Location, Location, Location: Where We Teach Primary Care Makes All the Difference

Creating a new model to train a high-quality primary care workforce is of great interest to American health care stakeholders. There is consensus that effective educational approaches need to be combined with a rewarding work environment, emphasize a good work/life balance, and a focus on achieving meaningful outcomes that center on patients and the public. Still, significant barriers limit the numbers of clinicians interested in pursuing careers in primary care, including low earning potential, heavy medical school debt, lack of respect from physician colleagues, and enormous burdens of record keeping. To enlarge and energize the pool of primary care trainees, we look especially at changes that focus on institutions and the practice environment. Students and residents need training environments where primary care clinicians and interdisciplinary teams play a crucially important role in patient care. For a variety of reasons, many academic medical centers cannot easily meet these standards. The authors propose that a major part of primary care education and training be re-located to settings in high-performing health systems built on comprehensive integrated care models where primary care clinicians play a principle role in leadership and care delivery

Do Parents Recognize Autistic Deviant Behavior Long before Diagnosis? Taking into Account Interaction Using Computational Methods

BACKGROUND: To assess whether taking into account interaction synchrony would help to better differentiate autism (AD) from intellectual disability (ID) and typical development (TD) in family home movies of infants aged less than 18 months, we used computational methods. METHODOLOGY AND PRINCIPAL FINDINGS: First, we analyzed interactive sequences extracted from home movies of children with AD (N = 15), ID (N = 12), or TD (N = 15) through the Infant and Caregiver Behavior Scale (ICBS). Second, discrete behaviors between baby (BB) and Care Giver (CG) co-occurring in less than 3 seconds were selected as single interactive patterns (or dyadic events) for analysis of the two directions of interaction (CG→BB and BB→CG) by group and semester. To do so, we used a Markov assumption, a Generalized Linear Mixed Model, and non negative matrix factorization. Compared to TD children, BBs with AD exhibit a growing deviant development of interactive patterns whereas those with ID rather show an initial delay of development. Parents of AD and ID do not differ very much from parents of TD when responding to their child. However, when initiating interaction, parents use more touching and regulation up behaviors as early as the first semester. CONCLUSION: When studying interactive patterns, deviant autistic behaviors appear before 18 months. Parents seem to feel the lack of interactive initiative and responsiveness of their babies and try to increasingly supply soliciting behaviors. Thus we stress that credence should be given to parents' intuition as they recognize, long before diagnosis, the pathological process through the interactive pattern with their child

Policy for an Aging Society: A Review of Systems

Medical students and residents are taught to perform a complete review of systems in a thorough patient workup. Through this process, patients may report less prominent concerns that may be meaningful to the physician's evaluation. As a complement to the new series, Care of the Aging Patient: From Evidence to Action, in this issue of JAMA, a Commentary will provide a forum for discussion of a policy review of systems for the care of older adults. In the first article, Reuben1 brings into sharp relief the need for greater expertise and new approaches to caring for older patients as they face physical decline and advanced illness. Using the case of Mr Z, Reuben examines the patient-care encounter and the analytical and interpersonal processes that the physician must undertake. For most US physicians, both specialists and generalists, this story is likely unfamiliar, and physicians may hardly be able to ..