HIV Preexposure Prophylaxis Training in Family Medicine Residencies: A National Survey

Background and Objectives: Preexposure prophylaxis (PrEP) reduces HIV transmission among high-risk individuals. Yet, the HIV epidemic continues to expand among marginalized populations and America’s Southeastern states. Various barriers remain to PrEP uptake, namely provider knowledge and education. We sought to investigate residency training, competency, and prescribing of PrEP among population size. Additionally, we asked program directors to identify barriers to PrEP. Methods: We surveyed family medicine program directors as part of the Council of Academic Family Medicine Educational Research Alliance survey from January 2018 through February 2018. Results: Our survey questions had a 52.9% (276/522) response rate. No programs in rural communities less than 30,000 population (0/27) reported significant PrEP training for their residents; those in nonrural communities of at least 30,000 reported this training more frequently (41/246, 16.7%). Compared to Fischer expected values, the finding was statistically significant (P=.019); using a 75,000 population demarcation lowered significance (P=.192). We found programs that identify significant PrEP training also cite more PrEP prescribing within their practice (OR 7.27, P<.001). Programs with significant training also report their residents graduate with greater PrEP competency (OR 18.33, P<.001). The largest barriers identified were faculty expertise, not having enough high-risk patients, inadequate screening, and resident knowledge/training. Conclusions: We identified natural associations between increased training in PrEP and perceived PrEP competencies. We identified a lack of significant PrEP training and associated PrEP competencies in rural residency programs. Barriers identified in this study can help inform curricular needs to improve primary care workforce capacity to lower HIV risk.

Emotions in the Time of COVID-19: Affections and Impacts among the Spanish Primary Care Workforce

Background: The literature review shows that most studies on the psychological impact of COVID-19 on healthcare professionals have focused on hospital staff, with few specifically addressing the primary care workforce. This study aims to explore primary care workers’ verbal accounts of the emotions they experienced. Methods: This is a qualitative study carried out between July and December 2020 in Spain. Semi-structured interviews and focus groups were conducted with primary care workers. Data were analysed through thematic content analysis. Participants were selected using purposive sampling. Results: A total of 53 primary care workers participated in the study, of whom 38 were individually interviewed, and 15 participated in three focus groups. Our analysis revealed themes in two categories: (1) from infection to affection; and (2) affected, but not patients—a discourse based on the acceptance of their experience as part of their work in primary care, creating an ideological construct or “shield” based on emotional self-management. Conclusions: Self-reflection on the emotional impact of COVID-19 is scarce. Examples of emotional affections include an obsessive focus on hygiene, the inability to establish clear boundaries between the personal and the professional spheres, and experiencing—and having to self-manage—emotional strain.

Acceptability of physician associate interns in primary care: results from a service evaluation

Background Physician associates (PA) form part of the policy-driven response to increased primary care demand and a general practitioner (GP) recruitment and retention crisis. However, they are novel to the primary care workforce and have limitations, for example, they cannot prescribe. The novel 1 year Staffordshire PA Internship (SPAI) scheme, introduced in 2017, was established to support the integration of PAs into primary care. PA interns concurrently worked in primary and secondary care posts, with protected weekly primary care focussed education sessions. This evaluation established the acceptability of PA interns within primary care. Methods All ten PAs from the first two SPAI cohorts, the nine host practices (supervising GPs and practice managers) and host practice patients were invited to participate in the evaluation. A conceptual framework for implementing interventions in primary care informed data collection and analysis. Data were gathered at three time points over the internship from practices, through discussions with the supervising GP and/or practice manager, and from the PAs via discussion groups. To enrich discussion data, PA and practices were sent brief surveys requesting information on PA/practice characteristics and PA primary care roles. Patient acceptability data were collected by the host practices. Participation at every stage was optional. Results By evaluation end, eight PAs had completed the internship. Seven PAs and six practices provided data at every time point. Five practices provided patient acceptability data. Overall PA interns were acceptable to practices and patients, however ambiguity about the PA role and how best to communicate and operationalise PA roles was revealed. An expectation-preparedness gap resulted in PAs needing high levels of supervision early within the internship. SPAI facilitated closure of the expectation-preparedness gap and its funding arrangements made the high supervision requirements more acceptable to practices. Conclusions The test-of-concept SPAI successfully integrated new PAs into primary care. However, the identified challenges risk undermining PAs roles in primary care before they have attained their full potential. Nationally, workforce leaders should develop approaches to support new PAs into primary care, including commitments to longer-term, sustainable, cohesive and appropriately funded schemes, including structured and standardised education and supervision.

