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The Certificate of Added Qualification in Sports Medicine (CAQSM) is administered by the American Board of Family Medicine (ABFM) and cosponsored by the American Board of Emergency Medicine (ABEM), the American Board of Pediatrics (ABP), and the American Board of Physical Medicine and Rehabilitation (ABPMR). The American Board of Internal Medicine (ABIM) is a qualifying board for the CAQSM. This article reviews the history of the blueprint development for the CAQSM certification examination. This article will also overview the methodology behind the creation of a new sports medicine certification blueprint. The redesign of the blueprint reflects the evolving practice of sports medicine. The intent was to develop an approach that would ensure that the sports medicine examination is relevant and reflects current practice of the subspecialty. Additionally, this blueprint will help guide the assembly of both the sports medicine certification examination and, eventually, a sports medicine certification longitudinal assessment. The new blueprint should provide more statistical precision and be more clinically relevant.
The Certificate of Added Qualification in Sports Medicine is administered by the American Board of Family Medicine (ABFM) and cosponsored by the American Board of Emergency Medicine (ABEM), the American Board of Pediatrics (ABP), and the American Board of Physical Medicine and Rehabilitation (ABPMR). This article reviews the methodology used to determine the weighting of CAQSM assessments across five content domains. A survey was comprised of 231 sports medicine clinical activities asking respondents to rate how often they perform a clinical activity (the Frequency Index- FI) and to rate the level of risk to the patient if the condition is misdiagnosed or not managed properly (the Index of Harm-IoH). A random sample of 800 diplomates representing Sports Medicine Diplomates from five member boards was selected to participate. Rasch modeling was employed to analyze the survey results. The sports medicine advisory committee voted to equally balance FI+IoH survey results to weight the content domains. The survey response rate was 42.2%. Survey respondents were demographically representative of the overall sampling frame across key variables, except for primary certifying board. Weights for the content domains were as follows: Musculoskeletal Conditions (32.1%), Medical Conditions (30.2%), Care of Emergency Conditions (22.4%) and Preventive Aspects of Sports Medicine (10.4%). This is the first nationally representative survey of sports medicine clinical activities performed in the United States. This survey data was used to develop a new sports medicine blueprint. In the future, this data may be used to develop curriculum or assessments.
The increasing advance of artificial intelligence (AI) in medicine will affect the future of Family Medicine in many ways. Some of the effects may be salutary, but others may infringe on the real work of family medicine/primary care. AI will change the way we experience practice. If AI can perform many current physician tasks, what will be left for the practicing human family physician? We believe that there will be several types of patient encounters that will still require the human touch that comes from established long-term continuous healing relationships between family physicians and their patients. As AI applications in primary care become more robust it will assume the function of a new member of the multi-professional healthcare team, and physicians will learn to operate in a new triad: the "doctor-patient-AI partner relationship". We explore possible further effects on the practice of family medicine under these new AI-enhanced circumstances and contemplate their impact on the current gap in primary care availability, continuity of care and the attractiveness of primary care careers. As we pass through this potential "hard fork" for family medicine we are convinced that family medicine is the most likely component of the healthcare system to survive and prosper with AI.
Cervical cancer screening (CCS) is shifting from in-office to self-screening. The primary aim of this study is to define a baseline distribution of in-office CCS providers by specialty and the race/ethnicity and age of those screened. We extracted electronic health record data (Truveta-multiple health systems in 34 states) of individuals eligible for CCS aged 21 to 65, documented between January 1, 2017-December 31, 2022. Those with a hysterectomy before 2017, had any gynecological cancer at any time, or had evidence of CCS after the hysterectomy, except if there was a history of cervical intraepithelial neoplasia grade 2 or 3 (CIN 2/3) disease were excluded. We reported the total number of CCS and colposcopies per eligible patient and the specialty of the performing clinician (medical taxonomy). Among the 2,439,331 individuals included in the study, the average age was 42.9 (SD 11.7). There were 3,412,148 CCSs linked with 1 of 3 provider specialties: obstetrics & gynecology (OG), family medicine (FM), and general internal medicine (GIM). OG provided less than half of all CCS, dropping to 31.6% of those 50 to 65. While only 70.5% (1,718,914) of the population received at least 1 CCS during the study, the mean CCS per patient was 2.6 (SD 2.7). The rate of colposcopy after a CCS was 3.9%. Family and Internal Medicine clinicians provide the majority of CCS in the US (61.9%), particularly for people aged 50 to 65 (68.4%), when cervical cancer risk is the highest.
