Future Primary Care Research Articles

Primary Care Strategies and Cooperation During the First Phase of the COVID-19 Pandemic in Baden-Wuerttemberg, Germany

Zusammenfassung Ziel der Studie Das Ziel der Arbeit war eine deskriptive frühzeitige Momentaufnahme von Einleitung und Umsetzung ambulanter Strategien im primärärztlichen Setting zur Bewältigung der frühen Phase der COVID-19- Pandemie in Baden-Württemberg (Deutschland). Methodik Im Juni 2020 erhielten alle 271 Corona-Anlaufstellen unter Trägerschaft der Kassenärztlichen Vereinigung (16 Abstrichstellen, 204 Corona-Schwerpunktpraxen, 51 Zentrale Fieberambulanzen) sowie eine zufällig generierte Stichprobe von 400 Hausarztpraxen aus Baden-Württemberg einen papierbasierten Fragebogen. Die Daten wurden anonym erhoben und deskriptiv ausgewertet. Ergebnisse Insgesamt nahmen n=63 (15,8%) Hausarztpraxen und n=92 (33,9%) Corona-Anlaufstellen teil. 78,7% der Hausarztpraxen nutzten Corona-Anlaufstellen (n=48). 92,1% hatten eine verpflichtende telefonische Anmeldung für PatientInnen mit (vermuteter) COVID-19-Erkrankung (n=58) implementiert. 81% boten bei leichtem Verlauf eine rein telefonische oder videokonsultatorische Versorgung an (n=51). Parallel dazu wurden die neuen ambulanten Corona-Anlaufstellen vorwiegend unter hausärztlicher Leitung (n=76, 82,6%) in Zusammenarbeit mit weiteren Akteuren, in fast der Hälfte der Fälle bereits im März aufgebaut (n=42, 48,3%). Die am häufigsten genannten Anmeldepfade waren gesteuert und konnten vorwiegend über HausärztInnen (n=88, 95,7%) und Gesundheitsamt (n=74, 80,4%), aber auch durch weitere Akteure erfolgen. In 92,4% (n=85) konnte eine telefonische Anmeldung erfolgen. Die mündliche Rückmeldung an die PatientInnen (n=65, 77,4%) war der am häufigsten genannte Rückmeldeweg. In weniger als der Hälfte der Corona-Anlaufstellen lagen standardisierte Anmelde-, Dokumentations- und Rückmeldebögen vor. Die Einschätzung der zukünftigen Versorgungsstrukturen von PatientInnen mit (vermuteter) COVID-19-Erkrankung waren heterogen. Schlussfolgerungen In einem gemeinsamen Kraftakt, mit Improvisation und Zusammenarbeit gelang eine rasche Implementierung von Maßnahmen zur Patientenversorgung während der Anfangsphase der Pandemie im primärärztlichen Setting. Aus den Ergebnissen können Impulse für die primärärztliche Versorgung in einer Pandemie abgeleitet werden.

General Practice in the Time of COVID-19: A Mixed-Methods Service Evaluation of a Primary Care COVID-19 Service

Primary care coronavirus disease 2019 (COVID-19) clinics were rapidly introduced across the UK to review potentially infectious patients. Evaluation of these services is needed to guide future implementation. This mixed-methods study evaluates patient demographics, clinical presentation, co-morbidities, service usage, and outcomes for the Islington COVID-19 service (London, UK) and from April to May 2020 and thematically analyses survey responses from 29 service clinicians and 41 GP referrers on their service experience. Of the 237 patients booked into the service, a significant number of referrals (n = 91; 38.6%) were made after the presumed infectious period of 14 days. Almost half of all adult referrals (49%) were dealt with remotely (via telephone/video consultation +/− remote oxygen saturation monitoring). The service was perceived to provide a safe way to see patients; it developed local expertise, learning, and empowerment; and it was a positive teamworking experience. These findings suggest that the management of many patients with COVID-19 symptoms is possible in routine general practice with minimal risk through the implementation of remote consultation methods and in patients who present after the post-infectious period. Additionally, the use of remote saturation monitoring and local GP COVID-19 “experts” can support practices to manage COVID-19 patients. Future primary care COVID-19 services should act as empowerment tools to assist GPs to safely manage their own patients and provide support for GPs in this process.

Augmented Consulting: the future of primary care?

