BACKGROUND AND OBJECTIVES:Place-based clinical education is vital for promoting the growth of the rural clinician workforce; where learners receive their education strongly influences where they practice. Yet students may struggle to find rural placements. In this study, we sought to understand trends in teaching by family physicians for varied health professions and the associated physician, practice, and community factors. METHODS:We analyzed data from 14,789 early career family physicians surveyed from 2016 to 2023. We compared the teaching status of rural and urban physicians overall and by year. We conducted trend analyses and multivariate regression to investigate the relationship between physician and practice characteristics, practice activities, community characteristics, and teaching status. RESULTS:More rural than urban physicians taught premedical students (30.8% vs 18.7%), medical students (62.2% vs 54.4%), and advanced practice professional students (51.2% vs 33.7%), while more urban than rural physicians taught residents (41.9% vs 37.8%) and fellows (8.7% vs 2.3%). Trend analyses showed an 8.4% increase in rural physicians teaching residents from 2016 to 2023, and a decline in teaching advanced practice professional students over the same time period. In adjusted analyses, family physicians who were younger, male, and White non-Hispanic were more likely to teach, as were osteopathic physicians, those with a broad scope of practice, and those who provided obstetric services. CONCLUSIONS:A larger share of rural than urban early career family physicians teach health professions students, but the rate who are teaching advanced practice professional students has declined significantly. Understanding and arresting the decline will be essential to addressing rural workforce capacity.

BackgroundOral anticoagulants (OACs) are critical for preventing stroke in patients with atrial fibrillation (AF), yet adherence and persistence remain suboptimal, especially in primary care settings. The COVID-19 pandemic introduced new barriers to care that may have further disrupted medication use. This study aimed to examine the impact of the COVID-19 pandemic on OAC adherence and persistence among patients with nonvalvular AF managed in primary care practices.MethodsIn this retrospective cohort study, we used clinical records from the American Board of Family Medicine's (ABFM) PRIME Registry, for March 2017 through March 2023. We included 3,010 patients with documented AF and at least two OAC prescriptions prior to baseline. Persistence was assessed annually using a treatment anniversary method, and adherence was measured using the proportion of days covered (PDC), analyzed among persistent patients only. Interrupted time series and multivariable logistic regression models evaluated changes in quarterly persistence and factors associated with persistence and good adherence.ResultsPersistence declined sharply during the pandemic from 49.9% in 2018-2019 to 8.2% in the pandemic year-1. Adherence also dropped, with >95% PDC decreasing from 46.0% pre-pandemic to 17.7% in the pandemic year-2. Interrupted time series analysis showed a significant immediate drop in persistence. Compared to warfarin, NOAC use was associated with lower persistence in the pre-pandemic period, but higher persistence by the second year of the pandemic.ConclusionsThe COVID-19 pandemic was associated with sustained declines in OAC adherence and persistence among AF patients in primary care. Targeted interventions including telemedicine, home-based care, and attention to high-risk subgroups are essential to maintain continuity of care and improve adherence during public health crises.

Given the recent expansion of US family medicine residency programs, we updated data on the link between training location and practice location and explored its relationship with primary care capacity. We found that most family physicians practice near their residency training programs, and many high-retention states have low primary care physician capacity.

OBJECTIVES:Family physicians (FPs) are well-positioned to integrate abortion into primary care. However, little is known about how FPs' abortion practices have been affected by the Dobbs v Jackson Women's Health Organization (Dobbs) Supreme Court decision. This study examines the percentage of FPs providing abortion, comparing across career stages, state restrictions, and before and after the Dobbs decision. METHODS:Data was collected from the American Board of Family Medicine National Graduate Survey (2016 to 2024) and the Practice Demographic Survey (2019 to 2024), representing early- and mid-to-late-career FPs, respectively. Respondents (n=60,077) were grouped by time of survey completion, before or after Dobbs. Bivariate analysis assessed associations between abortion provision and state restrictions, personal/practice characteristics, and reproductive health service provision. Regression analysis assessed changes in abortion provision after Dobbs. RESULTS:Of 31,553 respondents in the three years pre-Dobbs, 1.3% provided abortion, and of 28,544 respondents in the three years post-Dobbs, 1.4% provided abortion. Post-Dobbs in abortion legal states, early-career FPs increasingly provided abortion (2.8% to 6.3%) compared to mid-to-late-career FPs (1.3% to 1.8%), which was confirmed in adjusted analyses (adjusted OR= 2.12, 1.67-2.70). CONCLUSION:While the overall percentage of FPs providing abortion remained stably low pre- and post- Dobbs, a modest but notable increase was observed among early-career FPs in abortion legal states. This trend among early-career FPs in specific states suggests a developing opportunity to enhance access, necessitating increased training and resources for this group.

