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Publications

2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 | 2005 | 2004 | 2003 | 2002 | 2001 | 2000
Articles -- Abstracts of manuscripts submitted to and published in peer-reviewed journals.
One-Pagers -- Research summaries pertinent to family practice advocacy.
Commentaries and Editorials -- References to editorials by Graham Center staff that have been published in peer-reviewed journals.
Monographs & Books -- Comprehensive studies, syntheses of evidence and compilations of conversations on the history and future of family medicine.
Presentations -- Given by Graham Center staff at various events.

Delivery and Scope of the Medical Home

2012

Integrating community health centers into organized delivery systems can improve access to subspecialty care - August 2012
The Affordable Care Act is funding the expansion of community health centers to increase access to primary care, but this approach will not ensure effective access to subspecialty services. To address this issue, we interviewed directors of twenty community health centers. Our analysis of their responses led us to identify six unique models of how community health centers access subspecialty care, which we called Tin Cup, Hospital Partnership, Buy Your Own Subspecialists, Telehealth, Teaching Community, and Integrated System. We determined that the Integrated System model appears to provide the most comprehensive and cohesive access to subspecialty care. Because Medicaid accountable care organizations encourage integrated delivery of care, they offer a promising policy solution to improve the integration of community health centers into “medical neighborhoods.” (Articles)

The percentage of family physicians attending to women's gender-specific health needs is declining - July 2012
As the largest and most widely distributed of primary care physicians, family physicians have an important role in providing women's health care, especially in rural and underserved areas. The proportion of family physicians who are attending to women is declining. Policy intervention may be needed to help family physicians maintain the comprehensiveness of care necessary to address the wide range of medical problems of women they encounter within their practices. (Articles)

Proportion of family physicians providing maternity care continues to decline - May 2012
Family physicians traditionally have played an integral role in delivering babies as a component of the comprehensive care they provide for women. The proportion of family physicians who report providing any maternity care continues to decrease. This trend is particularly concerning because family physicians are the most widely distributed specialty and are essential to health care access in rural areas. (Articles)

Communities of solution: The Folsom Report revisited - May 2012
The 21st century primary care physician must be a true public health professional, forming partnerships and assisting data sharing with community organizations to facilitate healthy changes. We propose an updated vision of the Folsom Report for integrated and effective services, incorporating the principles of community-oriented primary care. (Articles)

Declining numbers of family physicians are caring for children - March 2012
Despite continued growth of the primary care workforce, profound maldistribution persists among providers available for the care of children. Family physicians (FPs) spend, on average, approximately 10% of their total practice time caring for children; however, given that, among physician specialties, FPs are geographically distributed most evenly across the US population, the self-reported decline in the share of FPs caring for children should be disturbing to policymakers, especially with the looming insurance expansion in 2014. (Articles)

Refocusing Geriatricians’ Role in Training to Improve Care for Older Adults - January 2012
The current number of geriatricians cannot keep up with the health care needs of the growing number of older adults. To fill the gap, more geriatricians should focus on training primary care and other specialty physicians to care for older adults. (One-Pagers)

2011

EHR implementation without meaningful use can lead to worse health outcomes - December 2011
Defying expectations, typical electronic health record (EHR) use in practices belonging to a primary care network has been associated with poorer diabetes care quality and outcomes. Current expansion of primary care EHR implementation must focus on use that improves care. (One-Pagers)

Rewarding family medicine while penalizing comprehensiveness? Primary care payment incentives and health reform: the Patient Protection and Affordable Care Act (PPACA) - November 2011
Family physicians’ scope of work is exceptionally broad, particularly with increasing rurality. Provisions for Medicare bonus payment specified in the health care reform bill (the Patient Protection and Affordable Care Act) used a narrow definition of primary care that inadvertently offers family physicians disincentives to delivering comprehensive primary care. (Articles)

What services do family physicians provide in a time of primary care transition? - November 2011
The Future of Family Medicine Report envisioned a new model of practice “committed to providing the full basket of clinical services offered by Family Medicine.” In actuality, variation in that basket is considerable and may influence patients’ access to care as much as supply and distribution of physicians does in the wake of health care reform. (Articles)

Better integration of mental health care improves depression screening and treatment in primary care - November 2011
Improving screening and treatment for depression in primary care will require better mental health care integration. Depression is common in primary care, yet screening for the condition remains low. Enhanced, coordinated financial support for the integration of mental health care into primary care could improve identification and treatment of depression. (One-Pagers)

