Medical education increasingly recognizes the need to prepare future physicians not only with biomedical expertise but also with the professional identities, skills, and reflexive capacities required to navigate uncertainty, complexity, and emotionally demanding clinical encounters. Drawing on scholarship on professional socialization and the emerging field of Graphic Medicine, this qualitative study explores how comics-enhanced education contributes to medical training. The paper reports findings from semi-structured, in-depth interviews with 14 North American medical and health professions educators who incorporate comics and graphic narratives into their teaching practices. Using a constructivist approach and template analysis, we examine educators' perspectives on the pedagogical value, limitations, and institutional challenges associated with comics-based teaching. Analysis revealed three interrelated themes describing the contribution of comics to medical education: Professional Identity formation, Professional Skills development, and Professional Implementation in clinical practice. Educators described how reading and creating comics supports students' reflection on their emerging professional identities, including emotional processing, ethical awareness, and coping with failure and uncertainty. Comics-based activities were also reported to enhance key professional skills such as empathy, communication (verbal and nonverbal), self-reflection, and awareness of bias and stigma. Finally, educators highlighted the potential of comics to improve professional practice by supporting patient-centered communication, health literacy, informed consent, and the destigmatization of illness.Despite challenges related to student resistance, institutional bias, and limited empirical evidence on outcomes, participants viewed comics as a valuable complement to traditional biomedical teaching. Overall, the study suggests that comics-enhanced education offers a creative and meaningful approach to fostering reflective, empathetic, and socially attuned medical professionals.

Canadian healthcare, particularly family medicine, is experiencing a capacity crisis. To address this challenge, systems-level reform is required. Specific to medical education, there is an urgency for educational institutions to prepare the next generation of physicians to meet Canadians’ healthcare needs. This will require not only the expansion of the number of physicians trained, but consideration of the specialty mix and types of practice those physicians are prepared to undertake. Building on an existing collaborative partnership, the Queen’s-Lakeridge Health Doctor of Medicine - Family Medicine Program (QLH MD FM) launched in 2023. This initiative is designed to address the needs of Canadians through purposeful recruitment and the development of learners interested in, and committed to, careers in family medicine. This paper shares the experiences of the QLH MD FM team, and the steps taken in conceptualizing and implementing this educational initiative. A program description is provided, focusing on the six program pillars: (a) admissions, (b) curriculum, (c) faculty and staff engagement, (d) community engagement, (e) infrastructure and supports, and (f) learner experience. The QLH MD FM Program is an innovative approach to medical education that emphasizes an authentic focus on addressing the complex healthcare needs of individuals and their communities.

This article explores the role of comics as a sustained pedagogical practice within medical education, presenting findings from a longitudinal qualitative study conducted at Penn State College of Medicine, United States. Over two pre-clinical years, a self-selected group of medical students-known as the Comics Cohort-were given comics-making assignments to integrate into their required Humanities curriculum. Through focus groups, individual interviews, and visual narrative analysis of students' drawings, the study investigated how engaging with comics over time shaped medical students' ways of seeing, learning, and becoming. We identified three main thematic domains: 1) students learn more deeply when they engage visually; 2) the personal reflection and vulnerability that arise from making comics can be challenging but are also tools for growth; and 3) making and sharing comics creates community and connection. Building on participants' accounts of repeated comics-based practices, this article conceptualizes drawing as a form of reflective engagement that shapes how students attend to clinical encounters. The act of drawing-repetitive, situated, and open-ended-functioned as a reflective tool through which students developed what we conceptualize as visual attunement: an ethically engaged perceptual stance that integrates attention to bodies, silences, emotions, and context. Rather than using art as an occasional creative supplement, this study found that drawing comics can serve as both a medium and method through which students cultivate professional identity, visual thinking, and critical reflection.

