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Health care reform will add millions of Americans to the ranks of the insured; however, their access to health care is threatened by a deep decline in the production of primary care physicians. Poorer access to primary care risks poorer health outcomes and higher costs. Meeting this increased demand requires a major investment in primary care training. Title VII, Section 747 of the Public Health Service Act previously supported the growth of the health care workforce but has been severely cut over the past 2 decades. New and expanded Title VII initiatives are required to increase the production of primary care physicians; establish high-functioning academic, community-based training practices; increase the supply of well-trained primary care faculty; foster innovation and rigorous evaluation of these programs; and ultimately to improve the responsiveness of teaching hospitals to community needs. To accomplish these goals, Congress should act on the Council on Graduate Medical Education's recommendation to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually. This amount represents a small investment in light of the billions that Medicare currently spends to support graduate medical education, and both should be held to account for meeting physician workforce needs. Expansion of Title VII, Section 747 with the goal of improving access to primary care would be an important part of a needed, broader effort to counter the decline of primary care. Failure to launch such a national primary care workforce revitalization program will put the health and economic viability of our nation at risk. [ABSTRACT FROM AUTHOR]

BACKGROUND: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. METHODS: Physician Insurers Association of America malpractice claims data (1985-2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. RESULTS: Of 49345 primary care claims, 26126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with 'diagnosis error' making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). CONCLUSIONS: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations. [ABSTRACT FROM AUTHOR]

Decreased libido disproportionately affects patients with depression. The relationship between depression and decreased libido may be blurred, but treating one condition frequently improves the other. Medications used to treat depression may decrease libido and sexual function. Frequently, patients do not volunteer problems related to sexuality, and physicians rarely ask about such problems. Asking a depressed patient about libido and sexual function and tailoring treatment to minimize adverse effects on sexual function can significantly increase treatment compliance and improve the quality of the patient's life. [ABSTRACT FROM AUTHOR]

Evidence supports the effectiveness of primary care interventions to improve nutrition, increase physical activity levels, reduce alcohol intake, and stop tobacco use. However, implementing these interventions requires considerable practice expense. If we hope to change behavior to reduce chronic illness, the way we pay for primary care services must be modified to incorporate these expenses. [ABSTRACT FROM AUTHOR]

Background and Objectives: Resident burnout may affect career choices and empathy. We examined predictors of burnout among family medicine residents., Methods: We used data from the 2019-2021 American Board of Family Medicine Initial Certification Questionnaire, which is required of graduating residents. Burnout was a binary variable defined as reporting callousness or emotional exhaustion once a week or more. We evaluated associations using bivariate and multilevel multivariable regression analyses., Results: Among 11,570 residents, 36.4% (n=4,211) reported burnout. This prevalence did not significantly vary from 2019 to 2021 and was not significantly attributable to the residency program (ICC=0.07). Residents identifying as female reported higher rates of burnout (39.0% vs 33.4%, AOR=1.29 [95% CI 1.19-1.40]). Residents reporting Asian race (30.5%, AOR=0.78 [95% CI 0.70-0.86]) and Black race (32.3%, AOR=0.71 [95% CI 0.60-0.86]) reported lower odds of burnout than residents reporting White race (39.2%). We observed lower rates among international medical graduates (26.7% vs 40.3%, AOR=0.54 [95% CI 0.48-0.60]), those planning to provide outpatient continuity care (36.0% vs 38.7%, AOR=0.77 [95% CI 0.68-0.86]), and those at smaller programs (31.7% for <6 residents per class vs 36.3% for 6-10 per class vs 40.2% for >10 per class). Educational debt greater than $250,000 was associated with higher odds of burnout than no debt (AOR=1.29 [95% CI 1.15-1.45])., Conclusions: More than one-third of recent family medicine residents reported burnout. Odds of burnout varied significantly with resident and program characteristics.