Changes in clinical practice shaped by COVID-19 have included rapid and widespread adoption of digital technologies1 that, while enabling primary care physicians to continue to deliver health care remotely, have also created further barriers to the human connection so vital in medicine. Even before the pandemic, the physician’s use of the computer and electronic health record (EHR) had come to dominate the consultation in primary care.2 Notwithstanding the obvious utility of providing physicians with instant access to extensive patient information, and evidence-based guidelines, this uninvited third party in the consultation has disrupted the relationship between patient and doctor leading to poorer patient care3 and physician burnout.4 With global organisations now encouraging digital healthcare strategies,5 more technology is not only being invited into healthcare, but lauded as central to its delivery. Given the prominence of the computer within the consultation, it is entirely possible that more technology may drive a wedge further between the patient and doctor. Despite primary care rapidly embracing technology such as digitally delivered prescriptions, ‘fit notes’, and video consultations, recent patient-centred research articulates the experience through the patient’s eyes, balancing this enthusiasm.6 We are at an inflection point in healthcare’s digital transformation and it is vital that we drive the discussion around when and where technology is helping or hindering us in serving our patients. As purveyors of change, primary care physicians must take a lead in defining how digital technologies are used within the consultation. We recognise that the pace of technological change has been painfully slow and often disappointing, and many primary care physicians may oscillate between anxiety and …

Suitability of Video Consultations During the COVID-19 Pandemic Lockdown: Cross-sectional Survey Among Norwegian General Practitioners.

BackgroundThe COVID-19 pandemic imposed an acute, sharp rise in the use of video consultations (VCs) by general practitioners (GPs) in Norway.ObjectiveThis study aims to document GPs’ experiences with the large-scale uptake of VCs in the natural experiment context of the pandemic.MethodsA nationwide, cross-sectional online survey was conducted among Norwegian GPs during the pandemic lockdown (April 14-May 3, 2020). Each respondent was asked to evaluate up to 10 VCs. Basic demographic characteristics of the GPs and their practices were collected. The associations between GPs’ perceived suitability of the VCs, the nature of the patients’ main problems, prior knowledge of the patients (relational continuity), and follow-up of previously presented problems (episodic continuity) were explored using descriptive statistics, diagrams, and chi-square tests.ResultsIn total, 1237 GPs (26% of the target group) responded to the survey. Among these, 1000 GPs offered VCs, and 855 GPs evaluated a total of 3484 VCs. Most GPs who offered VCs (1000/1237; 81%) had no experience with VCs before the pandemic. Overall, 51% (1766/3476) of the evaluated VCs were considered to have similar or even better suitability to assess the main reason for contact, compared to face-to-face consultations. In the presence of relational continuity, VCs were considered equal to or better than face-to-face consultations in 57% (1011/1785) of cases, as opposed to 32% (87/274) when the patient was unknown. The suitability rate for follow-up consultations (episodic continuity) was 61% (1165/1919), compared to 35% (544/1556) for new patient problems. Suitability varied considerably across clinical contact reasons. VCs were found most suitable for anxiety and life stress, depression, and administrative purposes, as well as for longstanding or complex problems that normally require multiple follow-up consultations. The GPs estimate that they will conduct about 20% of their consultations by video in a future, nonpandemic setting.ConclusionsOur study of VCs performed in general practice during the pandemic lockdown indicates a clear future role for VCs in nonpandemic settings. The strong and consistent association between continuity of care and GPs’ perceptions of the suitability of VCs is a new and important finding with considerable relevance for future primary health care planning.

A scoping review of research on Canadian team-based primary care pharmacists

An ageing population with an increasing prevalence of chronic disease and complex medication regimens has placed a strain on healthcare systems in Canada. A limited number of team-based primary care pharmacists are integrated into primary care clinics across the country, working alongside other members of the health care team to identify and resolve drug therapy problems and improve outcomes. While many studies have been completed in the area, the extent of research on integrated team-based primary care pharmacists in Canada is unknown. The objectives of this work were to describe the literature that exists surrounding pharmacists in a primary health care team setting in Canada. A scoping review of research focusing on pharmacists in team-based primary health care settings in Canada was performed. Thematic analysis was then performed to categorize the identified studies. The search identified 874 articles, of which 93 met inclusion criteria relevant to the objective. From these 93 studies, 4 themes and 23 subthemes were identified, with some studies having more than one theme or subtheme. Themes identified were the following: primary care pharmacist scope of practice (n = 79 studies), collaboration/communication within the primary care setting (n = 26), chronic disease management (n = 24) and 'other' (n = 15). This research quantified and categorized 93 studies on pharmacists in interprofessional primary care teams in Canada. As this is an expanding role for pharmacists in Canada, understanding the current state of the literature is an important consideration when developing future team-based primary care roles.

