Boswell, Christopher L.

Continuity of care has been an identifying characteristic of family medicine since its inception and is an essential ingredient for high-functioning health care teams. Many benefits, including the quadruple aim of enhancing patient experience, improving population health, reducing costs, and improving care team well-being, are ascribed to continuity of care. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) added two new continuity requirements—annual patient-sided continuity and annual resident-sided continuity—in family medicine training programs. This article reviews continuity of care as it applies to family medicine training programs. We discuss the various types of continuity and issues surrounding the measurement of continuity. A generally agreed upon definition of patient-sided and resident-sided continuity is presented to allow programs to begin to collect the necessary data. Especially within resident training programs, intricacies associated with maintaining continuity of care, such as empanelment, resident turnover, and scheduling, are discussed. The importance of right-sizing resident panels is highlighted, and a mechanism for accomplishing this is presented. The recent ACGME requirements represent a cultural shift from measuring resident experience based on volume to measuring resident continuity. This cultural shift forces family medicine training programs to adapt their various systems, policies, and procedures to emphasize continuity. We hope this manuscript’s review of several facets of contuinuity, some unique to training programs, helps programs ensure compliance with the ACGME requirements.

Background and Objectives: Social distancing and quarantine requirements imposed during the COVID-19 pandemic necessitated remote training in many learning situations that formerly focused on traditional in-person training. In this context, we developed an adaptive approach to teaching laceration repair remotely while allowing for synchronous instruction and feedback. Methods: In April 2020, 35 family medicine residents from 4 programs in the Midwest United States participated in a real-time, remotely-delivered, 2-hour virtual procedure workshop of instruction in suture techniques for laceration repair. Paired-sample t tests compared scores of learner self-confidence obtained during pre- and posttests. We interpreted short-answer responses with a mixed-methods analysis. Residents submitted photos and videos of suture techniques and received formative feedback based on a predefined rubric. Results: All residents completed the pre- and posttests. The posttest scores for self-confidence across the participants showed significant improvement for all suture techniques. Of the 67 short-answer responses, 38 responses (56.7%) were positive; 9 (13.4%) negative; 8 (11.9%) neutral; and 12 (17.9%) a combination of positive and negative. The workshop was rated by 34 residents (97.1%) as either “about the same as prior training experiences,” “better than prior training experiences,” or “much better than prior training experiences.” Conclusion: Learners reported that a remotely-delivered, real-time, synchronous suture technique workshop was a valuable experience. Further research is needed to establish the efficacy of this platform to promote procedural competence.

Introduction: Acrocyanosis and erythema pernio are 2 dermatologic manifestations of vasospastic changes. Primary care providers should consider that these conditions can occur as primary or idiopathic conditions and as secondary conditions related to another disease or medication. Herein we describe a case of acrocyanosis and erythema pernio attributed to vincristine therapy. Case Description: A 22-year-old man was evaluated for discomfort and red lesions involving the toes of both feet for several weeks. He had completed chemotherapy 1 month earlier for Ewing sarcoma in the right femur. Local control for the primary tumor included wide local excision and reconstruction with a vascularized fibular allograft from the right fibula. On examination, his right foot was dark blue and cool. Toes on both feet had nonpainful erythematous papules. After the case was discussed with the patient’s oncology team, the diagnosis was medication-induced acrocyanosis of the right foot and bilateral erythema pernio. Treatment consisted of supportive care to keep the feet warm and promote circulation to the feet. At 2-week follow-up, the patient’s symptoms and the appearance of his feet had markedly improved. Discussion: Primary care clinicians should be able to recognize dermatologic manifestations of vasospastic changes, including acrocyanosis and erythema pernio, and rule out possible secondary causes, such as pharmacologic agents. This patient’s history of therapy for Ewing sarcoma prompted consideration of medication-induced vasospastic changes most likely related to the adverse vasospastic effects of vincristine. Symptoms should improve with cessation of the offending medication.