The present study investigated the current trends of gender disparity in the National Institutes of Health (NIH) funding patterns for research within Family Medicine. Funding data was collected from the online NIH Research Portfolio Online Reporting Tools Expenditure and Results (RePORTER) system for fiscal years 2017-2020, and information regarding each Principal Investigator (PI) was retrieved from the Scopus database and departmental websites. Mann-Whitney U and Kruskal Wallis tests were performed on collected data for statistical comparison of continuous variables. We analyzed 730 grants in our analysis. Amongst them, 398 (54.5%) were awarded to women PIs and 332 (45.5%) to men PIs. The mean NIH grant amount awarded to men PIs (518,862±490,793.32) was significantly higher than the mean grant amount awarded to women PIs (450,195±428,405.62) (p = 0.04). The strongest correlation between NIH funding and academic output was observed for the number of publications of men PIs. When the gender of PI and co-PI were analyzed together, there was no significant difference in the number of grants or mean grant amount. Stratification by academic degree revealed no significant difference between both genders for the mean NIH grant amount. Despite the increasing representation of women within the discipline of family medicine, men continue to receive higher average NIH grant amounts compared to women. The differences are multifactorial and may include differences in academic productivity or grant committees' heuristics. Overall, the results were promising with little evidence of significant gender disequilibrium within NIH-funding for researchers in FM.
Half of the women who develop cervical cancer in the US have never had a cervical cancer screen. Self-sampling is an equivalent technique to the invasive speculum exam. We aim to evaluate the current knowledge, attitudes, and behaviors toward self-sampled primary HPV testing in family medicine. The annual cross-sectional survey of the Council of Academic Family Medicine's general membership included knowledge, attitudes, and beliefs about primary human papillomavirus (HPV) screening using self-sampling. The knowledge questions were based on current guidelines, as defined by the 2024 United States Preventive Services Task Force (USPSTF) 1. The attitude and belief questions were based on the Question-Behavior Theory 2. All surveys were emailed to the membership with up to five weekly reminders to complete. We had a 62% survey response rate with 744 respondents. Regardless of demographic descriptors, all respondents significantly changed their intended behavior regarding offering self-sampling for cervical cancer screening (p < 0.001). Of those with a baseline attitude of not offering self-sampling, 88% changed their response to offer self-sampling at the end of the survey. Baseline knowledge of the advantages of primary HPV screening was lowest among underrepresented minority Hispanic respondents (52% correct, compared to 80% among Whites, p < 0.001). Women respondents were 2.96 times more likely to intend to offer self-sampling for cervical cancer screening than men (OR 2.96 (95% CI: 1.18, 7.44, p<0.05). Based on the Question-Behavior Theory, over 90% of family medicine educators intend to offer women self-sampling for cervical cancer screening.
Workforce projections predict a significant lack of primary care providers nationally. Increased family medicine residency programs and positions have been celebrated as the answer to these projections. Since 2012, the number of positions offered annually has increased almost 2-fold from 2,740 to 5,357. While this has the potential to help alleviate this disaster, very few are questioning the unintended consequences of additional family medicine positions. Over this same 14-year period, the number of programs failing to fill in the National Residency Match Program have increased 4.5-fold (64 to 288) with the number of unfilled slots increasing over 5.5-fold (142 to 805). Linear rates of change for unfilled residency programs per every 1,000 residency positions created have increased from 0.4 prior to 2018 to 69.3 between 2018 and 2021 to 271.5 after 2021. Unfilled programs experience multiple negative consequences including reputation damage and increase coverage responsibilities. Further addition of family medicine training position volume is therefore likely harmful to existing programs. Better solutions should be explored to creatively increase student interest in family medicine by emphasizing and leveraging the value of family medicine physicians and primary care.