The impact of COVID-19 on primary care: Insights from the National Health Service (NHS) and future recommendations.

COVID-19 has changed health systems and services. In this commentary, we outline the impact COVID-19 has had on the delivery of primary health care, and on primary care teams, and describe the NHS response. We highlight the challenges of managing long-COVID and identify areas of importance for primary care in a post-COVID context. We describe ongoing public health measures and list recommendations for primary care for COVID-19 and future unknown pandemics. We conclude with salient points on the future of primary care.

Digital health in primary care: risks and recommendations.

Growing demand for access to NHS primary care means services are under increasing pressure. Many GP providers are using digital technologies (video/email/other online consultations) to try to improve access and efficiency. Alongside this is rapid growth in health technologies, which collect, measure, or interpret health data, and provide health information or advice. Many technologies have positive potential; however, the speed with which they are becoming available, increasingly blurred boundaries between health and lifestyle technologies and traditional healthcare provision, and the confidence and skills GPs have in using digital health technologies, bring new complexities and concerns. Successful adoption of innovative technologies in primary care requires effective preparation of future and current primary care workforce, enabling appropriate use by healthcare professionals, patients, and communities. Although some training programmes do exist, these are not routinely integrated within primary care training. There is a distinct gap in both training and capacity building in this area, and the evidence base to inform development and content of training is limited. In this article we explore risks and challenges of digital technologies in primary care and relate these to training needs for GPs, trainees, and medical students. In this analysis we draw on literature as well as first-hand experience of practising GPs. In June 2019 we conducted two workshops on digital health with approximately 30 GP teachers who supervise medical students’ placements, which informed our understanding of four key areas of digital health risks and challenges in general practice. Based on risks and challenges identified, we present recommendations for training to support the implementation of digital primary care. ### Consultation skills Telephone consultations (TCs) were initially introduced to meet increased patient demand to speak to a doctor. As early as 1978 TCs were described as being as much a part of a doctor’s equipment as a stethoscope, and …

Abstract 15232: Lifetime Risk of Nontraumatic Lower-extremity Amputation: The Atherosclerosis Risk in Communities Study

Introduction: Nontraumatic lower-extremity amputation is a serious clinical outcome. Major risk factors include peripheral artery disease and diabetic neuropathy. Although incidence rates of amputation have been reported, no lifetime risk estimates are available. Hypothesis: The lifetime risk of amputation is higher in men, blacks, and those of low socioeconomic status (SES). Methods: In 15,744 ARIC participants aged 45-64 at baseline (1987-89), we estimated the lifetime risk of amputation through age 80 by race-sex and race-SES using Fine and Gray’s proportional subhazards model accounting for the competing risk of death. This method is optimal for time-fixed exposures and thus our primary exposures are sex and race. SES included education, annual family income, and the Area Deprivation Index linked to census tract geocoding. Non-traumatic amputation was identified from hospitalization ICD codes (e.g., 84.1, Z89.4) and related operation codes. Results: There were 253 non-traumatic amputations during a median follow up of 29 years. Lifetime risk of amputation at age 80 was highest in black men (4.6%), followed by black women (2.8%), white men (1.1%) and white women (0.7%) ( Figure ). Blacks of low SES showed the highest lifetime risk (4.5%). Blacks with high SES had a higher lifetime risk of amputation than whites with low SES. The pattern was consistent when we investigated each of education (≤ vs. > high school), income (< vs. ≥$25,000) and Area Deprivation Index (< vs. ≥ race-specific median), separately. Conclusions: In this population-based cohort 5% of black men and 3% of black women experienced a non-traumatic amputation during their lifetime, while only 1% of white men and women had a hospitalization for amputation. The lifetime risk was higher among those with lower SES in both race groups. Future public health and primary care efforts should emphasize risk factor management (e.g., diabetes and smoking) among racial minority groups and those with low SES.

