September/October Annals of Family Medicine 2023 tip sheet

(Press-News.org) Transgender Persons Face Challenges When Seeking Clinical Care, Including Decisions About What Information to Disclose and Risk of Substandard Care

Researchers conducted a qualitative study to investigate transgender people’s experiences with sharing health information in clinical encounters. They held seven qualitative focus groups with 30 transgender adults living in North America. Four themes emerged: 1) Transgender people often perceive clinicians’ questions as voyeuristic, stigmatizing, or self-protective; 2) Patients describe being pathologized, denied, given substandard care, or harmed when clinicians learned they are transgender; 3) Transgender people frequently choose between risking stigma when sharing information and risking ineffective clinical problem solving if clinicians do not have all the information about their medical histories; and 4) Improving the safety of transgender people is difficult in the context of contemporary medical systems. The authors conclude that transgender people often must choose between stigma and potentially suboptimal care. Improvements in medical culture, policies, procedures, and data collection tools are necessary to improve the quality and safety of clinical care for transgender people. Institutional and system changes may be required to safely and effectively implement sexual orientation and gender identity (SOGI) data collection in clinical settings.

What We Know: Many transgender people experience mistreatment in health care encounters, which can include harassment, assault, and denial of care. Understanding the experiences of transgender people when their gender identities are known to clinicians and the reasons transgender people may share, modify, or withhold information, could yield important clinical insights.

What This Study Adds: The authors present short-term and long-term steps toward reducing ontological oppression and its health consequences. These include family medicine clinicians 1) ensuring their questions are medically relevant and explaining their medical relevance to patients, 2) avoiding putting information in patients’ EHR that may be used to stigmatize them, 3) advocating for patients who are stigmatized by other clinicians, and 4) shifting medical culture by ensuring formal curriculum, guidelines, and patient-facing forms and documents be inclusive of transgender people.

Transgender People’s Experiences Sharing Information With Clinicians: A Focus Group–Based Qualitative Study

Ash B. Alpert, MD, MFA, et al
Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut; Center for Gerontology and Healthcare Research, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York

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Repetitive Requests for Patient Intake Forms Could Lead to Inaccurately Reported Health Conditions

Researchers performed a retrospective analysis of EHR data from 24 Federally Qualified Health Centers that assessed effectiveness and accuracy of the PHQ-2 (depression screening) and GAD-2 (anxiety screening) tools from 2019 to 2021. In this high-risk population, only 9% of PHQ-2 and GAD-2 screening tests were positive for depression or anxiety. This was a significantly lower rate of depression and anxiety than what was expected given the published literature on screening outcomes. Even among patients who were newly diagnosed with depression or anxiety within the previous 30 days, the screening tests were only positive in about 57% of patients. One possible explanation that the authors propose is that when patients are asked to respond to repetitive screening questions to meet clinics’ performance metrics, it may have unintended consequences, including a decrease in accuracy of the patient-reported information. It may also not be delivering the intended value in a real-world setting and could risk distracting clinical effort from other high-value activities.

What We Know: Primary care visits often start with numerous standardized intake screening questions tied to performance metrics and incorporated into electronic health records (EHRs). Prioritizing repetition of intake screening questionnaires at primary care visits may have unintended consequences such as administrative burden, provision of low-value care, and reduced clinical capacity to deliver other high-value services.

What This Study Adds: Study findings indicate potentially compromised accuracy of anxiety and depression screeners when their implementation is driven by a need to meet performance metrics and they are repetitive and embedded into EHRs and visit workflows. The authors underscore the importance of not confusing metrics with objectives (“surrogation”) and that similar wisdom could be useful in health care given the implementation of care processes like depression and anxiety screening to meet a performance metric may inadvertently lead to reduced accuracy and low-value care.