The importance of time in treating mental health in primary care - June 2011
Primary care plays a critical role in treating mental health conditions, but caring for patients with comorbid mental health and medical conditions increases visit length. Lack of appropriate reimbursement mechanisms and competing priorities make it difficult to integrate mental health into primary care. Caring for patients with mental health comorbidities requires time not now affordable in the primary care setting and demands a new payment policy to promote team-based, integrated care for mental and physical illness in a patient-centered medical home. (Articles)

Innovations in primary care residency education - May 2011
Samuel M. Jones, MD; Warren Newton, MD, MPH; Washington Primary Care Forum #64 (Presentations)

Evidence About Your Value (and the return on investment) - May 2011
Robert L. Phillips, Jr., MD, MSPH; Family Medicine Congressional Conference (Presentations)

Evidence about the Role of the PCMH and ACOs in Improving Quality and Safety - May 2011
Robert L. Phillips, Jr., MD, MSPH; Georgetown University Department of Family Medicine Grand Rounds (Presentations)

Primary Care Physician Workforce and Outcomes - May 2011
(Commentaries and Editorials)

Evidence about the role of the Patient-Centered Medical Home and Accountable Care Organizations in Improving Quality and Safety - April 2011
Robert L. Phillips, Jr., MD, MSPH; Ohio Hospital Association/Ohio Patient Safety Institute (Presentations)

Establishing a baseline: Health information technology adoption among family medicine diplomates - March 2011
A majority of board-certified family physicians in the United States now use EHRs. The most rural of family physicians lag slightly behind the national adoption frequency, but 4-year trends suggest similar rates of uptake. Though board-certified family physicians may differ from those who do not maintain certification, understanding uptake among this cohort is critical because Maintenance of Certification (MOC) and the adoption of health information technology both are essential elements of quality improvement in primary care. Although further monitoring of adoption trends is important, the mounting challenge will not be adoption but the sufficiency of EHRs to help family physicians take better care of their patients. (Articles)

Case study of a primary care-based accountable care system approach to medical home transformation - February 2011
Over 20 years, WellMed Inc. (San Antonio, Texas) implemented many patient-centered services, experimenting to find which belong within clinics and which operate best as system functions. The adjusted mortality rate is half that of the state for people older than 65 years. Hospitalization and readmission rates and emergency department visits have not changed over time, but preventive services have improved. Phased implementation across the network makes it difficult to link improvements to specific processes but they seem to have improved outcomes collectively. (Articles)

Tackling primary care workforce demands in light of health care reform - January 2011
James C. Puffer, MD; Robert Phillips, MD, MSPH; Eric S. Holmboe, MD; and James A. Stockman III, MD; Washington Primary Care Forum #63 (Presentations)

2010

Travel medicine and the Maryland family physician - October 2010
Providing recommendations for a safe and healthy sojourn, without unnecessarily alarming travelers or blunting their cultural interchange and travel adventure, is a balancing act. That balance, best informed by thorough assessment of patient- and itinerary-specific risk, as well as risk tolerance, is an assessment perfectly suited to the relationships available to the traveler in the patient-centered medical home. (Articles)

Illinois Health Connect and Your Healthcare Plus Case Statement - August 2010
(Monographs & Books)

Building the research culture of family medicine with fellowship training - August 2010
There are many fellowship and research training opportunities for family physicians. But in many programs, research training is tenuous, and support for researchers is low. We recommend expanding research advocacy efforts within family medicine, Congress, and funding institutions. (Articles)

Measuring primary care expenses - May 2010
It is feasible to systematically collect intervention-specific expenses in primary care using formal expenditure methods. However, most practices and researchers lack the knowledge, expertise, and resources to collect such data independently. Further assistance and education is necessary to obtain reliable information about the expenses to transform and improve primary care. (Articles)

Harnessing Geographic Information Systems (GIS) to enable Community-Oriented Primary Care - January 2010
Analytic mapping was enthusiastically received and practically applied in the primary care setting, and was readily comprehended by clinic leaders for innovative purposes. This is a tool of particular relevance amid primary care safety-net expansion and increased funding of health information technology diffusion in these settings, particularly if the hurdles of cost and technological expertise are overcome by harnessing new advances in web-based mapping technology. (Articles)

2009

Improving the delivery of preventive services to Medicare beneficiaries - December 2009
(Commentaries and Editorials)

A comparison of chronic illness care quality in US and UK family medicine practices prior to pay-for-performance initiatives - December 2009
Following National Health Service (NHS) investment in primary care preparedness, but prior to the QOF, UK practices provided more standardized care but did not achieve better intermediate outcomes than a sample of typical US practices. US policymakers should focus on reducing variation in care documentation to ensure the effectiveness of P4P efforts while the NHS should focus on moving from process documentation to better patient outcomes. (Articles)