Primary Palliative Care for Patients with Advanced Hematologic Malignancies: A Pilot Trial of the SHARE Intervention.

Objective: Develop and pilot-test a nurse-led primary palliative care intervention for patients with advanced hematologic malignancies. Background: Nurse-led primary palliative care interventions may improve outpatient palliative care provision for patients with advanced hematologic malignancies. Methods: This two-phase, single-arm pilot study involved patients with recurrent or resistant hematologic malignancies, their caregivers, and oncology clinicians at two US-based urban, university-affiliated oncology clinics. Measurements included feasibility (enrollment rates, intervention fidelity, and outcome assessment rates) and acceptability (patient, caregiver, and clinician surveys). Results: In Phase 1 we developed and implemented an oncology nurse-led primary palliative care intervention for patients with recurrent or resistant hematologic malignancies and their caregivers. In Phase 2, we tested feasibility and acceptability. Twenty-six patient participants enrolled. Consent-to-approach rate was 78% and enrolled-to-consent rate was 84%. All enrolled participants received the intervention per protocol. Sixty-nine percent of patients and 100% of caregivers reported that the intervention helped them better understand the patient's illness and cope. Seventy-five percent of oncologists reported that the intervention improved their patients' quality of care, and 25% reported that it helped them take better care of patients. Conclusions: Although our pilot of oncology nurse-led primary palliative care for patients with advanced hematologic malignancies met some of its secondary feasibility endpoints, it did not meet its primary feasibility endpoint (enrollment) and acceptability was mixed. Protecting nursing staff time, increasing patient and clinician involvement in intervention development, and identifying patients with highest supportive needs may improve feasibility and acceptability of future primary palliative care in hematologic malignancy trials.

Setting Core Competencies of Health Workers Towards Quality Primary Care: Proceedings of a National Consultative Workshop

The National Academy of Science and Technology (NAST), in cooperation with the Philippine Primary Care Studies (PPCS), organized the Stakeholders’ Meeting on Training Objectives for Primary Care in the Philippines on February 1, 2018, at Hotel Jen, Pasay City. The stakeholder’s meeting arrived at a consensus on the objectives of primary care workshops, training the existing cadre of doctors, nurses, midwives, and BHWs in the country. Competencies built upon these training objectives will strengthen the capacity of health care workers to render patient-centered primary care services. The expected output was not intended to replace the objectives of existing professional training curricula. Instead, the consensus obtained through this meeting works to establish the framework from which future primary care training workshops can be built upon.

Private Video Consultation Services and the Future of Primary Care.

In many countries, private companies provide primary care services based predominantly on offering video consultations via smartphones. One example is Babylon GP at Hand (BGPaH), which offers video consultations to National Health Service patients, 24 hours a day, and has grown rapidly in London over the last 3 years. The development of this type of service has been controversial, particularly in the United Kingdom, but there has been little formal published evaluation of these services in any country. This paper outlines the main controversies about the use of privately provided video consultation services for primary care and shows how they are informed by the limited evaluations that have been conducted, particularly the evaluation of BGPaH. This paper describes the advantages of these services in terms of convenience, speed of access, the ability to consult without traveling or face-to-face patient-doctor contact, and the possibility of recruiting doctors who cannot work in conventional settings or do not live near the patients. It also highlights the concerns and uncertainties about quality and safety, demand, fragmentation of care, impact on other health services, efficiency, and equity. There are questions about whether private primary care services based on video consultations have a sustainable business model and whether they will undermine other health care providers. During the recent COVID-19 pandemic, the use of video consulting has become more widespread within conventional primary care services, and this is likely to have lasting consequences for the future delivery of primary care. It is important to understand the extent to which lessons from the evaluation of BGPaH and other private services based on a video-first model are relevant to the use of video consulting within conventional general practices, and to consider the advantages and disadvantages of these developments, before video consultation–based services in primary care become more widely established.

