Point-of-Care Ultrasound, Prevention and Screening, Family Medicine Workforce, Navigating Systems, and Improving Patient Care

Point-of-Care Ultrasound

American Board of Family Medicine (ABFM) data demonstrate a continued rise in both interest in and utilization of point-of-care ultrasound (POCUS) among family medicine residents and practicing diplomates with nearly 25% of recent graduates incorporate some POCUS 3 years out of training.¹ In 2023, the Accreditation Council for Graduate Medical Education (ACGME) added POCUS education to family medicine residency program requirements.² Despite rising momentum, empirical evidence on POCUS by family physicians and in family medicine settings remains limited. In this issue, we present a collection of articles which explore its use by family physicians. For physicians newer to POCUS, Hui’s³ commentary summarizes the wide variety of clinical scenarios for which POCUS can impact clinical decision making and meaningfully improve care – a useful primer to explain the enthusiasm of early adopters.

Three articles look at specific POCUS applications. Killeen et al.⁴ explore 1 of the most common indications for POCUS, soft tissue abnormalities, by examining 1 year of soft tissue ultrasounds ordered by academic family physicians referred to radiology. The study’s results – including the most common indications and findings – have implications for how POCUS education in family medicine should differ from emergency medicine. Paulus et al.⁵ validate the accuracy of abdominal aortic aneurysm (AAA) screening done by family physicians when compared with those performed in a radiology department. The United States Preventive Services Task Force (USPSTF)⁶ recommends screening for AAA in older male smokers. Though many POCUS applications are designed to answer clinical questions in acute, symptom-based encounters, screening for abdominal aortic aneurysm is 1 of the few where the potential of POCUS overlaps with evidence-based population health interventions. Further, a letter to the editor from Erickson⁷ points out the utility of POCUS in improving the pain and discomfort associated with IUD insertion.

Two commentaries provide United States and global perspectives on family medicine POCUS. Sadikoglu,⁸ an academic family physician in Turkey, discusses the benefits of expanding POCUS education into global family medicine settings, where it can reduce dependence on secondary and tertiary care settings, with parallels to US rural settings. Finally, Erickson’s⁹ commentary summarizes the challenges to incorporating POCUS into family medicine’s unique practice models and suggests several steps forward in technology, policy, reimbursement, and training that will help the specialty overcome some of the barriers to moving from early adopters to the early and late majorities that follow.

Prevention and Screening

The family medicine community watched with great interest as the US Supreme Court considered the Affordable Care Act provision mandating zero copay insurance coverage for USPSTF grade A and B recommended services (Kennedy v. Braidwood). In light of the decision upholding the mandate, Young et al.¹⁰ explain an important policy issue for our patients – how to advocate for expanded coverage of each step along the cervical cancer screening and diagnosis pathway. A study by Soltani et al.¹¹ evaluates the relative contributions of clinicians working in multiple specialties to cervical cancer screening in a large multi-state health system. The impressive findings confirm that this issue falls squarely in the domain of family medicine.

Decades of public health discussions debate the risks and benefits of prostate cancer screening. With current recommendations focused on shared decision making, Fenton and Tancredi¹² present the results of a system-level electronic health record reminder on prostate specific antigen ordering, both in target age groups and those in whom the balance of benefits and harms may be less favorable. The results will be useful for clinicians to influence their practice’s electronic health record alert structure.

Screening for disease or predictors of disease is important in family medicine. Two studies apply qualitative methods to explore how social screening can be improved in primary care settings. Cantor et al.¹³ explore barriers and facilitators to screening for anxiety and intimate partner violence. Ackerman et al.¹⁴ examine the factors important to clinics with demonstrated success of sustained integration of social risk screening. Calderon-Mora et al.¹⁵ focus on another method to reduce health disparities – improving HPV vaccination rates in rural Texas-Mexico border communities. The findings are relevant beyond the local study population.

Innovations in Office Practice

A series of articles directly address potential solutions to problems clinicians face in their daily practice. Herbert et al.¹⁶ examined disparities in portal access in safety net communities. Beliveau et al.¹⁷ provide an evidence-based commentary on the use of urine drug screening tests in the office-based care of patients with opioid use disorder. The work contains clinical pearls on how to use this tool more effectively and not perpetuate stigma. Further, though many of us were trained on the importance of providing private 1-on-on time with our teenage patients, Black et al.¹⁸ reveal how little it is actually happening. They discuss some of the ramifications of the lack of 1-on-one time with teenagers to discuss sensitive topics – an important reminder in our busy clinic days.

Two clinical reviews will be of particular interest to clinicians with busy office practices. One – a “PURL” (Priority Updates from the Research Literature) by Espinoza et al.¹⁹ – summarizes an important study on convenient single pill antihypertension treatment regimens. The review on practical counseling strategies for our patients and families with private well water sources by Jegen et al.²⁰ will be clinically relevant for clinicians practicing in rural settings.

Health Systems

Several other articles deal with issues facing our health systems. One such force is the push for alternative payment models supported by Medicare that move beyond fee-for-service. A study by Hague et al.²¹ evaluates participation in alternative payment models among primary care physicians (PCPs) and the positive impacts on the central tenets of our discipline –comprehensiveness, continuity, coordination of care, and access. This article represents the kind of work that can influence national payment reform conversations.

Family physicians can uniquely and substantially contribute to the care of patients with complex chronic medical conditions that start in childhood and affect them across the lifespan – such as cystic fibrosis. A report from Kolka et al.²² demonstrates the gap in primary care access for this patient population and some of the ramifications, including vaccination rates and blood pressure control. Fadem²³ reports on an intervention to allow systematic reporting of patients in a system with a history of breast cancer – a potentially transferable concept that could support practices looking to improve primary care for patients past their treatment phases. Adashi²⁴ provides a historic perspective on the various state-level approaches to legislation around Medical Aid in Dying.

Practice-based research networks (PBRNs) are 1 of the ways community clinicians contribute to research that advances medical science relevant to our patients. A model of such engagement reported by Lewis et al.²⁵ is replicable in other settings and will be familiar to family medicine educators who have engaged with the Council of Academic Family Medicine Educational Research Alliance (CERA).

Workforce Development

It is no secret that the nation’s primary care workforce is struggling to meet burgeoning demand. Several articles in this issue contribute to this discussion. First, the work of Britz et al.²⁶ used claims data in Virginia and simulation analyses to predict the need for primary care physicians in the state. The results – a concurrently aging PCP population and more part-time work by clinicians – paint a stark picture of a rising shortfall. How do we reverse this? A study from an ABFM team led by Barr²⁷ reflects on the critical importance of high-quality family medicine clerkships. A related commentary by Stickler et al.²⁸ note some critical issues facing the family medicine residency match process. How can we continue to improve the pool of applicants choosing family medicine? Readers across medical education will find the article and its themes familiar and thought-provoking.