Improving Health Through Family Medicine: New Opportunities, Missed Opportunities
=================================================================================

* Jacqueline Britz
* Marjorie A. Bowman
* Dean A. Seehusen
* Christy J. W. Ledford

## Abstract

This issue addresses evidence-based medicine, strengthening supports and resources for primary care, and clinical questions across the broad scope of primary care. Several articles address implementing evidence-based recommendations in primary care. How can you safely delabel low risk penicillin allergies in primary care? Which colorectal stool-DNA-FIT tests were preferred by patients and least difficult to use? Another group of articles address strengthening support and resources for clinicians, including the impact of a group-coaching intervention for burnout and a peer coaching approach to improve use of clinical performance data. Several articles address sexual and reproductive health. Does doxycycline postexposure prophylaxis (PEP) prevent bacterial sexual transmitted infections? What are the best methods to reduce pain and/or anxiety during IUD procedures? Is Mirena still effective at 8 years? Several articles address the care of transgender and gender-diverse patients, including the impact of testosterone on Papanicolaou test results. A variety of other articles provide recommendations related to common clinical concerns in primary care, including a novel, simplified approach to diagnosing and managing causes of shoulder pain.

## Implementing Evidence Based Recommendations in Practice

There are many barriers to implementing evidence based guidelines and recommendations into primary care practice. Several of the articles in this issue address practical solutions and insights to help primary care clinicians implement.

While nearly 10% of the US population report a penicillin allergy, many of these patients do not have a true IgE-mediated allergy. A growing body of literature has called for penicillin allergy delabeling.1 Madapoosi et al.2 describe a direct oral challenge (DOC) protocol, developed at 2 primary care sites, that validate patient allergies.

Colorectal cancer screening is evidence based and can save lives. One recommended screening option is stool DNA-FIT every 1 to 3 years. However, which tests do patients prefer and which are associated with fewer errors? Daly et al.3 compared liquid vial and card collection devices for more than 2000 patients, including variation in preferred method, difficulty, and errors.

The US Preventive Services Task Force recommends routine screening and brief counseling for unhealthy alcohol use in all adults aged 18 years and older.4 Jortberg et al.5 aimed to improve screening, brief intervention, medication-assisted treatment, and referral for treatment in primary care practices through a virtual practice facilitation intervention in 61 primary care practices.

A retrospective observational study including data of 310 patients for up to 13 years demonstrated sustainable weight loss following a family medicine-based wellness group program.6

As we think about discovering and applying new evidence, Hersch et al.7 describe how efforts to increase family medicine research capacity at the University of Minnesota have contributed to notable increases in faculty publications and positive perceptions of the research culture.

## Strengthening Support and Resources for Primary Care

In this issue, authors describe both the importance of primary care, as well as opportunities to support primary care clinicians across a spectrum, including coaching interventions, assessment of factors associated with failed board certification exams, and resources to strengthen family medicine research capacity.

Does an online group-coaching intervention reduce physician burnout? Fainstad et al.8 describe the impact of a group-coaching intervention on measures of physician distress and wellbeing. Kiran et al.9 evaluated a peer coaching approach to supporting family physicians use of clinical performance data for quality improvement.

Is late completion of certification stage associated with increased risk of family physicians failing their board certification examination? Dai et al.10 evaluate the relationship between timing of certification stage completion and subsequent board certification examination outcomes.

Stovitz et al.11 aim to counter the view of generalists as “Jack of all trades, master of none.” They describe an under-recognized advantage of the generalist perspective.

## Sexual and Reproductive Health

The Centers for Disease Control and Prevention (CDC) recently released clinical guidelines about the use of doxycycline for postexposure prophylaxis (PEP) for bacterial sexual transmitted infections (STI).12 A PURL summarizes the benefits and indications for Doxy PEP.13 Ringwald et al.14 reiterate the benefits of Doxy PEP in their correspondence describing the use of Doxy PEP to reduce bacterial STI and transmission specifically among men who have sex with men (MSM) and transgender women.

IUDs are one of the most effective and long-acting reversible contraceptive methods available in the US. Holt-McNair et al.15 investigated the evidence for the longitudinal effectiveness of Mirena IUD. Is Mirena still effective at 8 years?