Reduced Accuracy of Intake Screening Questionnaires Tied to Quality Metrics

Jodi Simon, DrPH, MS, et al
AllianceChicago, Chicago, Illinois

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Research That Severe Erythrocytosis is Rare Among People Using Testosterone for Gender-Affirming Care

Researchers explored the incidence of erythrocytosis in the first 20 months of testosterone therapy among people receiving gender-affirming hormone therapy (GAHT). Specifically, they conducted a descriptive fixed cohort study of hematocrit and hemoglobin data from the charts of 282 people taking testosterone for GAHT. During the first 20 months of testosterone therapy, the cumulative incidence of hematocrit levels over 50.4% was 12.6%; hematocrit levels over 52% was 1.0%; and hematocrit levels over 54% was 0.6%. In adults, normal hematocrit levels for cisgender men range from 41%-50%. For cisgender women, the normal range is slightly lower: 36%-44%. All people were taking injectable testosterone cypionate, with a median dose of 100 mg weekly. The authors concluded that severe erythrocytosis, where hematocrit was over 54%, is a rare outcome of gender-affirming testosterone therapy. Considering this rarity, and the paucity of outcomes data on clinical consequences of erythrocytosis in this population, the authors recommend that doctors who make clinical recommendations for frequent erythrocytosis screening within the first year of testosterone therapy reconsider that need among patients who prefer to minimize lab draws.

What We Know: Family medicine physicians are well-positioned to provide GAHT within their scope of practice. Gender-affirming care may include the use of testosterone, which can increase hemoglobin and/or hematocrit concentrations and can theoretically lead to arterial or venous thromboses. Secondary erythrocytosis from testosterone therapy has not specifically been identified as a cause of thromboses. There are few longitudinal patient-oriented outcomes in generally healthy transgender and gender diverse populations receiving testosterone therapy.

What This Study Adds: Researchers concluded that severe erythrocytosis, where hematocrit is more than >54%, is a rare outcome of gender-affirming testosterone therapy. They assert that primary care doctors making clinical recommendations and medical organizations establishing clinical guidelines reconsider the need for frequent erythrocytosis screening within the first year of testosterone therapy for patients who prefer to minimize lab draws.

Erythrocytosis in Gender-Affirming Care With Testosterone

Alana Tova Porat, et al
Virginia Commonwealth University, Richmond, Virginia

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Doctor and Pharmacist Revamp Standard Processes for Ordering and Documenting Mifepristone Use

Clinical researchers at the University of Minnesota Medical School partnered with the university health system’s compliance department to create standard processes for ordering and documenting mifepristone administration, which adhere to the Risk Evaluation and Mitigation Strategy (REMS) requirements. They established a single prescriber account to represent all system prescribers who met REMS requirements, allowing for centralized ordering and distribution by the pharmacy purchasing team. This process mirrors other standard operating procedures used by the health system to purchase other medications. Establishing processes for mifepristone for early pregnancy loss accelerated integration of its use for medical abortion. As the barriers to mifepristone use are similar, regardless of indication, the new process reduced barriers to providing abortion care at a time when access has become limited throughout the Midwest.

What We Know: Mifepristone and misoprostol taken together remain the standard for medical management of early pregnancy loss (EPL) and first-trimester abortion. While misoprostol is readily available, distribution of mifepristone has been restricted, regardless of reason for its use. Despite its documented safety, mifepristone is regulated by a Risk Evaluation and Mitigation Strategy (REMS) program—a barrier for both labeled and off-label use.

What This Study Adds: Study authors created standard processes for ordering and documenting mifepristone administration that were in compliance with the new regulations restricting use of this medication. This process reduced barriers to providing both management of early pregnancy loss and first-trimester abortion care.

Streamlining the Use of Mifepristone for Early Pregnancy Loss Across a Large Health Care System Sets the Stage for Rapid Expansion of Medication Abortion Access in a Post-Roe Environment 

Nicole Chaisson, MD, MPH, University of Minnesota Medical Center Residency Program, Department of Family Medicine and Community Health, University of Minnesota Medical School, St. Paul, Minnesota, and Katherine Montag Schafer, PharmD, St. John’s Hospital Family Medicine Residency Program, Department of Family Medicine and Community Health, University of Minnesota Medical School, St. Paul, Minnesota

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Learning Collaborative Promotes Mifepristone Education and Utilization Training in Federally Qualified Health Centers

Researchers created a learning collaborative that included implementing an intervention titled, “Excellence in Providing Access to New Directions in Mifepristone Use (ExPAND Mifepristone)” in two Chicago-area Federally Qualified Health Centers with a focus on enhancing educational and training support services for primary care doctors and staff to use mifepristone for miscarriage management and abortion provision.