Title VII's decline: Shrinking investment in the primary care training pipeline - October 2009
Title VII, Section 747 is a source of federal funding intended to strengthen the primary care workforce. Despite evidence that Title VII has been successful, its funding has declined over the past three decades, threatening the production of primary care physicians. (One-Pagers)

Race and ethnicity and rural mental health treatment - August 2009
Findings suggest that characteristics of the rural environment may disadvantage all residents with respect to mental health treatment. In more populated areas where mental health services are more plentiful, complex racial and service system factors may play a greater role in evident ethnic/racial treatment disparities. (Articles)

Ensuring access to a modern, Medical Home: The role for a primary care extension program in health reform - April 2009
Kevin Grumbach, MD; Primary Care Roundtable Dialogue Series (Presentations)

Medical school expansion, primary care, and policy: Engaging primary care educators in evidence-based advocacy - April 2009
Andrew Bazemore, Julie Phillips, Amy McGaha, Hope Wittenberg; STFM Annual Spring Conference (Presentations)

Is Colorado ready for a primary care-based health care system? - April 2009
Bob Phillips, MD MSPH and Andrew Bazemore, MD MPH; University of Colorado Levitt Distinguished Speaker Series (Presentations)

What influences medical student and resident choices? - April 2009
Bridget Teevan, MS; National AHEC Organization Spring Policy Days (Presentations)

Universal Primary Care -- Shovel Ready Health Care Reform - March 2009
Michael Fine, MD and Shannon Brownlee, MS; Primary Care Roundtable Dialogue Series (Presentations)

Usual source of care: An important source of variation in health care spending - March 2009
Based on analyses of data from the 2001–2004 Medical Expenditure Panel Surveys, we found significant differences in annual spending, especially for adults. Use of and spending for subspecialists were similar to those for general internists, and both were significantly higher than those for family physicians. Variation in spending might be the result of training differences among primary care specialties. (Articles)

Primary care's ecologic impact on obesity - March 2009
With a costly obesity epidemic, policy makers must recognize factors that may influence obesity not only for each person, but also across communities. Increased primary care physician density on the county level is associated with decreased obesity rates. As we move to restructure the primary care workforce and engage our patients and communities in behavior change, the implications of this association merit closer investigation. (One-Pagers)

2008

Characterizing breast symptoms in family practice - November 2008
Of patients with breast symptoms only a small subset is subsequently given a diagnosis of breast cancer (3.2%); however, the presence of a breast mass is associated with an elevated likelihood of breast cancer. These data illustrate the use of systematic data collection and classification from primary care offices to extract information regarding disease symptoms and diagnoses. (Articles)

Changing patient health-risk behavior requires new investment in primary care - October 2008
Evidence supports the effectiveness of primary care interventions to improve nutrition, increase physical activity levels, reduce alcohol intake, and stop tobacco use. However, implementing these interventions requires considerable practice expense. If we hope to change behavior to reduce chronic illness, the way we pay for primary care services must be modified to incorporate these expenses. (One-Pagers)

2007

Harmonizing primary care clinical classification and data standards - October 2007
(Monographs & Books)

2006

Imperative integration: Medical care for older patients - October 2006
The ecology of medical care changes for older people, with increases in usage of residential and institutional care, emergency departments, and home care. Care integrated across multiple settings, as is proposed for new models of primary care, is essential for the care of older patients. (One-Pagers)

Family physicians in the child health care workforce: Opportunities for collaboration in improving the health of children - September 2006
More than 5 million children and adolescents live in counties with no pediatrician. Unmet need, addressing health in the context of families and communities, and tackling "millennial morbidities" represent common ground for both specialties that could lead to specific, collaborative training, research, intervention, and advocacy. (Articles)

2005

Physician assistant and nurse practitioner workforce trends - October 2005
The physician assistant (PA) and nurse practitioner (NP) workforces have realized explosive growth, but this rate of growth may be declining. Most PAs work outside primary care; however, the contributions of PAs and NPs to primary care and interdisciplinary teams should not be neglected. (One-Pagers)

Number of persons who consulted a physician, 1997 and 2002 - September 2005
Most people in the United States consult a general physician each year, and some see other subspecialists. However, the proportion of people consulting a general physician who sees adults and children appears to be declining. (One-Pagers)