Objective: To test whether differences in hospital interoperability are related to the extent to which hospitals treat groups that have been economically and socially marginalized., Data Sources and Study Setting: Data on 2393 non-federal acute care hospitals in the United States from the American Hospital Association Information Technology Supplement fielded in 2021, the 2019 Medicare Cost Report, and the 2019 Social Deprivation Index., Study Design: Cross-sectional analysis., Data Collection/extraction Methods: We identified five proxy measures related to marginalization and assessed the relationship between those measures and the likelihood that hospitals engaged in all four domains of interoperable information exchange and participated in national interoperability networks in cross-sectional analysis., Principal Findings: In unadjusted analysis, hospitals that treated patients from zip codes with high social deprivation were 33% less likely to engage in interoperable exchange (Relative Risk = 0.67, 95% CI: 0.58-0.76) and 24% less likely to participate in a national network than all other hospitals (RR = 0.76; 95% CI: 0.66-0.87). Critical Access Hospitals (CAH) were 24 percent less likely to engage in interoperable exchange (RR = 0.76; 95% CI: 0.69-0.83) but not less likely to participate in a national network (RR = 0.97; 95% CI: 0.88-1.06). No difference was detected for 2 measures (high Disproportionate Share Hospital percentage and Medicaid case mix) while 1 was associated with a greater likelihood to engage (high uncompensated care burden). The association between social deprivation and interoperable exchange persisted in an analysis examining metropolitan and rural areas separately and in adjusted analyses accounting for hospital characteristics., Conclusions: Hospitals that treat patients from areas with high social deprivation were less likely to engage in interoperable exchange than other hospitals, but other measures were not associated with lower interoperability. The use of area deprivation data may be important to monitor and address hospital clinical data interoperability disparities to avoid related health care disparities., (© 2023 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

We report on the experience of small primary care practices participating in a national clinical registry with COVID-19 vaccines and vaccination data. At the end of 2021, 11.2 percent of these practices' 3.9 million patients had records of COVID-19 vaccination; 43.1 percent of clinics had no record of patients' COVID-19 vaccinations, but 93.4 percent of clinics had provided or recorded other routine vaccinations.

Edward Hannan and colleagues found that a lack of standardization of input variables to the Area Deprivation Index (ADI) available from the Neighborhood Atlas overweights the index for median home value and thus potentially further disadvantages already disadvantaged communities. We recommend that a revised ADI be created that addresses the error, and we offer five steps to avoid future errors in the creation of area deprivation measures.

A 2021 article, "Now is our time to act: Why academic medicine must embrace community collaboration as its fourth mission," by Association of American Medical Colleges (AAMC) authors, including AAMC president and CEO Dr. David J. Skorton, offers 2 aims that are highly related: community collaboration and health equity. The AAMC's call to prioritize community collaboration and health equity as pillars of the academic medicine mission echo earlier work on community-oriented primary care (COPC) and an even more robust model that builds on COPC, community-engaged health care (CEHC). COPC is a tested, systematic approach to health care by which a health clinic or system collaborates with a community to reshape priorities and services based on assessed health needs and determinants of health. COPC affirms health inequities' socioeconomic and political roots, emphasizing health care as a relationship, not a transaction or commodity. Communities where COPC is implemented often see reductions in health inequities, especially those related to socioeconomic, structural, and environmental factors. COPC was the foundation on which community health centers were built, and early models had demonstrable effects on community health and engagement. Several academic health centers build on COPC to achieve CEHC. In CEHC, primary care remains critical, but more of the academic health center's functions are pulled into community engagement and trust building. Thus, the AAMC has described and embraced a care and training model for which there are good, longitudinal examples among medical schools and teaching hospitals. Spreading CEHC and aligning the Community Health Needs Assessment requirements of academic health centers with the fourth mission could go a long way to improving equity, building trust, and repairing the social contract for health care., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of American Medical Colleges.)

Purpose: Care continuity is foundational to the clinician/patient relationship; however, little has been done to operationalize continuity of care (CoC) as a clinical quality measure. The American Board of Family Medicine developed the Primary Care CoC clinical quality measure as part of the Measures That Matter to Primary Care initiative., Methods: Using 12-month Optum Clinformatics Data Mart claims data, we calculated the Bice-Boxerman Continuity of Care Index for each patient, which we rolled up to create an aggregate, physician-level CoC score. The physician quality score is the percent of patients with a Bice-Boxerman Index ≥0.7 (70%). We tested validity in 2 ways. First, we explored the validity of using 0.7 as a threshold for patient CoC within the Optum claims database to validate its use for reflecting patient-level continuity. Second, we explored the validity of the physician CoC measure by examining its association with patient outcomes. We assessed reliability using signal-to-noise methodology., Results: Mean performance on the measure was 27.6%; performance ranged from 0% to 100% (n = 555,213 primary care physicians). Higher levels of CoC were associated with lower levels of care utilization. The measure indicated acceptable levels of validity and reliability., Conclusions: Continuity is associated with desirable health and cost outcomes as well as patient preference. The CoC clinical quality measure meets validity and reliability requirements for implementation in primary care payment and accountability. Care continuity is important and complementary to access to care, and prioritizing this measure could help shift physician and health system behavior to support continuity., (© 2022 Annals of Family Medicine, Inc.)

