Dyads completed surveys, and a subset of fathers participated in audio-recorded sessions with a father coach, which included conversations about adolescent male condom use. A sequential explanatory mixed methods design identified adolescent male developmental predictors for paternal guidance for condom use and explored how fathers perceive their sons' readiness for sex.

Results: The quantitative findings indicate that paternal perception of their sons' readiness for sex is an important predictor of providing guidance for condom use, and that fathers consider other factors (beyond age and perceived sexual activity) in understanding their sons' developmental readiness for sex. The qualitative findings provide insights into these additional factors, which should be considered when engaging fathers in primary care around issues of adolescent male condom use.

Conclusions: Fathers' perception of their sons' readiness for sex is a predictor of providing condom guidance. We provide practical suggestions for engaging fathers in primary care to promote correct and consistent condom use by adolescent males.

Purpose: Many individuals who are eligible for lung cancer screening have comorbid conditions complicating their shared decision-making conversations with physicians. The goal of our study was to better understand how primary care physicians (PCPs) factor comorbidities into their evaluation of the risks and benefits of lung cancer screening and into their shared decision-making conversations with patients.

Methods: We conducted semistructured interviews by videoconference with 15 PCPs to assess the extent of shared decision-making practices and explore their understanding of the intersection of comorbidities and lung cancer screening, and how that understanding informed their clinical approach to this population.

Results: We identified 3 themes. The first theme was whether to discuss or not to discuss lung cancer screening. PCPs described taking additional steps for individuals with complex comorbidities to decide whether to initiate this discussion and used subjective clinical judgment to decide whether the conversation would be productive and beneficial. PCPs made mental assessments that factored in the patient's health, life expectancy, quality of life, and access to support systems. The second theme was that shared decision making is not a simple discussion. When PCPs did initiate discussions about lung cancer screening, although some believed they could provide objective information, others struggled with personal biases. The third theme was that ultimately, the decision to be screened was up to the patient. Patients had the final say, even if their decision was discordant with the PCP's advice.

Conclusions: Shared decision-making conversations about lung cancer screening differed substantially from the standard for patients with complex comorbidities. Future research should include efforts to characterize the risks and benefits of LCS in patients with comorbidities to inform guidelines and clinical application.

Purpose: The COVID-19 pandemic disrupted pediatric health care in the United States, and this disruption layered on existing barriers to health care. We sought to characterize disparities in unmet pediatric health care needs during this period.

Methods: We analyzed data from Wave 1 (October through November 2020) and Wave 2 (March through May 2021) of the COVID Experiences Survey, a national longitudinal survey delivered online or via telephone to parents of children aged 5 through 12 years using a probability-based sample representative of the US household population. We examined 3 indicators of unmet pediatric health care needs as outcomes: forgone care and forgone well-child visits during fall 2020 through spring 2021, and no well-child visit in the past year as of spring 2021. Multivariate models examined relationships of child-, parent-, household-, and county-level characteristics with these indicators, adjusting for child's age, sex, and race/ethnicity.

Results: On the basis of parent report, 16.3% of children aged 5 through 12 years had forgone care, 10.9% had forgone well-child visits, and 30.1% had no well-child visit in the past year. Adjusted analyses identified disparities in indicators of pediatric health care access by characteristics at the level of the child (eg, race/ethnicity, existing health conditions, mode of school instruction), parent (eg, childcare challenges), household (eg, income), and county (eg, urban-rural classification, availability of primary care physicians). Both child and parent experiences of racism were also associated with specific indicators of unmet health care needs.

Conclusions: Our findings highlight the need for continued research examining unmet health care needs and for continued efforts to optimize the clinical experience to be culturally inclusive.

Purpose: Worldwide clinical knowledge is expanding rapidly, but physicians have sparse time to review scientific literature. Large language models (eg, Chat Generative Pretrained Transformer [ChatGPT]), might help summarize and prioritize research articles to review. However, large language models sometimes "hallucinate" incorrect information.

Methods: We evaluated ChatGPT's ability to summarize 140 peer-reviewed abstracts from 14 journals. Physicians rated the quality, accuracy, and bias of the ChatGPT summaries. We also compared human ratings of relevance to various areas of medicine to ChatGPT relevance ratings.

Results: ChatGPT produced summaries that were 70% shorter (mean abstract length of 2,438 characters decreased to 739 characters). Summaries were nevertheless rated as high quality (median score 90, interquartile range [IQR] 87.0-92.5; scale 0-100), high accuracy (median 92.5, IQR 89.0-95.0), and low bias (median 0, IQR 0-7.5). Serious inaccuracies and hallucinations were uncommon. Classification of the relevance of entire journals to various fields of medicine closely mirrored physician classifications (nonlinear standard error of the regression [SER] 8.6 on a scale of 0-100). However, relevance classification for individual articles was much more modest (SER 22.3).

Conclusions: Summaries generated by ChatGPT were 70% shorter than mean abstract length and were characterized by high quality, high accuracy, and low bias. Conversely, ChatGPT had modest ability to classify the relevance of articles to medical specialties. We suggest that ChatGPT can help family physicians accelerate review of the scientific literature and have developed software (pyJournalWatch) to support this application. Life-critical medical decisions should remain based on full, critical, and thoughtful evaluation of the full text of research articles in context with clinical guidelines.

Purpose: This mixed methods study sought to describe the extent to which family physicians in urban communities serve socially vulnerable patients and to better understand their practices, their challenges, and the structural supports that could facilitate their patient care.

Methods: We conducted a quantitative analysis of questionnaire data from 100% of US physicians recertifying for family medicine from 2017 to 2020. We conducted qualitative analysis of in-depth interviews with 22 physician owners of urban, small, independent practices who reported that the majority of their patients were socially vulnerable.

Results: In 2020, in urban areas across the United States, 19.3% of family physicians served in independent practices with 1 to 5 clinicians, down from 22.6% in 2017. Nearly one-half of these physicians reported that >10% of their patients were socially vulnerable. Interviews with 22 physicians who reported that the majority of their patients were socially vulnerable revealed 5 themes: (1) substantial time spent addressing access issues and social determinants of health, (2) minimal support from health care entities, such as independent practice associations and health plans, and insufficient connection to community-based organizations, (3) myriad financial challenges, (4) serious concerns about the future, and (5) deep personal commitment to serving socially vulnerable patients in independent practice.

Conclusions: Small independent practices serving vulnerable patients in urban communities are surviving because deeply committed physicians are making personal sacrifices. Health equity-focused policies could decrease the burden on these physicians and bolster independent practices so that socially vulnerable patients continue to have options when seeking primary care.

Building on previous efforts to transform primary care, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in 2015. This 3-year initiative provided external quality improvement support to small and medium-size primary care practices to implement evidence-based cardiovascular care. Despite challenges, results from an independent national evaluation demonstrated that the EvidenceNOW model successfully boosted the capacity of primary care practices to improve quality of care, while helping to advance heart health. Reflecting on AHRQ's own learnings as the funder of this work, 3 key lessons emerged: (1) there will always be surprises that will require flexibility and real-time adaptation; (2) primary care transformation is about more than technology; and (3) it takes time and experience to improve care delivery and health outcomes. EvidenceNOW taught us that lasting practice transformation efforts need to be responsive to anticipated and unanticipated changes, relationship-oriented, and not tied to a specific disease or initiative. We believe these lessons argue for a national primary care extension service that provides ongoing support for practice transformation.