Primary Care Physicians’ Experiences With and Adaptations to Time Constraints

Importance The primary care workforce shortage is significant and persistent, with organizational and policy leaders urgently seeking interventions to enhance retention and recruitment. Time constraints are a valuable focus for action; however, designing effective interventions requires deeper understanding of how time constraints shape employees’ experiences and outcomes of work. Objective To examine how time constraints affect primary care physicians’ work experiences and careers. Design, Setting, and Participants Between May 1, 2021, and September 31, 2022, US-based primary care physicians who trained in family or internal medicine were interviewed. Using qualitative analysis of in-depth interviews, this study examined how participants experience and adapt to time constraints during a typical clinic day, taking account of their professional and personal responsibilities. It also incorporates physicians’ reflections on implications for their careers. Main Outcomes and Measures Thematic analysis of in-depth interviews and a measure of well-being (American Medical Association Mini-Z survey). Results Interviews with 25 primary care physicians (14 [56%] female and 11 [44%] male; median [range] age, 43 [34-63] years) practicing in 11 US states were analyzed. Two physicians owned their own practice, whereas the rest worked as employees. The participants represented a wide range of years in practice (range, 1 to ≥21), with 11 participants (44%) in their first 5 years. Physicians described that the structure of their work hours did not match the work that was expected of them. This structural mismatch between time allocation and work expectations created a constant experience of time scarcity. Physicians described having to make tradeoffs between maintaining high-quality patient care and having their work overflow into their personal lives. These experiences led to feelings of guilt, disillusionment, and dissatisfaction. To attempt to sustain long-term careers in primary care, many sought ways to see fewer patients. Conclusions and Relevance These findings suggest that organizational leaders must align schedules with work expectations for primary care physicians to mitigate physicians’ withdrawal from work as a coping mechanism. Specific strategies are needed to achieve this realignment, including incorporating more slack into schedules and establishing realistic work expectations for physicians

Structural Competency: Curriculum for Medical Students, Residents, and Interprofessional Teams on the Structural Factors That Produce Health Disparities

Introduction: Research on disparities in health and health care has demonstrated that social, economic, and political factors are key drivers of poor health outcomes. Yet the role of such structural forces on health and health care has been incorporated unevenly into medical training. The framework of structural competency offers a paradigm for training health professionals to recognize and respond to the impact of upstream, structural factors on patient health and health care. Methods: We report on a brief, interprofessional structural competency curriculum implemented in 32 distinct instances between 2015 and 2017 throughout the San Francisco Bay Area. In consultation with medical and interprofessional education experts, we developed open-ended, written-response surveys to qualitatively evaluate this curriculum\u27s impact on participants. Qualitative data from 15 iterations were analyzed via directed thematic analysis, coding language, and concepts to identify key themes. Results: Three core themes emerged from analysis of participants\u27 comments. First, participants valued the curriculum\u27s focus on the application of the structural competency framework in real-world clinical, community, and policy contexts. Second, participants with clinical experience (residents, fellows, and faculty) reported that the curriculum helped them reframe how they thought about patients. Third, participants reported feeling reconnected to their original motivations for entering the health professions. Discussion: This structural competency curriculum fills a gap in health professional education by equipping learners to understand and respond to the role that social, economic, and political structural factors play in patient and community health

Bcl11a is essential for lymphoid development and negatively regulates p53

Transcription factors play important roles in lymphopoiesis. We have previously demonstrated that Bcl11a is essential for normal lymphocyte development in the mouse embryo. We report here that, in the adult mouse, Bcl11a is expressed in most hematopoietic cells and is highly enriched in B cells, early T cell progenitors, common lymphoid progenitors (CLPs), and hematopoietic stem cells (HSCs). In the adult mouse, Bcl11a deletion causes apoptosis in early B cells and CLPs and completely abolishes the lymphoid development potential of HSCs to B, T, and NK cells. Myeloid development, in contrast, is not obviously affected by the loss of Bcl11a. Bcl11a regulates expression of Bcl2, Bcl2-xL, and Mdm2, which inhibits p53 activities. Overexpression of Bcl2 and Mdm2, or p53 deficiency, rescues both lethality and proliferative defects in Bcl11a-deficient early B cells and enables the mutant CLPs to differentiate to lymphocytes. Bcl11a is therefore essential for lymphopoiesis and negatively regulates p53 activities. Deletion of Bcl11a may represent a new approach for generating a mouse model that completely lacks an adaptive immune system