An integrated primary care workforce planning toolkit at the regional level (part 1): qualitative tools compiled for decision-makers in Toronto, Canada

Background A regional health authority in Toronto, Canada, identified health workforce planning as an essential input to the implementation of their comprehensive Primary Care Strategy. The goal of this project was to develop an evidence-informed toolkit for integrated, multi-professional, needs-based primary care workforce planning for the region. This article presents the qualitative workforce planning processes included in the toolkit. Methods To inform the workforce planning process, we undertook a targeted review of the health workforce planning literature and an assessment of existing planning models. We assessed models based on their alignment with the core needs and key challenges of the health authority: multi-professional, population needs-based, accommodating short-term planning horizons and multiple planning scales, and addressing key challenges including population mobility and changing provider practice patterns. We also assessed the strength of evidence surrounding the models’ performance and acceptability. Results We developed a fit-for-purpose health workforce planning toolkit, integrating elements from existing models and embedding key features that address the region’s specific planning needs and objectives. The toolkit outlines qualitative workforce planning processes, including scenario generation tools that provide opportunities for patient and provider engagement. Tools include STEEPLED Analysis, SWOT Analysis, an adaptation of Porter’s Five Forces Framework, and Causal Loop Diagrams. These planning processes enable the selection of policy interventions that are robust to uncertainty and that are appropriate and acceptable at the regional level. Conclusions The qualitative inputs that inform health workforce planning processes are often overlooked, but they represent an essential part of an evidence-informed toolkit to support integrated, multi-professional, needs-based primary care workforce planning.

An integrated primary care workforce planning toolkit at the regional level (part 2): quantitative tools compiled for decision-makers in Toronto, Canada

Background Health workforce planning capability at a regional level is increasingly necessary to ensure that the healthcare needs of defined local populations can be met by the health workforce. In 2016, a regional health authority in Toronto, Canada, identified a need for more robust health workforce planning infrastructure and processes. The goal of this project was to develop an evidence-informed toolkit for integrated, multi-professional, needs-based primary care workforce planning for the region. This article presents the quantitative component of the workforce planning toolkit and describes the process followed to develop this tool. Methods We conducted an environmental scan to identify datasets addressing population health need and profession-specific health workforce supply that could contribute to quantitative health workforce modelling. We assessed these sources of data for comprehensiveness, quality, and availability. We also developed a quantitative health workforce planning model to assess the alignment of regional service requirements with the service capacity of the workforce. Results The quantitative model developed as part of the toolkit includes components relating to both population health need and health workforce supply. Different modules were developed to capture the information and address local issues impacting delivery and planning of primary care health services in Toronto. Conclusions A quantitative health workforce planning model is a necessary component of any health workforce planning toolkit. In combination with qualitative tools, it supports integrated, multi-professional, needs-based primary care workforce planning. This type of planning presents an opportunity to address inequities in access and outcome for regional populations.

Understanding the role of the paramedic in primary care: a realist review

Background Since 2002, paramedics have been working in primary care within the United Kingdom (UK), a transition also mirrored within Australia, Canada and the USA. Recent recommendations to improve UK NHS workforce capacities have led to a major push to increase the numbers of paramedics recruited into primary care. However, gaps exist in the evidence base regarding how and why these changes would work, for whom, in what context and to what extent. To understand the ways in which paramedics impact (or not) the primary care workforce, we conducted a realist review. Methods A realist approach aims to provide causal explanations through the generation and articulation of contexts, mechanisms and outcomes. Our search of electronic databases was supplemented with Google and citation checking to locate grey literature including news items and workforce reports. Included documents were from the UK, Australia, Canada and the Americas—countries within which the paramedic role within primary care is well established. Results Our searches resulted in 205 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) within a final programme theory. Our results outline that paramedics are more likely to be effective in contributing to primary care workforces when they are supported to expand their existing role through formal education and clinical supervision. We also found that unless paramedics were fully integrated into primary care services, they did not experience the socialisation needed to build trusting relationships with patients or physicians. Indeed, for patients to accept paramedics in primary care, their role and its implications for their care should be outlined by a trusted source. Conclusions Our realist review highlights the complexity surrounding the introduction of paramedics into primary care roles. As well as offering an insight into understanding the paramedic professional identity, we also discuss the range of expectations this professional group will face in the transition to primary care. These expectations come from patients, general practitioners (family physicians) and paramedics themselves. This review is the first to offer insight into understanding the impact paramedics may have on the international primary care workforce and shaping how they might be optimally deployed.

Matching 25% of Medical Students in Family Medicine by 2030: Realistic or Beyond Our Reach?

ABSTRACT: This article examines the America Needs More Family Doctors: 25x2030 Collaborative goal of “25x30”—that 25% of all medical students will enter family medicine residency programs by the year 2030. Filling 25% of all available postgraduate year-1 positions in the match is an important consideration in creating a strong primary care workforce. Data from the National Resident Matching Program (NRMP) matches for 2010 and 2020 are reviewed to examine trends not only in the US MD and DO categories, but also US international medical school graduates (IMGs) and non-US IMG categories over the last 10 years. If the total number of all programs and of all positions offered were held constant in 2030, what shifts in student choices would be required to reach the 25x30 goal in each applicant category as well as for all four categories combined? This discussion explores resources, power, physician income, and other factors that affect student numbers. Until a national health system is developed with national goals and priorities, it is unlikely that 25x30 will become a reality.