Prior to program implementation, clinicians and staff had little knowledge of mifepristone. After program implementation and completion, both clinics stocked and provided mifepristone for early pregnancy loss. However, significant barriers remained for use of the drug as part of abortion care. Doctors at both program sites noted that stringent financial procedures to separate federal funds from those that support abortion procedures proved a significant challenge. Despite these obstacles, the researchers believe that the participating clinics’ expanded ability to provide mifepristone for early pregnancy loss suggests that learning collaboratives could be an effective tool in improving access to comprehensive reproductive care.

What We Know: Primary care physicians face various barriers in providing mifepristone for early pregnancy loss and/or abortion, despite mifepristone being FDA-approved and highly effective for use in abortion at 10 or fewer weeks when paired with misoprostol. Based on study interviews with primary care physicians and previous research, modifying medication protocols is not enough to change the clinical practice of prescribing mifepristone.

What This Study Adds: Study authors determined that clinics need to build skills, self-efficacy, and capacity to create practice change. Their “Excellence in Providing Access to New Directions in Mifepristone Use (ExPAND Mifepristone)” learning collaborative enhanced educational and training support services for primary care doctors to use mifepristone for miscarriage management and abortion provision. Through the intervention, clinicians and staff increased their knowledge of mifepristone and were able to stock and provide the medication for early pregnancy loss. Despite existing obstacles that hindered clinicians from prescribing the drug for abortion, the study authors believe that the learning collaborative can be an effective way to improve overall access to comprehensive reproductive care.

ExPAND Mifepristone: Medical Management of Miscarriage and Abortion in FQHCs

Lisa Wu, BS, et al
University of Chicago Pritzker School of Medicine, Chicago, Illinois

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Screening for Adverse Childhood Experience Can Improve Trauma-Informed Care, Though Time Constraints and Limited Referral Resources Present Challenges

Researchers conducted a qualitative evaluation in five clinics in Los Angeles County to understand physician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care. The researchers employed focus group discussions with 125 clinic staff involved in ACE screening, including frontline staff who administer the screening; medical doctors who use screening to counsel patients and make referrals; and psychosocial support staff who may receive referrals. Clinical staff generally considered ACE screening to be acceptable and useful. Staff said that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening. However, regarding implementation and quality improvement, significant barriers included insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Clinic staff felt ACE screening could improve trauma-informed care and could be strengthened by addressing time constraints and limited referral resources.

What We Know: Many children experience adverse childhood experiences, which may include abuse, neglect, violence in the home, or separation from a parent. While stress is a natural response to such occurrences, ACEs can trigger toxic stress, which has health ramifications for children later in life. This includes decreased physical and mental health in childhood and adulthood, as well as developmental delays, depression, asthma, obesity, smoking, cancers, and heart disease. Clinicians are increasingly interested in using routine screening for ACEs in pediatric/primary care settings to mitigate physical and mental health effects of ACEs in children and adults.

What This Study Adds: Researchers found that clinicians and frontline staff felt comfortable administering and discussing ACE screening. Despite some challenges in using the screening within the clinic workflow, screenings worked effectively and staff were able to offer suggestions on how to improve implementation, quality, and acceptability. Staff also reported that ACE screenings helped them elicit important information and build trust with patients, along with giving them a structured way to ask questions that often go unasked. This contributed to a holistic approach to providing care. However, some staff reported frustration at not being able to provide resources to families with children experiencing ACEs. They also cited the burden of increased paperwork due to using ACE screening and recommended that providing emotional support to those who experienced the emotional burden of using the screening tool could help mitigate staff burnout.