BackgroundHip and knee pain are leading contributors to disability, reduced quality of life, and health care burden in Canada. Primary care is often the first point of contact for patients with these conditions, yet timely and appropriate care is limited due to provider shortages and system pressures. Interest is growing in interprofessional primary care models that integrate physiotherapists to enhance care delivery for musculoskeletal conditions such as hip and knee pain. ObjectiveThis study aims to communicate the protocol and analysis plan for a trial with two objectives: (1) to evaluate the effectiveness of a physiotherapist-led primary care model for hip and knee pain on physical functioning (primary outcome), pain intensity, quality of life, global rating of change, patient satisfaction, and adverse events, compared to usual physician-led primary care; and (2) to assess the impact of this model on health care system and societal outcomes, including access to care, health care use, productivity loss, and cost-effectiveness. A process evaluation will examine implementation, potential mechanisms, and patient experiences. MethodsA cluster randomized controlled trial involving 14 primary care organizations randomized equally to either a physiotherapist-led or usual physician-led primary care model for patients with hip and knee pain. Patients were recruited over 1 year, with data collected at baseline and at 3, 6, 9, and 12 months. The intervention integrates a physiotherapist as the initial point of contact within the primary care team for patients seeking care for hip or knee pain. It includes four components: (1) comprehensive assessment and screening, (2) brief individualized interventions during the initial visit, (3) guidance for accessing additional health care resources, and (4) follow-up physiotherapy for patients with unmet needs. Effectiveness will be assessed using linear mixed regression, accounting for clusters and prespecified covariates. The multimethods process evaluation will include descriptive and comparative analysis of implementation, mediation analysis to explore potential mechanisms, and qualitative exploration of patient experiences. ResultsThis research was funded in December 2022. Primary care sites (clusters) were recruited and randomized in June and July 2023, respectively. Patient enrollment occurred from October 2023 through November 2024. The final patient follow-up survey was completed in November 2025. Extraction of data from electronic health records is expected to finish in December 2025. Data analysis will begin after data collection is complete and will follow the predefined protocol and analysis plan. No interim analyses are planned. ConclusionsFindings from this trial will provide actionable evidence on whether integrating physiotherapists into primary care teams for hip and knee pain improves patient outcomes and health care system efficiency. Effectiveness and process evaluation evidence will inform policymakers and health system leaders on the adoption and implementation of interprofessional, team-based primary care models. Trial RegistrationClinicalTrials.gov NCT06358521; https://clinicaltrials.gov/study/NCT06358521 International Registered Report Identifier (IRRID)DERR1-10.2196/89006

BACKGROUND:Heart failure (HF) is often diagnosed during acute decompensation. Earlier diagnosis in community settings may improve outcomes. We examined differences in patient characteristics, care models, and clinical outcomes by diagnosis setting. METHODS:We conducted a population-based cohort study of 597,025 Ontarians age ≥40 years with incident HF between 2010 and 2022. Patients were classified by diagnosis setting (community vs. acute care). We compared baseline characteristics, primary care models, and outcomes, including all-cause mortality and HF-related health care use. RESULTS:Of the cohort, 36.9% were diagnosed in acute care settings. This was more common among older adults (46.4% among patients age >85 years vs. 28% in those age 40-61 years, P < .0001), women (38.2% vs. 35.8% in men; P < .0001), individuals in the lowest income quintile (40.4% vs. 33.3% in the highest; P < .0001), and people without a primary care provider (57.2% vs. 36.1% for those with a PCP; P < .0001). After adjusting for age, sex, and comorbidities, acute care diagnosis was associated with increased risk of 1-year all-cause mortality (hazard ratio [HR] at 1 year, 1.81; 95%, CI 1.80-1.83), HF-related hospitalizations (rate ratio [RR], 2.78; 95% CI, 2.74-2.83), and emergency department visits (RR, 2.58; 95% CI, 2.51-2.65). CONCLUSION:More than one third of patients are diagnosed with HF in acute care with disproportionately higher rates among older adults, women, low-income individuals, and those without a PCP. Acute care diagnosis was also associated with higher mortality and greater HF-related acute care use, underscoring missed opportunities for earlier community diagnosis and treatment.