The graduate medical education (GME) system is heavily subsidized by the public in return for producing physicians who meet society's needs. Under the terms of this implicit social contract, decisions about how this funding is allocated are deferred to the individual training sites. Institutions receiving public funding face potential conflicts of interest, which have at times prioritized institutional purposes and needs over societal needs, highlighting that there is little public accountability for how such funding is used. The cost and institutional burden of assessing many fundamental GME outcomes, such as specialty, geographic physician distribution, training-imprinted cost behaviors, and populations served, could be mitigated as data sources and methods for assessing GME outcomes and guiding training improvement already exist. This new capacity to assess system-level outcomes could help institutions and policymakers strategically address the greatest public needs. Measurement of educational outcomes can also be used to guide training improvement at every level of the educational system (i.e., the individual trainee, individual teaching institution, and collective GME system levels). There are good examples of institutions, states, and training consortia that are already assessing and using GME outcomes in these ways. The ultimate outcome could be a GME system that better meets the needs of society and better honors what is now only an implicit social contract., Competing Interests: The graduate medical education (GME) system is heavily subsidized by the public in return for producing physicians who meet society’s needs. Under the terms of this implicit social contract, decisions about how this funding is allocated are deferred to the individual training sites. Institutions receiving public funding face potential conflicts of interest, which have at times prioritized institutional purposes and needs over societal needs, highlighting that there is little public accountability for how such funding is used. The cost and institutional burden of assessing many fundamental GME outcomes, such as specialty, geographic physician distribution, training-imprinted cost behaviors, and populations served, could be mitigated as data sources and methods for assessing GME outcomes and guiding training improvement already exist. This new capacity to assess system-level outcomes could help institutions and policymakers strategically address the greatest public needs. Measurement of educational outcomes can also be used to guide training improvement at every level of the educational system (i.e., the individual trainee, individual teaching institution, and collective GME system levels). There are good examples of institutions, states, and training consortia that are already assessing and using GME outcomes in these ways. The ultimate outcome could be a GME system that better meets the needs of society and better honors what is now only an implicit social contract., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of American Medical Colleges.)

Despite reports of a physician burnout epidemic, there is little research on the relationship between burnout and objective measures of care outcomes and no research on the relationship between burnout and costs of care. Linking survey data from 1,064 family physicians to Medicare claims, we found no consistent statistically significant relationship between seven categories of self-reported burnout and measures of ambulatory care-sensitive admissions, ambulatory care-sensitive emergency department visits, readmissions, or costs. The coefficients for ambulatory care-sensitive admissions and readmissions for all burnout levels, compared with never being burned out, were consistently negative (fewer ambulatory care-sensitive admissions and readmissions), suggesting that, counterintuitively, physicians who report burnout may nevertheless be able to create better outcomes for their patients. Even if true, this hypothesis should not indicate that physician burnout is beneficial or that efforts to reduce physician burnout are unimportant. Our findings suggest that the relationship between burnout and outcomes is complex and requires further investigation.

Purpose: Physicians' use of self-assessment to guide quality improvement or board certification activities often does not correlate with more objective measures, and they may spend valuable time on activities that support their strengths instead of addressing gaps. Our objective was to study whether viewing quality measures, with peer comparisons, would affect the selection of certification activities., Methods: We conducted a cluster-randomized controlled trial-the Trial of Data Exchange for Maintenance of certification and Raising Quality (TRADEMaRQ)-with 4 partner organizations during 2015-2017. Physicians were presented their quality data within their online certification portfolios before (intervention) vs after (control) they chose board certification activities. The primary outcome was whether the selected activity addressed a quality gap (a quality area in which the physician scored below the mean for the study population)., Results: Of 2,570 invited physicians, 254 physicians completed the study: 130 in the intervention group and 124 in the control group. Nearly one-fifth of participating physicians did not complete any certification activities during the study. A sizable minority of those in the intervention group, 18.4%, never reviewed their quality dashboard. Overall, just 27.2% of completed certification activities addressed a quality gap, and there was no significant difference in this outcome in the intervention group vs the control group in either bivariate or adjusted analyses (odds ratio = 1.28; 95% CI, 0.90-1.82)., Conclusions: Physicians did not use quality performance data in choosing certification activities. Certification boards are being pressed to make their programs relevant to practice, less burdensome, and supportive of quality improvement in alignment with value-based payment models. Using practice data to drive certification choices would meet these goals., (© 2022 Annals of Family Medicine, Inc.)