This case involves a patient with severe COVID-19 pneumonia and massive pulmonary embolism requiring mechanical ventilation. His clinical course was complicated by delirium likely triggered by his critical illness and failed initial extubation, isolation from family, and escalating fear and desperation. In hopeful preparation for subsequent successful extubation, a unique approach was taken to decrease the risk of panic, delirium, and decompensation leading to reintubation. As a means of orienting him to his treatment pathway and to provide encouragement for continued recovery, an impromptu patient-directed checklist was constructed. The recovery checklist, written in simplified language, outlined the stages of severe illness that the patient had overcome after his emergent intubation. The list also outlined the tasks he needed to complete prior to hospital discharge. Unexpectedly, the checklist received a great deal of engagement from both the patient and medical team and played an important role in this patient’s successful recovery and rehabilitation.

Introduction: Performing clinical procedures is an essential component of family medicine (FM) residency training. A referral-based procedure clinic was established at our institution in 2014, and a yearly 2-week rotation was established for residents. The objective of this study was to determine the effect of a procedure clinic rotation on the numbers of procedures performed during residency training. Methods: We conducted a retrospective review on graduating FM residents from 2009 to 2019. Data collected include type and number of procedures performed each postgraduate year. We analyzed data as mean number of procedures per resident per year. We conducted statistical comparison with Wilcoxon-Mann-Whitney two-sample rank-sum tests. Results: Residents who participated in the procedure clinic rotation performed significantly more dermatologic procedures per year, joint and soft tissue injections and intrauterine device (IUD) insertions and removals, but did not perform significantly more circumcisions, endometrial biopsies, incision and drainages, subdermal contraceptive implant procedures, toenail removals, or vasectomies. Conclusion: The establishment of a 2-week procedure clinic rotation for FM residents was associated with a significant increase in dermatologic procedures, joint and soft tissue injections, and IUD procedures. Further research can explore the impact of this rotation on procedural competency and confidence.

Background While socioeconomic status has been linked to hospital readmissions for several conditions, reliable measures of individual socioeconomic status are often not available. HOUSES, a new measure of individual socioeconomic status based upon objective public data about one's housing unit, is inversely associated with overall hospitalization rate but it has not been studied with respect to readmissions. Purpose To determine if patients in the lowest HOUSES quartile are more likely to be readmitted within 30 days (short-term) and 180 days (long-term). Methods A retrospective cohort study of 11 993 patients having 21 633 admissions was conducted using generalized linear mixed-effects models. Results HOUSES quartile did not show any significant association with early readmission. However, when compared to the lowest HOUSES quartile, the second quartile (OR = 0.90, 95%CI 0.83-0.98) and the third quartile (OR = 0.91, 95%CI 0.83-0.99) were associated with lower odds of late readmission while the highest quartile (OR = 0.91, 95%CI 0.82-1.01) was not statistically different. Conclusion HOUSES was associated with late readmission, but not early readmission. This may be because early readmissions are influenced by medical conditions and hospital care while late readmissions are influenced by ambulatory care and home-based factors. Since HOUSES relies on public county assessor data, it is generally available and may be used to focus interventions on those at highest risk for late readmission.

Trigger finger is a common condition usually curable by a safe, simple corticosteroid injection. Trigger finger results from a stenotic A1 pulley that has lost its gliding surface producing friction and nodular change in the tendon. This results in pain and tenderness to palpation of the A1 pulley, progressing to catching and then locking. Splinting for 6 to 9 weeks produces gradual improvement in most patients as does a quick steroid injection with the latter resulting in resolution of pain in days and resolution of catching or locking in a few weeks. Percutaneous or open release should be reserved for injection failures particularly those at high risk for continued injection failure including diabetics and those with multiple trigger fingers. We present a step-by-step method for injection with illustrations to encourage primary care providers to offer this easily performed procedure to their patients.