INTRODUCTION:Poverty can have profound negative impacts on parent, child and family health. Primary care providers are in a unique position to address child poverty. Some team-based models have integrated community support workers (CSWs) for social service system navigation assistance. The overall aim of this study is to rigorously test a poverty reduction intervention (navigation of financial supports) embedded in primary care. The primary objective is to compare parenting stress between CSW-supported, structured review of financial supports and social system navigation (intervention) and receipt of written summary of local resources (usual care). METHODS AND ANALYSIS:This is a multisite pragmatic superiority randomised controlled trial with a 1:1 allocation to the CSW-supported social system navigation versus no navigation. Parent-child dyads (80 parents of children aged <3 years endorsing 'Do you ever have difficulty making ends meet at the end of the month?') will be recruited during a scheduled health supervision visit from primary care practices in Kingston, Ontario. Intervention group participants will have a structured review of financial supports with a trained CSW and will meet up to 6 times over 6 months. Outcomes are measured at baseline, 6 months and 12 months after randomisation. The primary outcome is the Parenting Stress Index Fourth Edition Short Form (PSI-4-SF) total score at 6 months. Secondary outcomes include household income, food insecurity, parent mental health (depression and anxiety) and child health. An internal pilot study was used to obtain more reliable estimates of the SD of PSI-4-SF at 6 months to recalculate the sample size (if needed) and assess randomisation and completion rates. Qualitative interviews conducted 9 months after enrolment explore parent experiences with the CSW intervention. ETHICS AND DISSEMINATION:Research ethics approval by Queen's University Health Sciences REB. Results will be shared with the College of Family Physicians of Canada, the Ontario SPOR SUPPORT Unit and academic forums. TRIAL REGISTRATION NUMBER:Connecting Families (Registered 12 October 2021 at www. CLINICALTRIALS:gov; NCT05091957).

BackgroundLow back pain (LBP) is a common and disabling condition that is costly for health systems and society. Interprofessional primary care models may improve care quality and reduce this burden. ObjectiveThis protocol and analysis plan communicates the methods for a cluster randomized trial with the following objectives: (1) evaluate the effectiveness of a physiotherapist-led (PT-led) primary care model for LBP at improving disability (primary outcome), pain intensity, quality of life, global rating of change, patient satisfaction, and adverse events compared with usual physician-led primary care; and (2) determine the impact of the PT-led primary care model for LBP on the health care system and society (health care access, health care use, missed work, cost-effectiveness). Both objectives are evaluated over a 1-year period. A multimethod process evaluation is embedded to assess model implementation, mechanisms, perspectives of patients and providers, and contextual influences. MethodsThis study is a cluster randomized controlled trial with 20 primary care practices (clusters) in Canada, randomized 1:1 to a PT-led or usual physician-led primary care model for LBP. Adults seeking care from their primary care team for LBP are recruited over 1 year. Data collection occurs at baseline, 6 weeks, and 3, 6, 9, and 12 months. Effectiveness will be analyzed using linear mixed regression. The process evaluation analysis will include: descriptive and comparative analyses to assess implementation; descriptive and mediation analyses to assess potential mechanisms; qualitative interpretive description to understand experiences and perspectives of patients, PTs, and other health professionals; and mixed methods to determine contextual influences on implementation. ResultsRecruitment of primary care sites (clusters) was completed in June 2023, following delays related to the COVID-19 pandemic. Cluster randomization occurred in July 2023. Recruitment of patient participants began in October 2023 and concluded in November 2024 (n=739). The final self-reported patient data was collected on November 25, 2025. Extraction of electronic health record data is scheduled for completion on December 19, 2025. Data analysis will be conducted in accordance with the study protocol and analysis plan and will begin once all data collection activities are complete. No interim analyses have been performed. ConclusionsThe results of this trial will provide evidence for knowledge users to determine whether a PT-led primary care model for LBP is effective and should be adopted more widely. Knowledge users have identified the impact of the new model of care on disability, quality of life, and cost-effectiveness as key evidence needed to inform key decision-making. The multimethod process evaluation will provide critical evidence to interpret trial results and inform future scale and spread of this model of care if effective. Trial RegistrationClinicalTrials.gov NCT04287413; https://clinicaltrials.gov/study/NCT04287413 International Registered Report Identifier (IRRID)DERR1-10.2196/89004