102 - Dementia and primary care – lessons from Europe: Symposium

Primary care doctors /General Practitioners are sometimes criticised for failing to recognise dementia in its early stages. Old age psychiatrists, neurologists or geriatricians take on the tasks of recognition, diagnosis (subtyping) and post-diagnostic support, and some Primary care doctors /General Practitioners welcome this division of labour as a way of avoiding the demanding tasks of dementia recognition and response. However, the rising prevalence of dementia syndromes in an ageing population is undermining the ability of secondary care specialists to fulfil their tasks of timely recognition, diagnosis and support. Primary care doctors /General Practitioners will be encouraged to take over some secondary care tasks. This will pose problems for Primary care doctors /General Practitioners, who may not have been trained to work with people with dementia, and who may not be able to incorporate such work into their practice even when trained. This symposium will explore the current and future challenges Primary care doctors /General Practitioners face in recognising and responding to dementia, and outline some lessons from four European countries (Ireland, Spain, Portugal and England). Themes to be presented include: Barriers to the recognition of dementia,The dementia-specific educational needs of Primary care doctors/General Practitioners,Interprofessional education of community-based primary care teams,Case management of people with dementia in primary care,IT solutions to problems of support for people with dementia.Effective dementia-care interventions in primary care post-diagnostic care pathways,Systemically-inspired brief interventions in primary care.Chair: Emeritus Professor Steve Iliffe, Centre for Ageing Population Studies, University College London [England]; co-chair: Professor Manuel Gonçalves-Pereira, Professor of Behavioural Medicine and Psychiatry, Nova Medical School, Universidade Nova de Lisboa [Portugal]Speakers:Dr Tony Foley, Lecturer Department of General Practice, University College Cork [Ireland]Professor Manuel A. Franco, Head of Psychiatry and Mental Health Department. University Rio Hortega Hospital (Valladolid) [Spain]Dr Conceição Balsinha, General Practitioner & Assistant professor/PhD student, Nova Medical School, Universidade Nova de Lisboa & Professor Manuel Gonçalves-Pereira, Nova Medical School, Universidade Nova de Lisboa [Portugal]Emeritus Professor Steve Iliffe, Centre for Ageing Population studies, University College London [England]

Will mild atypical pneumonia remain underdiagnosed and undertreated in primary care setting?

Abstract Background Non severe community acquired pneumonia (CAP) is a common problem in primary care. So called “walking” CAP is frequently caused by atypical intracellular pathogens Chlamydia pneumoniae and Mycoplasma pneumonia which are resistant to beta-lactams and can be transmitted from an infected person to a healthy one. Taking into account medical and epidemiologic importance of this problem we aimed to estimate appropriateness of the antimicrobial agent (AM) choice for outpatient treatment of mild CAP by current and future primary care providers with regard to atypical pathogens coverage. Methods Total 240 final year medical students of A.I.Yevdokimov Moscow State University of Medicine and Dentistry (Group 1) and 206 Moscow primary care physicians (Group 2) were surveyed in 2019. Respondents were asked to specify in writing what particular AM they would recommend to 35 year old previously healthy male patient with subfebrile body temperature (37.3 °C), non-productive cough and documented CAP. Chi-square test was used to compare the data obtained in both groups. Results Group 1 respondents returned questionnaires with 271 recommendations, Group 2 participants named 230 items. AMs with atypical pathogens coverage (macrolides, fluoroquinolones and doxycycline) accounted for just 33.2% in Group 1 versus 20.0% in Group 2 (p=.0009). Amoxicillin/clavulanate was the leading choice equally popular both in students and physicians (42.1% and 40.9% respectively). The rest of recommendations in both Groups included amoxicillin and various cephalosporins. Conclusions Only one of three students and one of five physicians made the right choice in offered clinical scenario. A majority of respondents in both groups hastily recommended beta-lactams instead of clinical estimation of atypical CAP probability in given situation, but students indicated appropriate AMs more often. This problem obviously persists and requires action from both academics and healthcare managers. Key messages Medical students and primary care physicians’ awareness of atypical CAP presentation and treatment is not quite satisfactory. Resulting undertreatment of atypical CAP may harm the patient and promote further spread of causative pathogen within the community.

Envisioning an artificial intelligence documentation assistant for future primary care consultations: A co-design study with general practitioners.