Background and Objectives: Despite highly effective therapies for the hepatitis C virus (HCV), treatment rates remain low. Management of HCV is shifting to primary care, and family physicians are positioned to provide this care. Our objective was to determine the extent of early-career family physicians' provision of HCV treatment. Methods: We merged 2016-2023 data from the American Board of Family Medicine National Graduate Survey, which is administered 3 years after completing residency, with state-level HCV mortality data from the Centers for Disease Control and Prevention (2017-2021). We conducted bivariate analyses to examine differences in HCV treatment by physician characteristics, practice type, and practice location. We created maps to visually explore HCV treatment and mortality by state. Results: Overall, less than 20% of early-career family physicians reported treating HCV patients. Early-career family physicians HCV treatment rates exceeded 25% in 2016 and 2017, with rates falling to below 15% from 2018 to 2020, before rebounding to 23% in 2023. Early-career family physicians who were males, had MDs (compared to DOs), were international medical graduates, and were in nonmetropolitan areas and in medically underserved area practice types had significantly higher HCV treatment rates. State-level variation was observed, with higher early-career HCV treatment rates in states with higher HCV mortality. Conclusions: While HCV treatment has been simplified over the past decade, HCV treatment by early-career family physicians has declined. Despite this decline, early-career family physicians have higher rates of HCV treatment in higher-need areas and in medically underserved practice settings. Supporting family physicians through education, clinical exposure, and incentives may increase provision of HCV care to address unmet needs.

This cross-sectional study explores the association between burnout and departure from the profession or move to a different practice among family physicians across the US.

BACKGROUND:The Person Centered Primary Care Measure (PCPCM) was developed to assess "aspects that contribute to patient perceptions regarding the integrating, prioritizing, and personalizing functions of primary care." Several psychometric issues remain unresolved. OBJECTIVES:We sought to examine the performance of the existing patient-level model, evaluate measurement bias, assess the impact of item-level missingness on reliability, examine the structural validity of creating a clinician-level score, and identify the number of patients needed to achieve a reliable clinician-level score. RESEARCH DESIGN:We used confirmatory factor analyses (CFA), item response theory, multilevel CFA, and retrospective survey data. PARTICIPANTS:Three thousand one hundred ten patients clustered within 32 clinics and 94 clinicians completed the PCPCM. RESULTS:CFA supported a single-factor patient-level model with 2 sets of correlated errors (RMSEA=0.06; CFI=0.98; TLI=0.98). Item response theory-based marginal reliability curves demonstrated that reliability drops precipitously if fewer than 6 items are answered. Multilevel CFA supported a single factor at the patient level and a single factor at the clinician level, with 2 sets of patient-level correlated errors (RMSEA=0.07; CFI=0.93; TLI=0.91). Scatter plots of clinician-level model-based and response-based scores showed nonlinearity and larger SEs when clinician scores were based on fewer than 5 patients. Reliability was >0.80 with 5 or more patients and 0.90 with 9 or more. CONCLUSIONS:Our study demonstrates the reliability and structural validity of creating a patient-level PCPCM score as the average of answers to at least 6 PCPCM questions and creating a clinician-level score as an average of the PCPCM scores from at least 5 patients within a clinician.