Clinician and Staff Perspectives on Implementing Adverse Childhood Experience (ACE) Screening in Los Angeles County Pediatric Clinics

Nicole Eberhart, PhD, et alRA
ND Corporation, Santa Monica, California

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Understanding Parents’ Care Expectations for a Child With Gastroenteritis Could Prevent After-Hours Care Requests

Researchers from the Netherlands conducted a qualitative study to explore parental motivations, expectations, and experiences of off-hours primary care contacts for children with acute gastroenteritis. They conducted 14 semistructured interviews with parents who contacted primary care physicians outside of normal operating hours seeking medical attention for their children. Parents were more likely to contact their primary care physician after hours when their child exhibited unusual behavior, to prevent symptom deterioration, and to gain medical reassurances. The researchers reported that parents expected their doctors to perform a thorough physical examination, provide information, and make follow-up care agreements. Parents reported dissatisfaction if they felt their doctors didn’t listen to them, misunderstood them, or didn’t take them seriously. This increased their likelihood of seeking another consultation. Researchers concluded that there is often a mismatch between parental expectations and GPs’ actions. Greater awareness and understanding on the part of GPs about the feelings and expectations of parents could guide them in interacting with parents, which may improve satisfaction with primary health care and reduce after-hours care requests.

What We Know: Acute gastroenteritis is a common infectious disease in children aged under 6 years. Although it often resolves on its own, it has a high consultation rate in primary care, especially during out-of-office hours.

What This Study Adds: Researchers found that among parents who requested out-of-office consultations for their children who were experiencing gastroenteritis, those that felt misunderstood or not listened to by their doctors were more likely to request such a visit. Taking greater account and understanding about parents’ feelings and expectations about care for their child may improve satisfaction with primary health care, specifically with requests that come in after normal clinic hours.

Acute Gastroenteritis: A Qualitative Study of Parental Motivations, Expectations, and Experiences During Out-of-Hours Primary Care 

Anouk A.H. Weghorst, Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands

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New Program Helps Health Professionals and Community Members Determine Health Risks and Create Medical Interventions for People Experiencing Homelessness  

A consortium of population health professionals, physicians, frontline staff, and community partners in Toronto established the Community Assessment and Risk Evaluation (CARE) program, a rapid risk assessment and clinical population medicine intervention to respond to challenges faced by people experiencing homelessness (PEH). The intervention also helped characterize health needs and mitigate risks among this population. Staff from various Toronto area shelters worked with population health professionals to group residents according to their health and support needs using the CARE tool. The five-item, open-access tool gathered data on immunization status, general health risk, support needs, substance use, and housing-specific support needs. Additional content concerning cognitive, behavioral, and general health status are currently in development. Automated and customized CARE dashboards were developed to provide shelter and primary care colleagues with secure, real-time information on resident needs, and comparisons with system-wide data. The authors assert that CARE demonstrates how collaborations of health and social service personnel can deliver rapid health assessments, and support enhanced care and protections for vulnerable populations. CARE also illustrates the need for expanded services for people experiencing homelessness with complex health and substance use needs.

What We Know: People experiencing homelessness (PEH) face an elevated burden of chronic and communicable disease, mental health, substance use disorders, and unmet health and support needs. Health professionals and housing providers lack real-time data to drive and enhance services.

What This Study Adds: The team’s development of the Community Assessment and Risk Evaluation (CARE) Program and corresponding tool can help the medical community respond to challenges that people experiencing homelessness face, as well as characterize their health needs. It also can give health care professionals a way to mitigate risks associated with PEH. Automated and customized CARE dashboards provide shelter and primary care colleagues with secure, real-time information on resident needs, and comparisons with system-wide data.