Patients are Waiting: Temporal Logics and Practices of Safety-Net Primary Care

Time is a problem in primary care. Patients and providers alike lament short visits and long wait times. Meanwhile, continuity over time is a defining asset of primary care. Drawing on ethnographic fieldwork in three publicly-run clinics in California and theoretical approaches to temporality and governance, this dissertation examines the multiple rhythms and temporal logics at play in the clinic. Those who work in safety-net primary care are charged with ensuring the health of a socially vulnerable patient population while being attentive to each member of that population. I examine how clinicians and staff negotiate contradictions in the organization of clinical time in part by shifting between temporal frames.Concern about patients waiting moralizes speed and efficiency in the clinic. This is always in tension with ideals of comprehensive care for each individual. Scheduling practices and management of clinic flow rely on a logic that I term enslotment, in which patients occupy uniform segments of time. I examine the practices that clinicians and staff use to reconcile patients and the schedule to one another. At the limits of these strategies, the non-congruence between the temporal norms of the clinic and patients’ needs generate a sense of temporal fragility. I describe how a sense of potentially unlimited demand drives efforts to protect time through clinical teamwork in ways that are patterned by the valuation of labor time. I also examine the demands that documentation, incentive-backed quality measurement and the imperative of continuous improvement make upon clinic time. Metrics can generate a sense of urgency around needs otherwise neglected. Meanwhile, the tempos of reporting and payment are often out of sync with the temporalities of sustainable organizational or political change. In this context, I explore how clinic staff confront the limits of time and navigate the contradictions between their obligations to individual patients and the collective under conditions of socially structured time scarcity. Care over time through continuity creates space for potential beyond the time pressures of a given clinic session. By taking time as an object of focused inquiry, this analysis traces the logics and ethics of healthcare policy and practice across multiple scales

"The idea is to help people achieve greater success and liberty": A qualitative study of expanded methadone take-home access in opioid use disorder treatment.

Background: Prior to the COVID-19 pandemic, the United States (US) was already facing an epidemic of opioid overdose deaths. Overdose deaths continued to surge during the pandemic. To limit COVID-19 spread and to avoid disruptions in access to medications for opioid use disorder (MOUD), including buprenorphine and methadone, US federal and state agencies granted unprecedented exemptions to existing MOUD guidelines for Opioid Treatment Programs (OTPs), including loosening criteria for unsupervised take-home doses. We conducted a qualitative study to evaluate the impact of these policy changes on MOUD treatment experiences for providers and patients at an OTP in California. Methods: We interviewed 10 providers (including two physicians, five social worker associates, and three nurse practitioners) and 20 patients receiving MOUD. We transcribed, coded, and analyzed all interviews to identify emergent themes. Results: Patient participants were middle-aged (median age 51 years) and were predominantly men (53%). Providers discussed clinical decision-making processes and experiences providing take-homes. Implementation of expanded take-home policies was cautious. Providers reported making individualized decisions, using patient factors to decide if benefits outweighed risks of overdose and misuse. Decision-making factors included patient drug use, overdose risk, housing status, and vulnerability to COVID-19. New patient groups started receiving take-homes and providers noted few adverse events. Patients who received take-homes reported increased autonomy and treatment flexibility, which in turn increased likelihood of treatment stabilization and engagement. Patients who remained ineligible for take-homes, usually due to ongoing non-prescribed opioid or benzodiazepine use, desired greater transparency and shared decision-making. Conclusion: Federal exemptions in response to COVID-19 led to the unprecedented expansion of access to MOUD take-homes within OTPs. Providers and patients perceived benefits to expanding access to take-homes and experienced few adverse outcomes, suggesting expanded take-home policies should remain post-COVID-19. Future studies should explore whether these findings are generalizable to other OTPs and assess larger samples to quantify patient-level outcomes resulting from expanded take-home policies

Teaching Structure: A Qualitative Evaluation of a Structural Competency Training for Resident Physicians.

BackgroundThe influence of societal inequities on health has long been established, but such content has been incorporated unevenly into medical education and clinical training. Structural competency calls for medical education to highlight the important influence of social, political, and economic factors on health outcomes.AimThis article describes the development, implementation, and evaluation of a structural competency training for medical residents.SettingA California family medicine residency program serving a patient population predominantly (88 %) with income below 200 % of the federal poverty level.ParticipantsA cohort of 12 residents in the family residency program.Program descriptionThe training was designed to help residents recognize and develop skills to respond to illness and health as the downstream effects of social, political, and economic structures.Program evaluationThe training was evaluated via qualitative analysis of surveys gathered immediately post-training (response rate 100 %) and a focus group 1 month post-training (attended by all residents not on service).DiscussionResidents reported that the training had a positive impact on their clinical practice and relationships with patients. They also reported feeling overwhelmed by increased recognition of structural influences on patient health, and indicated a need for further training and support to address these influences