This study examines the receipt of health care transition (HCT) preparation and anticipatory guidance by whether the teen had time alone with a health care professional using self-reported data collected from a nationally representative sample of teens aged 12 to 17 years. Data from the National Health Interview Survey-Teen (NHIS-Teen) a follow-back survey to the National Health Interview Survey (NHIS) were used (n = 1635). Prevalence estimates of teens' receipt of time alone with a health care professional, HCT preparation (eg, understanding the changes in health care that happen at age 18) and anticipatory guidance discussions (eg, use of tobacco products) were examined. Logistic regression models tested for associations between receipt of time alone and each measure; analyses were adjusted for selected teen and family level sociodemographic characteristics. Only 47.1% of teens with a medical care visit in the past 12 months had time alone with a health care professional. Approximately 25% of teens discussed changes in health care and 43.2% discussed gaining skills to manage their own health. In addition, 46.0% of teens discussed puberty and sexual health, 55.5% discussed use of tobacco products and 66.5% discussed mental or emotional health. Teens that had time alone with a health care professional were significantly more likely to receive HCT preparation and anticipatory guidance. Teen self-reported receipt of HCT preparation and anticipatory guidance was low. Having time alone with a health care professional was associated with increased receipt of HCT preparation and anticipatory guidance.
Ruptured abdominal aortic aneurysms (AAA) carry a mortality rate as high as 80% . Early detection through a screening ultrasound can lead to a large mortality reduction. Point-of-care ultrasound (POCUS) has preliminary data suggesting it is as accurate as hospital-based ultrasounds performed by a sonographer. This validation study investigated the relative concordance of family physicians using POCUS to determine aortic diameter compared with hospital-based ultrasound studies. The study was a cross-sectional, multi-observation study conducted at 3 office practices. Five family physicians with varying degrees of training and experience utilized various ultrasound machines to measure maximal aortic diameter at the proximal, mid, and distal aorta. Hospital-based ultrasound or Computed Tomography (CT) served as the validation scan. Pairwise comparisons were made, with statistical testing for difference using the T-TEST command with the PAIRS subcommand. Forty-four independent observations were completed by the 5 physicians on the 18 patients (n = 18). The mean difference between the POCUS and validation scans was 0.2 cm (95% CI -1.10 to 0.40). The family physicians generally underestimated the aortic diameter. The proximal aorta had the largest mean difference in aortic size (0.23 cm; P = .003). Type of ultrasound device used, the width of the largest aortic segment, and low patient body mass index had significant relations. This small study found data suggesting that family physicians with variable POCUS experience can accurately perform AAA screening in the ambulatory setting with either handheld or cart-based POCUS machines.
Family health history (FHH) is used to assess potential risk for diseases such as hereditary cancers. To date, limited data exist on potential barriers to collecting FHH information. We used National Center for Health Statistics Rapid Surveys System data collected between January-February 2024. The data were analyzed to estimate the prevalence of knowledge, perceptions, and barriers to collecting information on FHH. The final cumulative response rate ranged from 4.8%-4.4%. Over 60% of adults had knowledge of the health history of their biological parents or grandparents. Nearly all adults (94.8%) believed that knowledge of FHH was somewhat or very important to their own health, though only 15.2% of adults reported actively collecting this information. An estimated 66.5% of adults reported that it was somewhat or very difficult to collect information about the health history of their biological relatives. Of these adults, the top two reasons for reported difficulty in collecting FHH were not being in contact with relatives/relatives no longer alive (76.0%) and not knowing what information to collect (45.9%). Differences in knowledge, perceptions, or barriers to collecting FHH were observed by several sociodemographic characteristics. Some of the biggest differences were observed for health insurance coverage; for example, 76.2% of adults with health insurance shared their FHH with a clinician compared to 46.1% of adults without health insurance. This report provides national estimates that can guide intervention efforts to increase knowledge and collection of FHH and address common barriers to collecting this information.