BackgroundRoutine seeking of imaging for patients with low back pain is not concordant with the evidence-based recommendation that imaging is rarely of diagnostic value. Inappropriate imaging is a waste of resources and can lead to undesirable downstream effects for individuals and health systems. To develop effective strategies to reduce unwarranted referrals for imaging in primary care, we must understand the drivers for, and barriers to, guideline-adherent practice. We explored clinicians' views to identify the dominant influences on clinicians as they choose to pursue, or avoid, imaging for their patients with low back pain.MethodsWe interviewed a purposeful sample of 47 primary care clinicians (14 physiotherapists, 18 chiropractors, 15 physicians) throughout Ontario, Canada, with a guide based on the Theoretical Domains Framework (TDF). We investigated clinicians' views about their use of imaging in the management of low back pain. Interviews were recorded and transcribed verbatim. We analysed transcripts, then identified themes within TDF domains.ResultsMost clinicians reported that, for most clinical encounters, they adhered to guideline recommendations about imaging. Many clinicians across disciplines expressed the following themes: (1) imaging may result in an incidental finding or otherwise cause harm to patients, and drive up health system costs (TDF domain Beliefs about consequences); (2) clinicians were confident in their abilities to diagnose, to explain to patients the rationale for not recommending imaging, and to respond to their needs (domains Beliefs about capabilities; Skills). Many clinicians identified that patients occasionally want the validation that imaging provides (domain Social influences). Some clinicians described the value of imaging to corroborate a diagnosis (domain Beliefs about consequences).ConclusionsThis study is the first to examine influences on imaging behaviours of a large interprofessional sample of primary care clinicians in Canada. Even among knowledgeable, skilled, confident clinicians who reported mostly adhering to guideline recommendations, there are potential influences on deviating from guideline-adherent care.

To cite this article: Sathyaraj Venkatesan (2015): Graphic medicine manifesto, by M. K. Czerwiec, Ian Williams, Susan Merrill Squier, Michael J. Green, Kimberly R. Myers, and Scott T. Smith, Pennsylvania, Penn State University Press, 2015, 208 pp., US$29.95 (paperback), ISBN 978-0-271-06649-3 , Journal of Graphic Novels and Comics, DOI: 10.1080/21504857.2015.1108350 To link to this article: http://dx.doi.org/10.1080/21504857.2015.1108350

As healthcare systems are increasingly strained, policymakers in various jurisdictions have turned to pharmacies to offload services to treat minor ailments. These services were recently implemented in Ontario, Canada's largest province, with 7 of 19 eligible minor ailments being skin conditions. In this letter, we provide the first description of the initial uptake of this new service for skin conditions, describing its users and how they compare with the general population of Ontario. Our findings show high utilization, highlighting the growing role of pharmacy-based skin services. Users tend to already be strongly connected to the healthcare system, suggesting potential disparities in access. These insights offer valuable guidance for policymakers as they refine and expand such programmes.

Background: Variations in primary care practices may explain some differences in health outcomes during the COVID-19 pandemic. We sought to evaluate the characteristics of primary care practices by the proportion of patients unvaccinated against SARS-CoV-2.Methods: We conducted a population-based, cross-sectional cohort study using linked administrative data sets in Ontario, Canada. We calculated the percentage of patients unvaccinated against SARS-CoV-2 enrolled with each comprehensive-care family physician, ranked physicians according to the proportion of patients unvaccinated, and identified physicians in the top 10% (v. the other 90%). We compared characteristics of family physicians and their patients in these 2 groups using standardized differences.Results: We analyzed 9060 family physicians with 10 837 909 enrolled patients. Family physicians with the largest proportion (top 10%) of unvaccinated patients (n = 906) were more likely to be male, to have trained outside of Canada, to be older, and to work in an enhanced fee-for-service model than those in the remaining 90%. Vaccine coverage (>= 2 doses of SARS-CoV-2 vaccine) was 74% among patients of physicians with the largest proportion of unvaccinated patients, compared with 87% in the remaining patient population. Patients in the top 10% group tended to be younger and live in areas with higher levels of ethnic diversity and immigration and lower incomes.Interpretation: Primary care practices with the largest proportion of patients unvaccinated against SARS-CoV-2 served marginalized communities and were less likely to use team-based care models. These findings can guide resource planning and help tailor interventions to integrate public health priorities within primary care practices.

Background: Family members of intensive care unit (ICU) patients often report poor communication, feeling unprepared for ICU family meetings, and poor psychological outcomes after decision-making. The objective of this study was to create a tool to prepare families for ICU family meetings and assess feasibility of using Communication Quality Analysis (CQA) to measure communication quality of family meetings. Methods: This observational study was conducted at an academic tertiary care center in Hershey, PA from March 2019 to 2020. Phase 1a involved conceptual design. Phase 1b entailed acceptability testing of 2 versions of the tool (text-only, comic) with 9 family members of non-capacitated ICU patients; thematic analysis of semi-strucutred interviews was conducted. Phase 1c assessed feasibility of applying CQA to audio-recorded ICU family meetings (n = 17); 3 analysts used CQA to assess 6 domains of communication quality. Wilcoxon Signed Rank tests were used to interpret CQA scores. Results: Four themes emerged from Phase 1b interviews: participants 1) found the tool useful for meeting preparation and organizing thoughts, 2) appreciated emotional content, 3) preferred the comic form (67%), and 4) had indifferent or negative perceptions about specific elements. In Phase 1c, clinicians scored higher on the CQA content and engagement domains; family members scored higher on the emotion domain. CQA scores in the relationship and face domains had the lowest quality ratings. Conclusions: Let's Talk may help families become better prepared for ICU family meetings. CQA provides a feasible approach to assessing communication quality that identifies specific areas of strengths and weaknesses in communication.