PURPOSE:Working on the electronic health record (EHR) after usual clinic hours (pajama time) is associated with burnout and decreased professional satisfaction in attending physicians. This study examines the association between resident pajama time and burnout, professional satisfaction, and medical knowledge among family medicine (FM) residents. METHOD:A cross-sectional survey of US FM residents was administered by the American Board of Family Medicine after the 2024 In-Training Examination in October 2024. The survey included questions about EHR use and satisfaction along with multiple other measures, including assessment of burnout with a 2-item screening measure and professional and training satisfaction. High pajama time was defined as an average of 3 hours or more per night on ambulatory EHRs. Bivariate analysis of outcomes by high EHR use and multiple logistic regressions were performed. RESULTS:The survey was administered to 9,731 FM residents who reported being postgraduate year 2 or above. Of the 9,653 residents who answered the EHR questions (response rate, 99.1%), 3,124 (32.3%) reported high pajama time. High pajama time was more common in older, female, underrepresented in medicine, and international medical graduate residents. After these characteristics were controlled for, high pajama time was associated with lower examination scores (odds ratio [OR], 1.28; 95% CI, 1.15-1.41), decreased odds of professional satisfaction (OR, 0.61; 95% CI, 0.55-0.68), training program satisfaction (OR, 0.62; 95% CI, 0.56-0.70), and higher odds of burnout (OR, 1.61; 95% CI, 1.46-1.78). CONCLUSIONS:Nearly one-third of upper-year US FM residents report spending 3 hours or more per day working after hours on ambulatory EHRs. This high pajama time is associated with lower medical knowledge, lower professional satisfaction, and higher burnout. Residency programs should implement strategies at the system and learner levels to reduce after-hours EHR use to prevent long-term negative effects on physician well-being and professional practices.

Background and Objectives: Despite being critical to maternity care access, family physicians attending births continue to decrease in number. We aimed to determine the level of obstetric training at family medicine residencies and to use this variable to quantify the impact of residency training on the maternity care workforce. Methods: We used data from the 2016 to 2023 American Board of Family Medicine National Graduate Survey and the 2018 Council of Academic Family Medicine Educational Research Alliance residency program director survey. Our exposure variable was created from a self-reported number of births attended in residency and tested using bivariate analyses with eight survey items that may indicate strong obstetric training. We then included residency obstetric training in a multilevel multiple logistic regression with attending births in practice as the outcome. Results: Sixty percent of residencies train all the family physicians who attend births. Of the 11,728 family physicians included, the higher the obstetric training exposure for their residency, the higher the rate of attending births in practice (35.8% for average 81 + births per resident across residency vs 22.6% average 61-80 births per resident vs 10.9% average 41-60 births per resident). After adjusting for multiple other variables, graduating from a residency with higher exposure was significantly associated with attending births in practice. Conclusions: Independent of other factors, residency obstetric training exposure has a significant impact on whether a family physician attends births in practice. Policies protecting and developing residencies with the highest exposure may improve access to safe maternity care.

Medical claims are widely used in workforce estimation and health services research but identifying primary care (PC) clinicians is challenging. Existing methods relying on specialty or activity-based metrics are imprecise and hard to duplicate. We seek to develop a simple, accurate decision tree classifier using claims data, trained on survey responses from family physicians (FPs). And to use this classifier to estimate the PC workforce in Virginia. We linked 2016–2023 Virginia All-Payer Claims Database (APCD) data with responses from American Board of Family Medicine surveys to infer whether FPs provided PC. Using claims-derived features, we trained a decision tree to classify clinicians providing PC. We developed an enhanced version of the tree, adding exclusion criteria, and applied both classifiers to the entire APCD, including other PC clinician types. Virginia clinicians. Estimated classifier accuracy by clinician type and workforce estimates with bootstrapping used to estimate 95

INTRODUCTION:The Family Medicine Certification Longitudinal Assessment (FMCLA) is an open book spaced alternative to the traditional 1-day Family Medicine Certification Examination (FMCE). We studied whether FMCLA improves test scores beyond predicted scores. METHODS:We used American Board of Family Medicine data from 2008 to 2023, with scores reported on a scale from 200 to 800. We built a predictive model of FMCE performance using linear regression with the 2008 exam cohort. We then applied that model to the 2009 to 2011 cohorts, who could opt for FMCLA beginning in 2019, controlling for choice of exam mode using an inverse probability weight for selecting FMCE. RESULTS:Our final sample sizes were 9699 for the FMCE predictive model and 12,851 for the FMCLA versus FMCE analysis. Physicians who opted for FMCLA were more likely to be younger, female, US medical graduates, and have lower prior FMCE scores. Adjusted analyses controlling for propensity to select FMCE revealed that FMCLA was associated with an increase of 39 points (95% CI 36.2-42.0) over predicted score with physicians on the high end scoring 100 more points than predicted, while physicians predicted to fail did worse. Modality of exam had no impact near the passing score. DISCUSSION:FMCLA was associated with gains in scores over a 1-day exam. This supports cognitive psychology principles such as spaced repetition and immediate feedback that can strengthen long-term knowledge retention. There was little impact of exam delivery method on scores near the passing score, which suggests that important functions of assessing knowledge can be retained in longitudinal assessment.