ObjectiveThe study sought to understand the potential roles of a future artificial intelligence (AI) documentation assistant in primary care consultations and to identify implications for doctors, patients, healthcare system, and technology design from the perspective of general practitioners.Materials and MethodsCo-design workshops with general practitioners were conducted. The workshops focused on (1) understanding the current consultation context and identifying existing problems, (2) ideating future solutions to these problems, and (3) discussing future roles for AI in primary care. The workshop activities included affinity diagramming, brainwriting, and video prototyping methods. The workshops were audio-recorded and transcribed verbatim. Inductive thematic analysis of the transcripts of conversations was performed.ResultsTwo researchers facilitated 3 co-design workshops with 16 general practitioners. Three main themes emerged: professional autonomy, human-AI collaboration, and new models of care. Major implications identified within these themes included (1) concerns with medico-legal aspects arising from constant recording and accessibility of full consultation records, (2) future consultations taking place out of the exam rooms in a distributed system involving empowered patients, (3) human conversation and empathy remaining the core tasks of doctors in any future AI-enabled consultations, and (4) questioning the current focus of AI initiatives on improved efficiency as opposed to patient care.ConclusionsAI documentation assistants will likely to be integral to the future primary care consultations. However, these technologies will still need to be supervised by a human until strong evidence for reliable autonomous performance is available. Therefore, different human-AI collaboration models will need to be designed and evaluated to ensure patient safety, quality of care, doctor safety, and doctor autonomy.

Designed to Fail? the Future of Primary Care.

Primary care is widely viewed as being in crisis despite its purported central role in addressing population issues related to healthcare cost, quality, access, and equity. Despite this pivotal role, the nature of the clinical practice today has largely emerged by default. We review the evolution of clinical practice in primary care from its genesis in small practices with paper charts and telephonic patient communication to managed care, pay-for-performance, and today’s era of the electronic medical record, value-based payment, and consumerism. We suggest a necessary “reset” of expectations that focuses on today’s practice structure and the historic face-to-face patient care expectations. Only by doing so can we successfully meet the demands of patients, society, and practicing internists.

Facilitators and barriers to utilization of medications for opioid use disorder in primary care in South Carolina.

Utilization of medications for opioid use disorder (MOUD) has not been widely adopted by primary care providers. This study sought to identify interprofessional barriers and facilitators for use of MOUD (specifically naltrexone and buprenorphine) among current and future primary care providers in a southeastern academic center in South Carolina. Faculty, residents, and students within family medicine, internal medicine, and a physician assistant program participated in focus group interviews, and completed a brief survey. Survey data were analyzed quantitatively, and focus group transcripts were analyzed using a deductive qualitative content analysis, based upon the theory of planned behavior. Seven groups (N = 46) completed focus group interviews and surveys. Survey results indicated that general attitudes towards MOUD were positive and did not differ significantly among groups. Subjective norms around prescribing and controllability (i.e., beliefs about whether prescribing was up to them) differed between specialties and between level of training groups. Focus group themes highlighted attitudes about MOUD (e.g., "opens the flood gates" to patients with addiction) and perceived facilitators and barriers of using MOUD in primary care settings. Participants felt that although MOUD in primary care would improve access and reduce stigma for patients, prescribing requires improved provider education and an integrated system of care. The results of this study provide an argument for tailoring education to specifically address the barriers primary care prescribers perceive. Results promote the utilization of active, hands-on learning approaches, to ultimately promote uptake of MOUD prescribing in the primary care setting in South Carolina.

Optimizing childhood oncology care transition from pediatric to adult settings: A survey of primary care physicians' and residents' perspectives.

The majority of childhood cancer survivors suffer from late adverse effects after the completion of treatment. The prospect of most survivors reaching middle-age is a relatively new phenomenon, and the ways by which current and future primary care physicians (PCPs) will address this novel public health challenge are uncertain. A survey assessing knowledge level and information delivery preferences regarding long-term follow-up guidelines for adult patients having survived a childhood cancer was distributed by e-mail through the Quebec (Canada) national associations of PCPs and residents (n=238). Participants reported an estimated average of 2.9 ± 1.9 cancer survivors in their yearly caseload, and only 35.3% recalled having provided services to at least one survivor in the last year. Most participants indicated ignoring validated follow-up guidelines for these patients (average score 1.66 on a Likert scale from "1-totally disagreeing" to "5-totally agreeing"). Scarce access to personalized follow-up guidelines and lack of clinical exposure to cancer survivors were identified as main obstacles in providing optimal care to these patients (respective averages of 1.66 and 1.84 on a Likert scale from "1- is a major obstacle" to "5-is not an obstacle at all"). The PCPs and residents rarely provide care for childhood cancer adult survivors. On an individual basis, there is a clear need for increased awareness, education and collaboration regarding long-term care of childhood cancer adult survivors during medical training. On a more global basis, structural, organizational and cultural changes are also needed to ensure adequate care transition.

