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This is a list of articles by the Graham Center published in peer-reviewed journals. Please e-mail the Graham Center at, for more information.


Aligning Expansion of Graduate Medical Education With Recent Recommendations for Reform - November 2014
Federal funds support graduate medical education positions, but expansion is needed in urban and rural areas that experience shortages in health professionals. This commentary discusses the need for existing funds to be used to expand primary care training programs and thus improve access to care in underserved areas.

The Impact of Debt Load on Physician Assistants - July 2014
The study analyzed results of a series of focus group discussions with second-year PA students and the 2011 American Academy of Physician Assistants (AAPA)–PAEA Graduating Student Survey on career choices, education debt, and demographic characteristics of PA students.

Trends in Family Physicians Performing Deliveries, 2003-2010 - March 2014
This observational study examined the proportion of family physicians continuing to perform deliveries from 2003–2010.

The Impact of Insurance and a Usual Source of Care on Emergency Department Use in the United States - February 2014
Finding a usual source of care (USC) is difficult for certain populations. This analysis determines how insurance type and having a USC affect the settings in which patients seek care. Methods. In this cross-sectional study of the 2000–2011 Medical Expenditure Panel Surveys, we assessed the percentage of low-income persons with half or more of their ambulatory visits to the emergency department (ED). Respondents were stratified based on insurance type and presence of a USC.

Patients With High-Cost Chronic Conditions Rely Heavily on Primary Care Physicians - January 2014
Today’s US physician workforce principally comprises specialists trained in the care of specific chronic conditions in the outpatient setting. However, a majority of patients seeking care for most of 14 high-cost chronic conditions, for example hypertension, were more likely to see a primary care physician than a specialist physician.


Do Residents Who Train in Safety Net Settings Return for Practice? - December 2013
This study examines the relationship between training during residency in a federally qualified health center (FQHC), rural health clinic (RHC), or critical access hospital (CAH) and subsequent practice in these settings.

State Patterns in Medical School Expansion, 2000-2010: Variation, Discord, and Policy Priorities - October 2013
This study used established national health workforce and training site datasets to compare total medical school enrollment (2000-2010) with change in population, medical student retention in state (those returning to practice in the state where they graduated), and primary care supply.

Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions - September 2013
This study developed and tested candidate GME outcome measures related to physician workforce. The findings can inform educators and policy makers during a period of increased calls to align the GME system with national health needs.

Toward Defining and Measuring Social Accountability in Graduate Medical Education: A Stakeholder Study - September 2013
Since 1965, Medicare has publically financed graduate medical education (GME) in the United States. Given public financing, various advisory groups have argued that GME should be more socially accountable. Several efforts are underway to develop accountability measures for GME that could be tied to Medicare payments, but it is not clear how to measure or even define social accountability.

Factors Influencing Family Physician Adoption of Electronic Health Records (EHRs) - July 2013
Physician and practice characteristics associated with family physician adoption of electronic health records (EHRs) remain largely unexplored but may be important for tailoring policies and interventions. Variation in EHR adoption is associated with physician and practice characteristics that may help guide intervention.

A Needs-Based Method for Estimating the Behavioral Health Staff Needs of Community Health Centers - July 2013
Federally Qualified Health Centers are expanding to increase access for millions of more Americans with a goal of doubling capacity to serve 40 million people. Health centers provide a lot of behavioral health services but many have difficulty accessing mental health and substance use professionals for their patients. To meet the needs of the underserved and newly insured it is important to better estimate how many behavioral health professionals are needed.

Communities of Solution - May 2013
JABFM and the Folsom Group editing team have just released a special edition dedicated to Communities of Solution, featuring a number of primary care-led case studies and commentaries

Trends in Physician Supply and Population Growth - April 2013
The physician workforce has steadily grown faster than the U.S. population over the past 30 years, context that is often absent in conversations anticipating physician scarcity. Policy makers addressing future physician shortages should also direct resources to ensure specialty and geographic distribution that best serves population health.

The Association Between Global Health Training and Underserved Care: Early Findings From Two Longstanding Tracks - April 2013
Global health tracks (GHTs) improve knowledge and skills, but their impact on career plans is unclear. The objective of this analysis was to determine whether GHT participants are more likely to practice in underserved areas than nonparticipants. In this retrospective cohort study, using the 2009 American Medical Association Masterfile, we assessed the practice location of the 480 graduates from 1980--2008 of two family medicine residencies-Residency 1 and Residency 2. The outcomes of interest were the percentage of graduates in health professional shortage areas (HPSAs), medically underserved areas (MUAs), rural areas, areas of dense poverty, or any area of underservice.