Patterns of visits to physicians' offices, 1980 to 2003 - September 2005
In the past quarter century, the number of office visits to physicians in the United States increased from 581 million per year to 838 million per year, with slightly more than one half of total visits since 1980 being made to primary care physicians. Most visits to primary care physicians were made to family physicians (FPs) and general practitioners (GPs) until the mid 1990s, when visits to general internists and general pediatricians exceeded visits to FPs and GPs. (One-Pagers)

Who filled first-year family medicine residency positions from 1991 to 2004? - August 2005
Graduates of U.S. allopathic schools have filled less than one half of the family medicine positions offered in the National Resident Matching Program (NRMP) Match since 2001. Overall fill rates in July have been relatively stable at approximately 94 percent. Family medicine has become reliant on international medical graduates (IMGs), who in 2004 made up 38 percent of first-year residents. (One-Pagers)

Cost-effective roles for nurse practitioners in secondary prevention - June 2005
(Commentaries and Editorials)

Overcoming obstacles in U.S. health care delivery with a new practice model for family practice - June 2005
This essay highlights some of the hurdles and obstacles that have hindered physicians and presents brief summaries of some proposals currently being discussed to overcome them. (Articles)

Four-year residency training for the next generation of family physicians - May 2005
(Commentaries and Editorials)

COGME's 16th Report to Congress: Too many physicians could be worse than wasted - May 2005
(Commentaries and Editorials)

2004

The continuity of care record - October 2004
(Commentaries and Editorials)

The importance of having health insurance and a usual source of care - September 2004
The effects of insurance and having a usual source of care are additive. Efforts to improve health care access for all should provide a medical home and health insurance. (One-Pagers)

Chiropractors are not a usual source of primary health care - June 2004
Chiropractors are the largest source of office-based care in the United States that does not involve a physician, but people do not view chiropractors as primary providers of health care or advice. Unlike the care given by primary care providers, the majority of care provided by chiropractors is limited to musculoskeletal problems. (One-Pagers)

What people want from their family physician - May 2004
The public wants and is satisfied by care provided within a patient-physician relationship based on understanding, honesty and trust. If the U.S. healthcare system is ever to become patient-centered, it must be designed to support these values and sustain, rather than fracture relationships people have with their primary physician. (One-Pagers)

Few people in the United States can identify primary care physicians - May 2004
Almost one decade after the Institute of Medicine defined primary care, only one-third of the American public is able to identify any of the medical specialties that provide it, and only 17% were able to accurately distinguish primary care physicians from medical or surgical specialists and non-physicians. This lack of discrimination compromises the goal of achieving primary care for all and merits immediate attention. (One-Pagers)

Specialist physicians providing primary care services in Colorado - April 2004
The contribution of specialists should be considered in future primary care needs assessments, and specialists who experience low demand for their particular specialties may be especially inclined to provide primary care services. (Articles)

2003

Why does a U.S. primary care physician workforce crisis matter? - October 2003
(Commentaries and Editorials)

General internists and family physicians: Partners in geriatric medicine? - October 2003
(Commentaries and Editorials)

The U.S. primary care physician workforce: Minimal growth 1980-1999 - October 2003
Growth in the primary care physician workforce (physicians per capita) in the United States has trailed the growth of the specialist physician population in recent years. This has occurred despite calls during the same period for increased production of primary care physicians and educational reforms focusing on primary care. (One-Pagers)

The U.S. primary care physician workforce: Persistently declining interest in primary care medical specialties - October 2003
A persistent, six-year trend in the choice of specialty training by U.S. medical students threatens the adequacy of the physician workforce of the United States. This pattern should be reversed and requires the attention of policy makers and medical educators. (One-Pagers)

Family physicians are an important source of newborn care: The case of the state of Maine - August 2003
FPs provided 30 percent of inpatient newborn care in Maine in the year 2000. FPs cared for a large proportion of newborns, especially those insured by Medicaid and in smaller, rural hospitals where FPs also delivered babies. Family medicine’s commitment to serve vulnerable populations of newborns requires continued federal, state, and institutional support for training and development of future FPs. (One-Pagers)

Family physicians increase provision of well-infant care despite decline in prenatal services - January 2003
Over the past 20 years, both FP/GPs and pediatricians have upheld their commitment to preventive care for infants. Non-Metropolitan Statistical Areas (non-MSAs) depend on family physicians for almost half of their well-infant care. In fact, FP/GPs have increased their overall provision of well-infant care despite a decline in delivery of prenatal services. This commitment to child health care demands continued excellence of FP training in pediatric medicine, preventive care, and child advocacy. (One-Pagers)

2002

Family physicians are the main source of primary health care for the Medicare population - December 2002
Of people 65 years and older who reported an individual provider as their usual source of health care, 60 percent identified a family physician or general practitioner. The Medicare population relies heavily on family physicians. (One-Pagers)