IntroductionMental health and substance use diagnoses are increasing, and many patients cannot access behavioral health (BH) care. One-third of family physicians work in independently owned practices, but only a minority work collaboratively with BH clinicians. Our study sought to describe barriers to implementing integrated BH in independently owned family medicine practices and the alternate approaches family physicians are using to offer BH care services to their patients. # Methods We recruited eligible family physicians who completed the American Board of Family Medicine 2021-2022 Continuous Certification questionnaire. We interviewed 16 family physicians working in independently owned family medicine practices. Interviews were analyzed using a qualitative exploratory design guided by the Framework Method. # Results Participants identified cost, staffing, and space as principal barriers to implementing and sustaining integrated BH at independent practices. In the absence of integrated BH, participants reported that they provide BH support to their patients in the form of assessment and diagnosis, basic medication management, coaching on BH skills, and referring to outside resources. # Conclusions This study highlights that barriers to integrating BH at independent family medicine practices align with those at larger health systems, but that the nuances of those barriers differ based on the smaller practice context. Family physicians at independent practices are filling in BH services gaps to the best of their abilities but are constrained by training and resource limitations. Targeted strategies, particularly addressing cost, staffing, and clinical space limitations, are needed to support independent family physicians in achieving sustainable access to integrated BH care.
Cystic fibrosis transmembrane conductance regulator (CFTR) modulators have revolutionized care for people with cystic fibrosis (pwCF) by improving quality of life and extending life spans. These factors support the need for pwCF to establish care with a Primary Care Provider (PCP). It is currently unclear how many adult pwCF routinely interact with a PCP. This IRB approved, retrospective study included patients over 18 years old, seen in the adult Cystic fibrosis (CF) clinic, who were prescribed elexacaftor/tezacaftor/ivacaftor (ETI) between 8/31/2022 and 8/31/2023 at University of Iowa Health Care. The primary outcome of the study was to determine the percentage of pwCF with a PCP designated as a member of their care team in the electronic medical record (EMR). The secondary outcomes determined the percentage of pwCF who completed preventative health screenings for comorbid conditions and received appropriate cancer screenings and immunizations. Of the 115 included patients, 60% (69/115) had a PCP identified in the EMR. PwCF have uncontrolled blood pressure regardless of whether they have a PCP identified in the EMR (76.5%) or not (78.3%). Rates of influenza (p=0.006) and pneumococcal (p=0.006) vaccinations were significantly lower for pwCF without a PCP. There is a gap in healthcare for pwCF, especially for those who do not routinely interact with a PCP. CF clinicians may not be up to date on primary care management and PCPs may not be comfortable with treating patients with a high acuity chronic condition. PCPs should be better integrated into the CF care team to ensure pwCF are receiving comprehensive care.
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.
The impact of medical school clerkship rotations on specialty choice is assumed but unknown. A 2024 survey of first year Family Medicine residents revealed that 37% Doctor of Medicine (MD) to 43% Doctor of Osteopathic Medicine (DO) chose Family Medicine during their core clerkship rotation. This underscores the pivotal importance of earlier clinical experiences in shaping future family physicians' career choices and highlights the potential positive impact of required clerkship experiences in addressing primary care physician shortage.
Soft tissue concerns are common, yet most primary care physicians must refer patients to radiology for further imaging, leading to potential delays in diagnosis and management. Point-of-care ultrasound (POCUS) is increasingly available in primary care and has been shown to improve clinical decision making. However, current Family Medicine POCUS curricula focus primarily on cellulitis and abscess, overlooking other common soft tissue pathologies. This study aims to evaluate the frequency of soft tissue pathologies and associated follow-up recommendations on comprehensive radiology ultrasound exams ordered by Family Medicine physicians. A retrospective study of radiology-performed comprehensive ultrasound exams ordered by an academic urban Family Medicine practice over the course of the 2019 was performed. Data collected included patient demographics, ultrasound findings, anatomic location, and follow-up recommendations. Diagnoses were categorized, and time from order to completion was calculated. Soft tissue ultrasounds comprised 10% (n = 168) of all ultrasound studies ordered. The most common diagnosis were lymph nodes, n = 44 (25%), lipomas n = 32 (18%), and no lesion/normal n = 23 (13%). Only 2 studies diagnosed abscess (1%). The median time from order date to completion was 6 days (IQR 2 to 22 days), with 48% waiting over a week. Half (51%) of studies required no further follow up, while 26% required additional imaging or biopsy. These findings highlight the need for expanded Family Medicine POCUS training to include high-yield diagnoses such as lipomas, lymph nodes, and cysts. POCUS could reduce unnecessary referrals, expedite care, and improve diagnostic confidence. Future research should explore primary care-specific POCUS protocols and their impact on patient outcomes.
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. 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. 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. 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.