Rapid and Collaborative Population Health Assessment for People Experiencing Homelessness in Toronto: The CARE Program

Aaron Orkin, MD, MSc, MPH, PhD, et al
Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, ON, Canada

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Men Who Trust Their Doctors, Receive Adequate Time and General Information About Prostate Cancer Screening Are More Likely to Have Productive Discussions

Members of the University of Ottawa Department of Family Medicine conducted a scoping review to understand men’s communication preferences when they discuss prostate cancer screening with their doctors. Researchers analyzed a total of 29 studies and identified four main themes: men preferred that their doctors use everyday language; men wanted more information; men wanted the doctor to spend adequate time with them to explain prostate cancer; and desired a trusting and respectful relationship with their doctor. Three additional themes emerged that prohibited men from having any discussions at all: men who had already decided to pursue prostate cancer screening; men who were passive about their health; and those who felt their well-being was threatened by discussing prostate cancer screening. Additionally, the researchers found that some Black men faced racism, which impacted medical interactions. The authors discuss strategies to support men’s communication preferences and to address preconceptions surrounding prostate cancer screening.

What We Know: Prostate cancer is the number one diagnosed malignancy and the third‐leading cause of cancer‐related death in men, according to the Canadian Cancer Society. Despite this, the 5‐year survival rate for the disease is 91% and the overall mortality attributed to prostate cancer has decreased by 50% since 1995. Although screening for prostate cancer can reduce mortality, there are significant risks of overtreatment due to false-positives. Because of the risks and benefits of prostate cancer screening for men aged 55-69, the USPSTF recommends individualized counseling and shared decision making around the screening.

What This Study Adds: Researchers identified four main themes that men characterized as important to them for having successful prostate cancer risk discussions with their PCP: using everyday language; having enough information that was balanced and thorough to make an informed decision; spending enough time having a useful discussion; and sharing a respectful and trusting relationship.

Patient Communication Preferences for Prostate Cancer Screening Discussions: A Scoping Review

Justin Fong, MD, et al
University of Ottawa, Faculty of Medicine, Department of Family Medicine, Ottawa, Ontario, Canada

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Study Identifies Patient and Clinician-Level Characteristics Associated With Sexual History Screening Administration

Researchers conducted a mixed methods study that investigated patient- and clinician-level characteristics associated with a sexual history screening (SHS). Participants included 53,246 patients and 56 clinicians from 13 clinical sites. Less than half (42.41%) of patients had any SHS documentation. Gay and lesbian patients; patients who were cisgender women; and patients whose doctors were cisgender women had significantly higher odds of having any SHS documented in their medical chart. Conversely, older patients; patients whose doctors have more patients on their panel; and patients whose primary language was not English had significantly lower odds of SHS documentation. During interviews, participants expressed discomfort discussing sexual health and assumptions about older patients; patients in long-term relationships; and patients from other cultures. Discordance of patient-clinician gender and patients’ sexual orientation were also pertinent factors. The authors argue that programmatic efforts should address the interplay between the identified social and contextual factors, especially those that elicited discomfort, and the implementation of sexual history screening.

What We Know: Sexually transmitted infections (STIs) rates have consistently increased over time, with a preliminary estimate of 2.5 million cases in 2021. Sexual history screening (SHS) is an evidence-based medical guideline to identify risk of STIs (including HIV), and adverse sexual health outcomes. Primary care settings are an important environment for universal SHS, as patients predominantly report seeking STI care from their primary care physicians (PCP).  Primary care clinics also diagnose approximately half of all reported STIs annually.

What This Study Adds: Among a pool of  53,246 adult patients, less than half had any sexual history documented in their medical charts (42.41%). Study findings demonstrate key sociodemographics associated with the likelihood of implementing SHS, building on both data from the medical record and from the perspective of PCPs. This study underscores the importance of patient-physician relationships, sociodemographics, and SHS. It also indicates the existence of an interplay between social and contextual factors and the implementation of SHS as part of routine clinical care.