BACKGROUND AND OBJECTIVES:Associations between training length and clinical preparedness are unknown. We compared assessments of clinical preparedness for family medicine graduates from 3-year and 4-year training programs. METHODS:In this prospective case-control study, we compared responses from two surveys, which occurred 3 months after graduates started their first job. One survey was conducted by a supervising physician. The other was conducted by a clinic staff member who rated family medicine graduates from both 3-year and 4-year programs. RESULTS:Our study included 403 graduates of 3-year programs, 185 who trained in 4-year programs with 36 months of training (4YR-36) and 274 who trained in 4-year programs with 48 months of training (4YR-48). Physician assessor ratings were similar across study groups on 18 of 21 Entrustable Professional Activities. The 4YR-48 graduates were rated higher for "practicing independently" on providing a usual source of comprehensive, longitudinal medical care for people of all ages (86.5% vs 77.9%); managing prenatal (63.1% vs 41.2%); and labor, delivery, and postpartum care (41.4% vs 25.7%). For five care process areas, physician assessors were more likely to rate 4YR-48 graduates as having "no challenges" with speed/timing related health care visits (91.9%) compared to 3YR graduates (82.4%). We noted no differences according to study group for staff member assessors. CONCLUSIONS:We found several differences in clinical preparedness according to length of training in this pilot study. Comprehensive longitudinal care, including prenatal and maternity care, were rated higher among graduates of 4YR-48 programs.

INTRODUCTION:The COVID-19 pandemic has reduced the number of elective in-person visits to primary care practices. This study examined how the pandemic may have affected cervical cancer (CC) screening rates in primary care settings across the United States. METHODS:We conducted a retrospective cross-sectional study using data from the PRIME Registry of the American Board of Family Medicine from March 15, 2017, to March 14, 2022. We included 2,207,355 women aged 21 to 65 years who had visited a clinician (n = 1,052) from any of 472 primary care practices. We compared CC screening rates among eligible women during in-person visits over the 3 prepandemic years with those during the 2 years of the pandemic. RESULTS:Screening rates (per 100 eligible patients with in-person visits) decreased from 1.85 to 1.12 in the first quarter of the first year and remained lower throughout both years of the pandemic compared with prepandemic year, had not returned to prepandemic levels by the end of the second year. Hispanic or Latino (odds ratio [OR] = 1.96) and Black or African American (OR = 1.37) women were more likely to be screened, whereas those receiving care from male clinicians (OR = 0.34) were less likely to be screened. CONCLUSIONS:CC screening rates remained below prepandemic levels throughout the 2 years of the pandemic. Policy makers and health care professionals should strategize approaches to enhance CC screening rates, including the exploration of alternative methods, such as home-based CC screening. New screening approaches are needed to ensure preparedness for future health crises.

BACKGROUND AND OBJECTIVES:Associations between training length and scope of practice in family medicine are unknown. We compared scope of practice among family medicine graduates from 3YR and 4YR training programs. METHODS:We compared survey responses 1 year after graduates started their first job as an independently practicing physician according to their length of training. Comparisons were made across three groups: (1) 3-year program graduates with 36 months of training (3YR-36); (2) all 4-year program graduates with either 36 or 48 months of training (4YR-36/48); (3) 4-year program graduates with only 48 months of training (4YR-48). RESULTS:Our sample included 1,136 graduates. Of these 423 (37.2%) were in 3YR programs, 447 (39.4%) were in 4YR-36/48, and 266 (23.4%) were in 4YR-48 months. Participant demographics and practice characteristics were similar across groups. Graduates with 4 years of training were more likely to provide pediatric inpatient care than 3YR program graduates (4YR-48 [43.6%] vs 3YR [35.1%], P=.032); and more 4YR program graduates provide adult inpatient care (3YR [39.8%] vs 4YR-48 [52.5%], P=.002). Graduates of 4YR programs (both groups) were statistically more likely to include 13 of 24 procedures in practice compared to those from 3YR programs, including point-of-care ultrasound, vaginal delivery, joint injection/aspiration, circumcision, and vasectomy. Graduates of all participating programs reported performance that exceeded national means for 20 of 32 (62.5%) clinical practice areas and procedures. CONCLUSIONS:Graduates of 4YR programs reported obtaining a unique set of skills and undertaking a broader scope of practice postgraduation compared to graduates of 3YR programs.