Background: The Centers for Medicare and Medicaid Services proposed that the Transforming Clinical Practice Initiative (TCPI) would improve health outcomes for patients, reduce utilization of institutional services, and generate significant savings for payers by the end of September 2019., Objective: The objective of this study was to investigate whether participation in TCPI's Practice Transformation Networks (PTNs) was associated with improved cost and utilization outcomes for Medicare patients of family medicine-based practices in the first 2 years, that is, 2016-2017, of the Initiative., Study Design: A quasi-experimental design with a longitudinal cohort of family medicine-based practices and a propensity-matched comparison sample., Subjects: A total of 761 PTN practices and 3451 non-PTN practices., Measures: To measure practice-level patient outcomes, we attributed patients to practice based on the plurality of office visits. We obtained Medicare claims from 2011 to 2017 to assess PTN participation effects for Medicare Part A and B costs, hospital admission, and emergency department visit rates using a Difference-in-Differences design, adjusting for baseline characteristics., Results: The differences in Medicare Part A and B costs (-1.71%, P=0.25), annual rates of hospitalization (-0.59%, P=0.12) and emergency department visit (-0.29%, P=0.46) were not significantly lower among PTN practices (N=761) than among propensity score-matched non-PTN practices (N=3541)., Conclusions: TCPI's transforming efforts, such as the outcomes examined in the study, might need a longer time frame to manifest and require evaluation after the full 4-year participation period. The indistinguishable effect of PTN participation may also be attributed to the fact that non-PTN practices might have participated in other initiatives that changed their care and curbed health care utilization and costs consequently., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Primary care (PC) is an essential building block for any high quality healthcare system, and has a particularly positive impact on vulnerable patients. It contributes to the overall performance of health systems, and countries that reorient their health system towards PC are better prepared to achieve universal health coverage. Monitoring the actual performance of PC in health systems is essential health policy to support PC. However, current indicators are often too narrowly defined to account for quality of care in the complex populations with which PC deals. This article reviews a number of conceptual frameworks developed to capture PC values in robust measures and indicators that can inform policy and practice performance. Each have benefits and limitations. Further work is needed to develop meaningful primary health care (PHC) and PC measures to inform strategic action by policymakers and governments for improved overall performance of health systems., (Copyright © 2021, The Authors.)

To improve health care quality and decrease costs, both the public and private sectors continue to make substantial investments in the transformation of primary care. Central to these efforts is the patient-centered medical home model (PCMH) and the adoption and meaningful use of health information technology (IT). We used 2018 national family medicine data to provide a perspective on the implementation of PCMH and health IT elements in a variety of US physician practices. We found that 95 percent of family medicine-affiliated practices used electronic health records (EHRs) in 2018, but there was wide variation in whether those EHRs met meaningful-use criteria. Federally qualified health centers and military clinics were significantly more likely than other settings to have adopted PCMH elements. Adoption of PCMH elements was lowest among independently owned practices, which make up one-third of the primary care delivery system. Our findings suggest that achieving PCMH transformation across all types of practices will require a coordinated approach that aligns strong financial incentives with tailored technical assistance, an approach similar both to that used in federally qualified health centers over the past decade and to that used to drive EHR adoption a decade ago.

Background: Strong primary health care (PHC) is the cornerstone for universal health coverage and a country's health emergency response. PHC includes public health and first-contact primary care (PC). Internationally, the spread of COVID-19 and mortality rates vary widely. The authors hypothesised that countries perceived to have strong PHC have lower COVID-19 mortality rates., Aim: To compare perceptions of PC experts on PC system strength, pandemic preparedness, and response with COVID-19 mortality rates in countries globally., Design & Setting: A convenience sample of international PHC experts (clinicians, researchers, and policymakers) completed an online survey (in English or Spanish) on country-level PC attributes and pandemic responses., Method: Analyses of perceived PC strength, pandemic plan use, border controls, movement restriction, and testing against COVID-19 mortality were undertaken for 38 countries with ≥5 responses., Results: In total, 1035 responses were received from 111 countries, with 1 to 163 responders per country. The 38 countries with ≥5 responses were included in the analyses. All world regions and economic tiers were represented. No correlation was found between PC strength and mortality. Country-level mortality negatively correlated with perceived stringent border control, movement restriction, and testing regimes., Conclusion: Countries perceived by expert participants as having a prepared pandemic plan and a strong PC system did not necessarily experience lower COVID-19 mortality rates. What appears to make a difference to containment is if and when the plan is implemented, and how PHC is mobilised to respond. Many factors contribute to spread and outcomes. Important responses are first to limit COVID-19 entry across borders, then to mobilise PHC, integrating the public health and PC sectors to mitigate spread and reduce burden on hospitals through hygiene, physical distancing, testing, triaging, and contract-tracing measures., (Copyright © 2020, The Authors.)