Patient and Clinician Sociodemographics and Sexual History Screening at a Multisite Federally Qualified Health Center: A Mixed Methods Study

Kelly W. Gagnon, PhD, MPH, et al
Division of Infectious Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama

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Researchers Identify Important Strategies for Diabetes Care and Quality Improvements in the Primary Care Setting

This qualitative study considers how the strategies used by high-performing primary care practices to improve diabetes care might play a role in successfully managing practice change. The research team conducted semistructured interviews at 10 Minnesota primary care practices (rural and urban) ranked in the top quartile of diabetes care improvement per their Optimal Diabetes Care (ODC) scores. (Minnesota’s ODC scores are calculated based on mandatory reporting of performance data.) They asked three questions to prompt discussions of how practice leaders managed change:

1)         What changes do you think contributed most to that improvement in ODC scores?
2)         How did you implement those changes? Did you use any particular strategies?
3)         Were there any other factors that contributed to your improvement?

What We Know: Improving diabetes outcomes in primary care depends on successfully implementing effective changes to diabetes care. However, changes can be disruptive in a busy practice, and problems with clinician engagement, staff education, or support from leadership can render changes ineffective and compromise results. Although differences in care management processes (CMPs, specific activities performed with the goal of providing high-quality care) used by high- and low-performing practices have been reported, how high- and low-performing practices adopt and manage CMPs may be another differentiating factor.

What This Study Adds: The research team found that high-performing primary care practices tend to use similar strategies to manage change and quality improvement in caring for patients with diabetes. Nine common strategies emerged: 1) standardizing the care process, 2) performance awareness, 3) enhancing care teams, 4) health care organization participation, 5) improving reporting systems, 6) engaging staff and clinicians, 7) accountability for tasks, 8) engaging leadership, and 9) tracking change. The three top management themes identified by most practices were proactive care, pre-visit planning, and improving patient relationships. Primary care practices may be able to improve care for chronic conditions in addition to diabetes by adopting similar strategies.

Successful Change Management Strategies for Improving Diabetes Care Delivery Among High-Performing Practices

Kevin A. Peterson, MD, MPH, et al
Department of Family Medicine and Community Health, UMN Medical School, University of Minnesota, Minneapolis, Minnesota

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Attentiveness to Resting Leg Cramps May Afford Greater Insight Into Advancing Age and Declining Health

Researchers developed and conducted a cross-sectional survey to examine the prevalence and characteristics of leg cramps in 294 primary care patients (with a mean age of 46.5 years), with 51.7% reporting leg cramps. Patients who experience resting or exercise-induced leg cramps were more likely to be older (mean age 49.1 years) and female (which comprised 69% of surveyed participants and 72% of the cohort experiencing leg cramps). Cramp severity among patients averaged 5.6 on a scale of 1-10 and disturbed sleep was “sometimes” or “often” present in 55% of patients. Most patients did not discuss cramps with their clinician. Authors recommend that clinicians should review resting leg cramps as a symptom of declining health and advancing aging. Clinicians should also be aware of the high prevalence of leg cramps to spur additional research on the physiological condition.

What We Know: Primary care physicians commonly see patients experiencing leg cramps, which can cause significant distress and symptoms that can last many hours. Cramps may cause sleep disruption, reduced quality of life, and depression. Although common, there is a dearth of research about leg cramps, their prevalence, and their impact on primary care patients in the United States. 

What This Study Adds: This study not only contributes to the development of a validated survey to identify leg cramps, it also updates information from the last major study conducted on leg cramps conducted in 1991. The new study reveals that patients don’t often bring up the subject with their doctors despite having lived with leg cramps for an average of four years. The authors state that there is emerging evidence that leg cramps are a symptom of declining health, diminishing fitness, and/or advancing aging. Primary care doctors should review leg cramps, regard them as a symptom of impaired quality of life, and be active in addressing the issue as a part of optimizing healthy aging. 