Objectives Coordinated care plans (CCPs) for high-cost health care system users aim to improve system-level performance. We evaluated health care resource use and costs among CCP patients (enrollees) versus a control group that did not receive coordinated care (comparators) in Southeastern Ontario. Methods A difference-in-differences analysis of a quasi-experimental, double propensity score-matched and adjusted cohort was conducted. Linked population-based administrative data were used to measure health care utilization and costs and to identify comparators for two enrollee groups who began CCPs between April 1, 2013, and March 31, 2019. Enrollees were recruited from hospitals in Quinte or community care centres in Rural Hastings/Thousand Islands, and were 1:1 propensity score matched to comparators. Difference-in-differences estimates were calculated using generalized estimating equations for hospitalization rates, homecare visits, primary care visits, other health care resources and total costs. Results A total of 558 enrollees in Quinte and 538 in Rural Hastings/Thousand Islands were identified and matched to comparators. Difference-in-differences estimates were significant in both enrollee groups for number of homecare visits ([IRR 1.72; 95% CI (1.44, 2.06)] and [IRR 1.73; 95% CI (1.45, 2.06)], respectively). Number of primary care visits were 1.76 times greater for Rural Hastings/Thousand Islands enrollees versus comparators [IRR 1.76; 95% CI (1.32, 2.35)]; total costs increased by 23% ([IRR 1.23; 95% CI (1.09,1.39)]. Conclusions Homecare use significantly increased for enrollees versus comparators, indicating specific priority areas of Ontario CCPs were met. However, no reductions were shown for other health system performance indicators. We also showed increased 7-day primary care follow-up visits for community care centre-recruited patients, but not for hospital-recruited patients. Decision-makers may wish to target patients who are less advanced in their chronic disease trajectory.

BACKGROUND:Having a primary care provider is associated with better care experiences and lower care costs. In 2021, INSPIRE-PHC released Primary Care Data Reports - publicly available summaries of administrative billing data about how populations in each of Ontario's 60 health teams use primary care services. Given the characterization of Canadian primary care systems as 'in crisis', publicly available data about primary care at the regional level presented a significant opportunity for knowledge mobilization. An understandable resource could ground the public conversation about primary care access in data. Recognizing the role that lived experience plays in ensuring the public understands research findings, a partnership between patient advisors, Ontario Health Team representatives, researchers, and trainees was established to co-produce public-facing infographics based on primary care data. METHODS:Evidence-based guidelines for public health infographic creation and elements of transformative action research guided a six-meeting process to engage up to 14 patient advisors, three Ontario Health Team staff and two primary care trainees. Patient advisors were affiliated with a provincial patient-oriented primary health care research group or a Hamilton-based Ontario Health Team. Ninety-minute meetings were conducted virtually, and notes were shared with attendees to ensure they accurately reflected the conversation. Two consultations with Ontario Health Team-affiliated primary care providers provided direction and ensured project outputs aligned with local priorities. RESULTS:Project partners shared feedback on draft infographics, audience identification, priority elements from Primary Care Data Reports to include in the infographics, and aesthetic features (e.g., headings, colour scheme, charts). Project partners felt the most important metrics to convey to the public were those that simultaneously reinforced the benefits of primary care on individual health outcomes and health system costs. CONCLUSIONS:Patient engagement in research is becoming widespread, but co-developing knowledge products with patient and health system partners is less common. Our approach to engaging patients prevented both oversimplification and unnecessary complexity in a public-facing visual about attachment to primary care.

When patients lose decision-making capacity, others must make surrogate decisions on their behalf. What counts as a surrogate decision might seem self-evident. But as clinician-researchers in the field of advance care planning, we have found that it is not always so clear-cut. In this paper, we describe how and why this is a matter of concern, a novel approach for assessing whether a surrogate decision occurred, and findings from this assessment.