The social contract between the public and health professions is fraying, challenged by changes in the organization and financing of health care, and by a collective failure to meet some of the expectations of society. It is timely for family medicine to acknowledge the social contract, to accept responsibility for its the role in renegotiating this contract, and to partner with other practice communities in doing so. Human behavior is strongly directed by our environment and risk aversion rather than rational decision making and it is possible to design our practice environment to "nudge" clinician behaviors purposefully toward professionalism. Current leveraging of professionalism is a path to burnout and the alternative is to create a built environment for good care that also supports professionalism rather than taking advantage of it. There are good examples to draw on, and further experimentation, partnerships, policy, and facilitation of practice redesign are needed to get there., Competing Interests: Disclosures: None., (© Copyright 2020 by the American Board of Family Medicine.)

Clinicians are concerned about their patients' social determinants of health (SDH); yet, they are unsure how to effectively gather patient-level SDH data and intervene without adding to current administrative burdens. Designed properly, clinical registries offer solutions to integrate neighborhood SDH data with clinical data from electronic health records, enabling the understanding of community factors to guide patient care. Federal and state interest in adjusting reimbursements based on SDH further underscores the need for strategies that integrate SDH and clinical data. The Population Health Assessment Engine (PHATE) exemplifies a registry-based SDH data integration solution that adjusts payments, contributes to public health surveillance, organizes care around hot spots (gaps in quality or uncontrolled disease), assesses patient risk, and connects with community organizations. PHATE also permits residency training to meet community health competency milestones by incorporating the PHATE curriculum. These functions enhance value, and their utility in education and care delivery would benefit from further investigation., Competing Interests: Conflicting and Competing Interests: Drs. Phillips and Bazemore are employed by the American Board of Family Medicine. Dr. Liaw has received funding from the American Board of Family Medicine., (© Copyright 2020 by the American Board of Family Medicine.)

The American Board of Family Medicine routinely surveys its Diplomates in each national graduating cohort 3 years out of training. These data were used to characterize early career family physicians whose services include management of pregnancy and prescribing buprenorphine. A total of 261 (5.1%) respondents both provide maternity care and prescribe buprenorphine. Family physicians who care for pregnant women and also prescribe buprenorphine represented 50.4% of all buprenorphine prescribers. The family physicians in this group were trained in a small number of residency programs, with only 15 programs producing at least 25% of graduates who do this work., (© 2020 Annals of Family Medicine, Inc.)

The U.S. lags behind other developed countries in the use of indices and novel reimbursement models to adjust for social determinants of health (SDH) in medicine. This may be due in part to the inadequate body of research regarding outcomes after implementation of healthcare payments designed to address SDH. This perspective article focuses on four models employed both internationally and domestically to outline the implementation, successes, limitations, and research needed to support national application of SDH models. A brief history of prior models is introduced as a primer to the current U.S. system. Internationally, the United Kingdom and New Zealand employ small area indices to adjust healthcare dollar allocation based on increased social need in an area. Despite published evidence of disparate health outcomes based on SDH, research is limited on the association of SDH indices, subsequent increased reimbursement, and improved healthcare equity. In the U.S., the Massachusetts Managed Care Organization assesses and addresses social needs within communities served by Medicaid. Unsurprisingly, there is evidence of overlap between those with worse health outcomes and those with high social need. However, implementation in Massachusetts is too recent to demonstrate reduced healthcare disparities. Within Minnesota, Hennepin Healthcare System initiated a novel Medicaid waiver that provides extended services to high-need patients under a partial capitation reimbursement program. These services, including increased access to primary care, have promising results in financial improvement of the system, but have not yet demonstrated patient-oriented outcomes. The association between high social risk and poor medical outcomes has been established globally; however, healthcare payment policies designed to respond to this relationship generally lack evidence of affecting outcomes. U.S. policymakers are demonstrating increasing interest in requiring capture of SDH in health care, creating accountability for addressing SDH, paying differentially for patients with increased social risk, or all three. In countries with a legacy of adjusting healthcare payments for social risk, more robust evaluation of associated effects could be helpful. Payers, states, or health systems making similar resource commitments should build in robust longitudinal evaluations of outcomes to inform evolution of their payment policies. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: A family physician's ability to provide continuous, comprehensive care begins in residency. Previous studies show that patterns developed during residency may be imprinted upon physicians, guiding future practice. The objective was to determine family medicine residency characteristics associated with graduates' scope of practice (SCoP)., Method: The authors used (1) residency program data from the 2012 Accreditation Council for Graduate Medicine Education Accreditation Data System and (2) self-reported data supplied by family physicians when they registered for the first recertification examination with the American Board of Family Medicine (2013-2016)-7 to 10 years after completing residency. The authors used linear regression analyses to examine the relationship between individual physician SCoP (measured by the SCoP for primary care [SP4PC] score [scale of 0-30; low = small scope]) and individual, practice, and residency program characteristics., Results: The authors sampled 8,261 physicians from 423 residencies. The average SP4PC score was 15.4 (standard deviation, 3.2). Models showed that SCoP broadened with increasing rurality. Physicians from unopposed (single) programs had higher SCoP (0.26 increase in SP4PC); those from major teaching hospitals had lower SCoP (0.18 decrease in SP4PC)., Conclusions: Residency program characteristics may influence family physicians' SCoP, although less than individual characteristics do. Broad SCoP may imply more comprehensive care, which is the foundation of a strong primary care system to increase quality, decrease cost, and reduce physician burnout. Some residency program characteristics can be altered so that programs graduate physicians with broader SCoP, thereby meeting patient needs and improving the health system.