Patient-Reported Prevalence, Characteristics, and Impact of Leg Cramps in an Urban Primary Care Clinic

Birgit Khandalavala, MBBS, et al
University of Nebraska Medical Center, College of Medicine, and Department of Family Medicine, Omaha, Nebraska

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Staffing Challenges and General Time Constraints May Harm Primary Care Teams’ Ability to Implement Quality Improvement Efforts

Researchers aimed to identify factors leading primary care practice personnel to decline participation in quality improvement (QI) projects, and strategies to improve the feasibility and attractiveness of QI projects in the future. Representatives from 31 practices agreed to participate in the study. Overwhelmingly, respondents said that staff turnover, staffing shortages, and general time constraints, exacerbated by the COVID-19 pandemic, prevented participation in QI projects. Challenges with electronic health records (EHR); an expectation for greater financial compensation for participation; and confidence in the practices’ current care practices were secondary reasons for declining participation. The authors identified major strategies to help facilitate recruitment in conducting QIs, including tying participation to value‐based programs and offering greater compensation. However, none of the respondents’ recommendations addressed the primary issues of staffing challenges and time constraints.

What We Know: Numerous supportive quality improvement (QI) projects exist, which can facilitate the implementation of evidence‐based practices in primary care. However, recruiting physician practices to join these projects is challenging, costly and time‐consuming.

What This Study Adds: Through the use of qualitative interviews, researchers found that primary care clinic personnel face myriad challenges to participating in QI efforts, including staff turnover, staffing shortages, and general time constraints, exacerbated by the COVID-19 pandemic. They recommend that policy makers consider direct support for primary care, which may also help to alleviate burnout.

Declining Participation in Primary Care Quality Improvement Research: A Qualitative Study

Megan McHugh, PhD, et al
Center for Health Services and Outcomes Research, Northwestern University, Feinberg School of Medicine, Chicago, Illinois

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Editorialists Challenge Primary Care Doctors to Create a Safe and Affirming Medical Home for Transgender Individuals

Mary-Frances Hall and Daphna Strousma write this issue’s editorial about the two Annals of Family Medicine papers (Alpert and Porat) that discuss care for transgender (trans) individuals. Hall and Strousma argue that providing empathetic and evidence-based care to trans patients has never been more important in this age of disinformation and political persecution. Porat and team studied the prevalence of severe erythrocytosis in trangender individuals who are taking testosterone to evaluate the need for constant blood draws. Considering that Porat et al found a weak link between testosterone and severe erythrocytosis, the editorialists argue that Porat’s study is timely within the context of the recent World Professional Association for Transgender Health Standards of Care guidelines. Hall and Strousma note that the association’s updated guidelines parallel Porat and team’s hesitancy in that association members “suggest rather than recommend testing to be carried out every three months in the first year to allow some flexibility on the timing of these tests as there is no strong evidence or evidence from published studies supporting specific testing intervals.”

Citing Alpert’s study, which describes the various social and clinical factors that go into transgender individuals’ decisions about what to disclose with their doctor, Hall and Strousma place the study’s results within the gender minority stress model, which they argue is central to understanding health inequities faced by trans individuals, as well as the steps needed to advance the quality of and access to care.

The editorialists write that historically, the medical system has done more to harm than heal members of the trans community. The Porat et al and Alpert et al studies consider how the over-medicalization of trans patients has negatively influenced not only patient care interactions but also medical care guidelines. The editorialists write that family medicine physicians have the unique role of building close, longitudinal relationships with patients over their lifespan. “As the primary point of care, this position must be used to think critically about how the medical field can be an unsafe space for trans individuals, and then use that awareness to instead create a safe and affirming medical home,” Hall and Strousma write.

From Medicalization to Empowerment: New Horizons in Transgender Care

Mary-Frances E. Hall, MPH, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, and Daphna Stroumsa, MD, MPH, Department of Obstetrics and Gynecology, Institute for Healthcare Policy and Innovations, University of Michigan, Ann Arbor, Michigan

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Primary Care Investigators, Clinicians, Patients and Community Members Reflect on NAPCRG’s 50 Years of Leadership and Service