Many people experience severe pain and anxiety related to IUD insertion, which can deter use of this contraceptive method. Ovsepyan et al.16 summarize effective pharmacological and nonpharmacologic treatments for reducing both pain and/or anxiety during IUD procedures. Should misoprostol be used or avoided? What treatments have the most evidence?

## Health care for Transgender and Gender Diverse Patients

According to a national survey of transgender and nonbinary individuals, 29.3% report having experienced health care discrimination, which can lead to postponing health care.17 A mixed-methods study by Kaplan et al.18 provides insights on positive and negative experiences of transgender and nonbinary patients in health care, as well as recommendations to improve clinical care.

Chen et al. highlight that current cervical cancer screening guidelines do not incorporate gender identity or gender-affirming hormone status in recommendations for Papanicolaou test interpretation or surveillance.19–20 The authors describe the effects of testosterone on Papanicolaou test results in transgender and gender-diverse individuals and implications for these findings.21

## Sociodemographic Considerations in Health care

Despite the potential life-saving potential for cardiac stress tests, there are high rates of incompletion. Amat et al.22 examined individual patient factors associated with completion of a stress test and found inequities in those with completed tests.

Datta et al.23 studied variations in diabetes monitoring among Latino adults based on birthplace. The authors argue that clinicians should ask patients about nativity and subgroup information to inform treatment plans.

Traditional estimated glomerular filtration rate (eGFR) equations incorporated race in eGFR calculations; however, race-based modifiers in clinical equations can perpetuate and exacerbate existing disparities in health care.24 In “Filtering Race Out of GFR Calculation,” Smith et al.25 describes the new eGFRcr-cys equation, which estimates GFR incorporating both serum creatinine and serum cystatin C levels. The new equation has improved accuracy in predicting chronic kidney disease (CKD) prognosis.

## Expanding Health Care Beyond the Walls of Clinics and Hospitals

Vilendrer et al.26 investigated a systemwide program to screen and address social determinants of health and found it to be challenging yet feasible.

A study by Brillakis et al.27 evaluated the connections between primary care practices and multisector community organizations, using data from the 2023 American Board of Family Medicine (ABFM) Continuing Certification Questionnaire.

## Addressing Common Musculoskeletal Concerns in Primary Care

Sidhar et al.28 provide a novel, simplified approach to diagnosing and managing causes of shoulder pain, from adhesive capsulitis to labral pathology. They provide an overview of triaging symptoms, diagnostic approaches and special tests, and management approaches. Want a review of Speed’s test and Yergason’s test to diagnose Biceps tendinopathy?

Leg cramps are common and upsetting for patients; do we know what interventions are being used? A survey of 365 patients experiencing leg cramps provides insights on commonly used pharmacologic and nonpharmacologic treatment options used by patients. The authors call attention to frequent use of over-the-counter analgesics and use of internet searches to find treatments.29 Could there be a role for increased clinician education of patients to reduce medication adverse events and potential for misinformation?

## Notes

*   *Conflict of interest*: The authors are editors of the *JABFM.*

*   To see this article online, please go to: [http://jabfm.org/content/37/6/987.full](http://jabfm.org/content/37/6/987.full).

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21. 21.Chen D, Erroba J, Liu S, et al. The effects of testosterone on cervicovaginal cytology in transgender and gender-diverse individuals. J Am Board Fam Med 2024;37:1009–1013.
    
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    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6OToiMzcvNi8xMTAzIjtzOjQ6ImF0b20iO3M6MjA6Ii9qYWJmcC8zNy82Lzk4Ny5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

27. 27.Brillakis H, Fleischer S, Hogg-Graham R, Peterson LE. Rural family physicians are more likely to collaborate with multisector community organizations. J Am Board Fam Med 2024;37:1167–1169.
    
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28. 28.Sidhar K, Lim HJ, Gutierrez L. A simplified approach to evaluate and manage shoulder pain. J Am Board Fam Med 2024;37:1156–1166.
    
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29. 29.Khandalavala B, Geske J, Karloff M. Patient-reported leg cramp treatments and their effectiveness. J Am Board Fam Med 2024;37:1123–1129.
    
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