Trust me - I'm a millennial GP.

Little has changed in much of general practice for the last 20 years, despite the evolution of PCTs, CCGs, STPs, and PCNs. COVID-19 has shown us innovation can happen quickly with the money and shared agenda to drive it. It’s proved we can be flexible and successfully collaborate across localities. As a 20-something millennial GP trainee, the sudden talk about the future of primary care is exciting. I once heard a futurologist say, ‘Don’t ask “what will it look like down line?” ask “what do you want it to look like?”’ I may not yet be in a position to orchestrate significant service redesign, but I can tell you what I would like my work place and career to look like. It may come as a surprise, but I’m not entirely against partnership responsibility. I like leading projects, discussing improvements to patient care, and understanding financial management …

Conditions Influencing Collaboration Among the Primary Care Disciplines as They Prepare the Future Primary Care Physician Workforce.

Much can be gained by the three primary care disciplines collaborating on efforts to transform residency training toward interprofessional collaborative practice. We describe findings from a study designed to align primary care disciplines toward implementing interprofessional education. In this mixed methods study, we included faculty, residents and other interprofessional learners in family medicine, internal medicine, and pediatrics from nine institutions across the United States. We administered a web-based survey in April/May of 2018 and used qualitative analyses of field notes to study resident exposure to team-based care during training, estimates of career choice in programs that are innovating, and supportive and challenging conditions that influence collaboration among the three disciplines. Complete data capture was attained for 96.3% of participants. Among family medicine resident graduates, an estimated 87.1% chose to go into primary care compared to 12.4% of internal medicine, and 36.5% of pediatric resident graduates. Qualitative themes found to positively influence cross-disciplinary collaboration included relationship development, communication of shared goals, alignment with health system/other institutional initiatives, and professional identity as primary care physicians. Challenges included expressed concerns by participants that by working together, the disciplines would experience a loss of identity and would be indistinguishable from one another. Another qualitative finding was that overwhelming stressors plague primary care training programs in the current health care climate-a great concern. These include competing demands, disruptive transitions, and lack of resources. Uniting the primary care disciplines toward educational and clinical transformation toward interprofessional collaborative practice is challenging to accomplish.

The Use of Behavior Change Theories in Dietetics Practice in Primary Health Care: A Systematic Review of Randomized Controlled Trials

BackgroundBehavior change theories frameworks provide the theoretical underpinning for effective health care. The extent to which they are applied in contemporary dietetics interventions has not been explored. ObjectiveTo systematically review the evidence of behavior change theory-based interventions delivered by credentialed nutrition and dietetics practitioners in primary health care settings. MethodsMedline, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Embase, and Cochrane databases were searched for English language, randomized controlled trials before August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. Eligible interventions included adults (aged ≥18 years) receiving face-to-face dietetics care underpinned by behavior change theories in primary health care settings with outcome measures targeting changes in health behaviors or health outcomes. Screening was conducted independently in duplicate and data were extracted using predefined categories. The quality of each study was assessed using the Cochrane Risk of Bias tool. The body of evidence was assessed using the Academy of Nutrition and Dietetics Evidence Analysis Manual Conclusion Grading Table. ResultsThirty articles reporting on 19 randomized controlled trials met the eligibility criteria, representing 5,172 adults. Thirteen studies (68%) showed significant improvements for the primary outcome measured. Social cognitive theory was the behavior change theory most commonly applied in interventions (n=15) with 11 finding significant intervention effects. Goal setting, problem solving, social support, and self-monitoring were the most commonly reported techniques (n=15, n=14, n=11, and n=11, respectively). Most studies had a high (n=11) or unclear (n=8) risk of bias. There was fair evidence (Grade II) supporting the use of behavior change theories to inform development of dietetics interventions. ConclusionsInterventions delivered by credentialed nutrition and dietetics practitioners that were underpinned by behavior change theories and utilizing various behavior change techniques were found to have potential to be more effective at improving patient health outcomes than dietary interventions without theoretical underpinnings. Findings from this review should inform future primary health care research in the area of dietary behavior change. In addition, findings from this review highlight the need for stronger documentation of use of behavior change theory and techniques that map on to the theory within dietetics practice.