The human papillomavirus (HPV) vaccine, launched in 2006, has proven effective at reducing HPV infection rates and preventing HPV-associated cancers. However, less than 60% of adolescents have completed the recommended vaccine series, and the rate is even lower among Hispanic children and adolescents. This study explores the age of initiation within our comprehensive vaccination program in West Texas, Tiempo de Vacunarte. This study is a retrospective analysis of HPV vaccine completion among individuals 9 to 17 years old from Tiempo de Vacunarte between June 2015 and February 2018. The program was open to individuals 9 to 26 years old who had at least one prior dose of the HPV vaccine, were uninsured or underinsured, and had a Texas address. The primary outcome was completion of the HPV vaccine series. A total of 2,380 individuals were enrolled, and this study analyzed a subset of 613 children aged 9 to 17 years; 59.8% completed the vaccine series. Most were female (53.8%) and had parents born in Mexico (75.2%). Children 11 to 14 years old were likelier to complete the vaccine series than other age groups (OR: 2.802, P = .006). Children with parents with higher education and less time residing in the US were likelier to complete the series. Our study supports advocating for initiating the HPV vaccine at a younger age and completing the series by 14 years old. Multi-component and culturally tailored programs are an effective means to increasing HPV vaccine uptake and decreasing the burden of HPV-associated cancers.
There has yet to be a comprehensive multi-state study describing the children that use school-based health centers (SBHCs). This study seeks to determine sociodemographics, care utilization patterns, and prevalence of asthma and overweight among children seeking care at SBHCs. This retrospective cross-sectional analysis examined electronic health record data of children utilizing SBHCs within a large network of community-based clinics, consisting of 180 SBHCs in 14 U.S. states from 2012-2018. Demographics of exclusive SBHC users (SBHC-only group) were compared to utilizers of SBHCs plus non-SBHC community health centers (SBHC+ group). Of 179,970 children with ≥1 ambulatory visit at a SBHC, 75.6% received care exclusively at SBHCs. Many SBHC-users reported family income <138% of the federal poverty line (48.9%) and self-identified as Hispanic (45.7%). Among SBHC utilizers, the prevalence of asthma (8%) and overweight (30%) were comparable to national statistics. Overall, 33% of children received well-childcare and 24% received influenza vaccinations exclusively at SBHCs. When comparing the two groups within the study, the SBHC-only group were older, and more lacked insurance (13.4%) compared with SBHC+ children (2.6%). The SBHC-only group had fewer total yearly visits, fewer yearly well-child visits, and fewer influenza vaccinations. In age stratified groups, preschool-aged children received the most well-childcare and influenza vaccinations in SBHCs. SBHCs serve a pediatric population that is disproportionately low-income, uninsured, and Hispanic. Children, particularly preschoolers, receive preventive healthcare at SBHCs. Given the population served, SBHCs have strong potential to address pediatric health inequities if adequately resourced, utilized, and integrated with other facilities including community health centers.
In 2018, prostate cancer screening with prostate specific antigen (PSA) received a "C" recommendation from the US Preventive Services Task Force for men aged 55 to 69 years. In January 2023, our health system implemented a point-of-care electronic reminder for primary care clinicians to discuss PSA screening for men aged 55 to 69. We assessed the impact of reminder implementation on monthly rates of PSA ordering from January 1, 2022 to July 31, 2024 by performing interrupted time series analyses for men aged 55 to 69 years (for whom the reminder was implemented) and men aged 50 to 54, 70 to 74, and ≥75 years. Before reminder implementation, PSA was ordered in a median of 6.4% of visits for men aged 55 to 69 years versus a median of 10.2% of visits after reminder [adjusted incidence rate ratio (aIRR) 1.57 (95% CI: 1.43-1.73)]. The postreminder period was associated with smaller but significantly increased rates of PSA ordering in men aged 50 to 54 [aIRR 1.44 (1.25-1.65)], 70 to 74 [aIRR 1.26 (1.14-1.39)], and ≥75 years [aIRR 1.11 (1.02-1.11)]. Implementation of an electonic medical record (EMR) reminder to discuss PSA screening was associated with a large increase in PSA ordering among men in the targeted age-group, but also smaller increases in age groups for whom the balance of benefits and harms of PSA screening may be less favorable.
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.