Family physicians' declining contribution to prenatal care in the United States - December 2002
There has been a substantial decline in prenatal care by family physicians over the past 20 years in all geographic regions of the country. Even so, during the past two decades, FP/GPs have provided over two million prenatal visits per year. As the field re-explores future scope, it should consider the erosion of the provision of prenatal care, its effect on the U.S. population and the specialty, and possibilities for revitalization of prenatal care in residency curricula and practice. (One-Pagers)

Can nurse practitioners and physicians beat parochialism into plowshares? - September 2002
The country can ill afford doctors and nurses who ignore one another's capabilities and fail to maximize each other's contributions cost-effectively. A collaborative, integrated health care workforce could improve patient care. (Articles)

Family practice in the United States: A status report - September 2002
To reflect on and reconsider the role of family practice in US health care, this article reviews the development of the status of family medicine in the United States, and comments on issues that are of ongoing important to family practice. (Articles)

Family practice in the United States: Position and prospects - August 2002
Family practice's mistakes include expending much effort on justification and less on assuring practical means to accomplish its work; permitting an erosion of public trust; failing to strengthen relationships with interfacing specialties and organizations; and neglecting research. Nonetheless, there are promising opportunities to improve health and health care through strengthening family practice that depend in part on redesigning the family practice setting, defining carefully critical interactions with other elements of the health care system, fostering discovery of family practice, and further differentiating family practice as a scientific and caring field. Another period of adaptation by family practice is already under way; this may be the first time in history that its ambitious aspirations are actually achievable. (Articles)

The increase in international medical graduates in family practice residency programs - June 2002
Family practice is becoming increasingly reliant on IMGs to fill residency positions. (Articles)

Making choices about the scope of family practice - May 2002
(Commentaries and Editorials)

The delicate task of workforce determination - March 2002
(Commentaries and Editorials)

2001

It takes a balanced health care system to get it right - December 2001
(Commentaries and Editorials)

Taking necessary steps to position U.S. health care to be the best - November 2001
No abstract available. Full, free text available. (Articles)

Uncoordinated growth of the primary care workforce - November 2001
Family physicians, nurse practitioners and physician assistants are distinctly different in their clinical training, yet they function interdependently. Together, they represent a significant proportion of the primary care work force. Training capacity for these three professions has increased rapidly over the past decade, but almost no collaborative work force planning has occurred. (One-Pagers)

Trumping professional roles: Collaboration of nurse practitioners and physicians for a better U.S. health care system - October 2001
Professional turf battles have yielded variations in the scope of practice for nurse practitioners (NPs) obstructing collaboration with physicians that would enhance patient care. Patients would be better served if NPs and physicians worked together to develop better combined models of education and service that take advantage of the benefits of both professions' contributions to care. (One-Pagers)

The view from 2020: How family practice failed - April 2001
This article is part of a special issue of Family Medicine dedicated to The Keystone Papers: Formal Discussion Papers from Keystone III. (Articles)

A preface concerning Keystone III - April 2001
This article is part of a special issue of Family Medicine dedicated to The Keystone Papers: Formal Discussion Papers from Keystone III. (Articles)

2000

The importance of primary care physicians as the usual source of healthcare in the achievement of prevention goals - November 2000
Having a usual source of care enhances achieving clinical prevention goals for both children and adults. There is room for improvement, and differences between the practices of internists and family physicians suggest that slightly longer visits and having health insurance might contribute to achieving proven prevention strategies. medica (One-Pagers)

The importance of having a usual source of health care - August 2000
Most people (82%) in the United States have and use a usual source of care, and a majority of them name a particular primary care physician as that source. Regardless of self-reported health status, people benefit from having a usual source of health care even if they are uninsured. (One-Pagers)

The effect of accredited rural training tracks on physician placement - July 2000
Accredited family practice rural training tracks place their graduates in rural settings at very high rates: 76% overall and 88% among programs implemented in the last ten years. Favorable, immediate results could be expected from their continuation and expansion, permitted by adjustments in the Balanced Budget Act of 1997. (One-Pagers)

Educating doctors to provide counseling and preventive care: Turning 20th century professional values head over heels - March 2000
We draw on data from the National Ambulatory Medical Care Survey to compare roles of primary care physicians and other office-based medical specialties in delivering preventive health care. We also estimate the cost of providing preventive care in terms of physician time. Finally, we contemplate how medical education values must change in the US and other countries if 21st century physicians are to be prepared to meet the health care needs of their communities. (Articles)