A team of primary care investigators, clinicians, learners, patients, and community members reflected on the North American Primary Care Research Group (NAPCRG) as it passed a 50-year milestone at its 2022 meeting. NAPCRG was started in 1972 by a small group of general practice researchers in the US, Canada, and the UK. It has evolved into an international, interprofessional, interdisciplinary, and intergenerational group devoted to improving health and health care through primary care research. The authors of the special report write that NAPCRG provides a nurturing home to researchers and teams working in partnership with individuals, families, and communities. The organization builds upon enduring values to create partnerships, advance research methods, and nurture a community of contributors. NAPCRG has made foundational contributions, including identifying the need for primary care research to inform practice. It also has made contributions to practice-based research networks; qualitative and mixed-methods research; community-based participatory research; patient safety; practice transformation; and partnerships with patients and communities. Landmark documents produced by NAPCRG members have helped define classification systems for primary care; responsible research with communities; and the central role of primary care in health care systems, Members have also created opportunities to revitalize generalist practice and shared strategies to build the future of family medicine. The authors argue that the future of health and health care depends upon strengthening primary care and primary care research with stronger support, infrastructure, training, and workforce. New technologies offer opportunities to advance research, enhance care, and improve outcomes. The authors assert that stronger partnerships can empower primary care research with patients and communities. These partnerships can also increase commitments to diversity and quality care for all.

What We Know: The discipline of primary care emerged in the 1970s as a response to the need for personal generalist doctors to care for patients, regardless of their medical or health problems. A group of pioneering primary care practitioners teamed with colleagues, including early researchers in general internal medicine, pediatrics, nursing, epidemiology, and behavioral sciences, to create a new organization devoted to research in primary care.

What This Report Adds: With the formation of NAPCRG, the organization and its members have been guided for over 50 years by enduring core values including building partnerships, innovating research methods, and nurturing a diverse community of contributors. The authors assert that NAPCRG can help primary care move forward with foundational values, interdisciplinary teams, diverse voices, community partnerships, critical thinking, rigorous methods, clinical experience, and “audacious” imagination.

Primary Care Research: Looking Back and Moving Forward With Reflections on NAPCRG’s First 50 Years

William R. Phillips, MD, MPH, et al
Department of Family Medicine, University of Washington, Seattle, Washington

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Longtime Primary Care Doctor Recommends the ‘Human Touch’ to Improve Patient Care, Employee Morale, and Clinical Efficiencies

Written as a resident scholar at the Robert Graham Center and the Center for Professionalism and Value in Healthcare, primary care doctor David Loxterkamp, MD, presents what he believes are the elements of ‘human touch,’ which can improve primary care for patients: human voice, where patients feel acknowledged, respected, and welcomed by a human with whom they can discuss their health concerns; human scale, where patient needs like prescriptions or referrals don’t fall through the cracks due to overly large organizations; human continuity, where patients who need care continuity receive it; human conversation, where doctors take the time to discuss health issues with patients so that they arrive at holistic and accurate diagnoses; and human potential, where the office climate enables caregivers to make good clinical decisions, prevent burnout, and adopt improvement strategies. “Patients need to feel acknowledged, respected, and welcomed,” Loxterkamp writes. “Caregivers want a work environment where they can make individualized decisions, improve their skills, and feel like they are making a difference in the lives of others. Not surprisingly, when we care for patients in the right kind of way, we are caring for ourselves, too.”

What Humans Need

David Loxterkamp, MD
Seaport Community Health Center, Belfast,, Maine

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Family Physician Reflects on His Years on Night Call and Worries About Connecting With Patients

On his final night of being on call, academic family physician Jonathan L. Temte, MD, PhD, reflects on the job that entailed roughly 1,000 call nights over nearly 30 years. His experiences of the drive to the hospital, interactions with resident physicians, and caring for patients through what he calls the “neglected hours of the day” blend together in the stories that emerge. Temte said that he misses the interaction with the hospital residents, the stories of the patients, and the many reminders of the frailty and resilience of the human condition. He also worries that as medical practice changes, he and his primary care colleagues may become increasingly divorced from the intimate contact during those neglected hours of the day: late at night, guarded by terror, vulnerable, yet blessed by humility and the richness of narrative.

Last Call: Reflections on the Neglected Hours of the Day

Jonathan L. Temte, MD, PhD
University of Wisconsin Departmentof Family Medicine and Community Health, Madison, Wisconsin

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