INTRODUCTION:Geographic variation in physician scope of practice (SOP) has been documented but the causes remain unknown. We examined whether geographic variation in family physician (FP) SOP is explained by differences in the characteristics of the FPs, their practices, practice environment, or health care market. METHODS:We utilized 2 datasets from the American Board of Family Medicine (ABFM) from 2017 to 2022. The National Graduate Survey captures early career FPs while the Continuous Certification Questionnaire is administered to mid to late career FPs. We used a SOP score that ranges from 0 to 30 with a larger score reflecting a broader SOP. Bivariate analyses assessed for differences by Census division in clinician, practice, community, and health care market characteristics. A series of multilevel linear regression analyses tested if geographic differences in SOP were attenuated by the aforementioned characteristics. RESULTS:Our analytic included 9,378 early career FPs and 28,832 mid to late career FPs in the unadjusted regression model. We found significant differences in clinician characteristics by division and cohort. In unadjusted results, SOP score differed by division and career stage within division (range 11.49 to 14.95 for later career FPs and 15.22 to 17.51 for early career FPs). Adjusting for clinician, practice, community, and health care market characteristics did not attenuate divisional variation in SOP. DISCUSSION:Significant geographic variation in FP SOP was not explainable by adjustment for clinician, practice, community, and health care market characteristics. This suggests that health care variation is multifactorial and will require more multifaceted interventions to ameliorate.

PURPOSE:Understanding the different challenges rural and urban family physicians faced during the COVID-19 pandemic is essential for developing strategies to combat burnout. This study described the prevalence of burnout among rural and urban family physicians before and during the pandemic, examining physician and practice characteristics associated with burnout. METHODS:We conducted a repeated cross-sectional analysis of survey responses of 25,018 family physicians from the American Board of Family Medicine National Graduate Survey and Practice Demographic Survey from 3 time periods: pre-pandemic (January 2019-March 2020), early pandemic (April 2020-April 2021), and later pandemic (May 2021-June 2022). We used bivariate analyses and logistic regression to compare self-reported burnout in rural and urban family physicians over these time periods, controlling for physician and practice characteristics. RESULTS:Overall, 43.5% of family physicians included in this study met the criteria for burnout. The burnout rate was slightly higher for rural physicians (45.2%) compared to urban physicians (43.2%), but not statistically significant. In the adjusted analyses, there was no association of rurality and burnout (adjusted risk ratio [aRR] 1.04, 95% CI 1.00-1.09). Family physicians in the later stage of the pandemic were more likely to report burnout than in the pre-pandemic stage (aRR 1.06, 95% CI 1.02-1.10). CONCLUSIONS:We found burnout was a pervasive concern among family physicians over the stages of the pandemic, although we found no differences in burnout between rural and urban family physicians. Addressing family physician burnout is crucial to maintaining a resilient rural primary care workforce.

Background and Objectives: The proportion of family physicians caring for children is decreasing. At the same time, US family medicine residency training requirements have increased flexibility in how to train future family physicians in caring for this population. Our objective was to evaluate the correlation between residency program structures and curriculum with graduates caring for children. Methods: We conducted a prospective cohort study of family medicine graduates using the 2018 Council of Academic Family Medicine Education Research Alliance program director study to measure program characteristics and pediatric curricular elements, and the 2021 family medicine National Graduate Survey (NGS) of residents who graduated in 2018 to measure outcomes. We used logistic regression to determine associations between residency elements and graduate practice of outpatient pediatrics, inpatients pediatrics, or newborn hospital care. Results: After data from the two sources were merged, our final sample was 779 family medicine graduates (48% of the NGS sample), where 74.7% reported practicing outpatient pediatrics, 16.8% inpatient pediatrics, and 25.9% newborn care. In multivariate analyses, residency processes associated with the care of children in one or more settings included having more than 10% of continuity clinic patients under the age of 10 and having two or more family medicine faculty supervising inpatient pediatrics or newborn care. Conclusions: In a large national cohort study, we found that residency processes—especially faculty role modeling care of children and the inclusion of children in continuity clinic—are positively associated with residency graduates providing care for children. With residency training requirements changing, these results offer evidence-based interventions for programs to produce graduates who will care for children.