The quality of any health care system depends on the caliber, enthusiasm, and diversity of the workforce. Yet, workforce research often focuses on the number and type of health professionals needed and anticipated shortages compared with anticipated needs. These projections do not address whether the workforce will have the requisite social, intellectual, cultural, and emotional capital needed to deliver care in an increasingly complex health care system.Building a workforce that can deliver care in such a system begins by recruiting individuals with the requisite knowledge, skills, and attributes. To address this and other workforce needs, the authors argue that health professions education programs must make purposeful changes to their admissions criteria, such as focusing on emotional intelligence and diversity and recruiting students from the communities where they will return to work; partner with communities; ensure that accreditation systems support these goals of fostering diversity; recruit students who can bridge the gap between public health and health care; and invest in health professions education research.In this article, they contemplate how health professions education programs can recruit and educate talented health professionals to create a high-performing workforce that is capable of serving in the complex health care system of tomorrow. They provide examples of successful programs to highlight the potential effects of their recommendations.

To help health care practices transition away from fee-for-service reimbursement and toward value-based payment, the Transforming Clinical Practice Initiative was launched in October 2015. It was designed to provide clinicians support through peer-based Practice Transformation Networks (PTNs). A group of American Board of Family Medicine board-certified family physicians enrolled in PTNs described their expectations of and experiences with PTN participation; we analyzed open-text comments. Physicians expected and experienced PTN support in informatics and data, team building, and workflow and care coordination; however, expectations regarding patient care and engagement, costs and payment reform, and population and panel health were described less frequently.

Introduction: Previous studies have found that medical students and internal medicine residents with high educational debt perform less well on examinations. The purpose of this study was to examine the relationship between educational debt and family medicine residents' performance on initial in-training and board certification examinations., Methods: Our study was a cross-sectional secondary analysis of American Board of Family Medicine (ABFM) data collected from residents (N=5,828) who registered for the Family Medicine Certification Examination (FMCE) in 2014 and 2015, representing 85.8% of graduating family medicine residents in the United States in those years. Multivariable linear and logistic regression modeling was used to examine the relationship between debt level and examination scores, and also to explore the relationship between debt level and passing the initial FMCE., Results: After controlling for demographic variables, residents with high debt ($150,000 to $249,999) and very high debt (more than $250,000) performed significantly worse than those with no debt on the initial in-training examination (score differences of 14.2 [CI 8.6, 19.8] and 15.8 [CI 10.3, 21.4] points, respectively) and FMCE (score differences of 19.3 points [CI 13.4, 25.3] and 30.4 points [CI 24.6, 36.3], respectively). Additionally, those with debt above $250,000 had half the odds of passing their initial FMCE (OR 0.45; CI 0.27-0.75)., Conclusions: High educational debt is associated with lower examination performance among family medicine residents. This may be because residents with more debt have more stress or fewer day-to-day financial resources. However, confounding factors may also contribute to this association., (© 2019 by the Society of Teachers of Family Medicine.)