Family Physicians Are Essential for Mental Health Care Delivery - March 2013
As the largest and most widely distributed of primary care physicians, family physicians have an important role in providing mental health care, especially in rural and underserved areas. However, the proportion of family physicians who report providing mental health care is low. Policy barriers such as payment for mental health services should be explored to ensure access to mental health care for patients across the urban to rural continuum.

The Primary Care Extension Program: A Catalyst for Change - March 2013
The Affordable Care Act authorized, but did not fund, the Primary Care Extension Program (PCEP). Much like the Cooperative Extension Program of the US Department of Agriculture sped the modernization of farming a century ago, the PCEP could speed the transformation of primary care. It could also help achieve other goals such as integrating primary care with public health and translating research into practice. The urgency of these goals and their importance to achieving the Triple Aim for health care should increase interest in rapidly building the PCEP, much as the need to feed the country did a century ago.

A Small Percentage of Family Physicians Report Time Devoted to Research - January 2013
Despite calls by family medicine organizations to build research capacity within the discipline, few family physicians report research activity. Policy that supports efforts in family medicine research and increases awareness of opportunities for primary care research in the practice setting is essential for family medicine to expand its scholarly foundations.

The Rise of Electronic Health Record Adoption Among Family Physicians - January 2013
Realizing the benefits of adopting electronic health records (EHRs) in large measure depends heavily on clinicians and providers' uptake and meaningful use of the technology. This study examines EHR adoption among family physicians using 2 different data sources, compares family physicians with other office-based medical specialists, assesses variation in EHR adoption among family physicians across states, and shows the possibility for data sharing among various medical boards and federal agencies in monitoring and guiding EHR adoption.

The Redistribution of Graduate Medical Education Positions in 2005 Failed to Boost Primary Care or Rural Training - January 2013
Graduate medical education (GME), the system to train graduates of medical schools in their chosen specialties, costs the government nearly $13 billion annually, yet there is little accountability in the system for addressing critical physician shortages in specific specialties and geographic areas. Medicare provides the bulk of GME funds, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 redistributed nearly 3,000 residency positions among the nation's hospitals, largely in an effort to train more residents in primary care and in rural areas.


Engagement of family physicians in Maintenance of Certification remains high - December 2012
Maintenance of Certification for Family Physicians was created to enhance the quality of care delivered by family physicians but risked decreasing their engagement due to the increased burden of meeting additional requirements to remain board-certified. Participation by family physicians in Maintenance of Certification remains higher than predicted.

Projecting US Primary Care Physician Workforce Needs: 2010-2025 - November 2012
Researchers project the United States will need 52,000 additional primary care physicians by 2025 — a 25 percent increase in the current workforce — to address the expected increases in demand due to population growth, aging, and insurance expansion following passage of the Affordable Care Act. Analyzing nationally representative data, the researchers conclude population growth will be the single greatest driver of increased primary care utilization, requiring approximately 33,000 additional primary care physicians by 2025, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion, they estimate, will require approximately 8,000 additional primary care physicians, a 3 percent increase in the current workforce.

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.”

Measures of social deprivation that predict health care access and need within a rational area of primary care service delivery - July 2012
The geographic index has utility for identifying areas in need of assistance and is timely for revision of 35-year-old provider shortage and geographic underservice designation criteria used to allocate federal resources.

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.

A re-emerging political space for linking person and community through primary health care - June 2012
Current efforts to reform primary care are only intermediate steps toward a system with a greater focus on community and population health. Transformed and policy-enabled primary care is an essential link between personalized care and population health.

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.

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.

Medical school rural programs: A comparison with international medical graduates in addressing state-level rural family physician and primary care supply - April 2012
Despite their relatively small size, RPs had a significant impact on rural family physician and primary care supply compared with the much larger cohort of IMGs. Wider adoption of the RP model would substantially increase access to care in rural areas compared with increasing reliance on IMGs or unfocused expansion of traditional medical schools.

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.

The next phase of Title VII funding for training primary care physicians for America's health care needs - March 2012
Congress should act on the Council on Graduate Medical Education's recommendation to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually. This amount represents a small investment in light of the billions that Medicare currently spends to support graduate medical education, and both should be held to account for meeting physician workforce needs. Expansion of Title VII, Section 747 with the goal of improving access to primary care would be an important part of a needed, broader effort to counter the decline of primary care. Failure to launch such a national primary care workforce revitalization program will put the health and economic viability of our nation at risk.

Increasing Graduate Medical Education (GME) in Critical Access Hospitals (CAH) could enhance physician recruitment and retention in rural America - January 2012
Critical Access Hospitals (CAHs) are essential to a functioning health care safety net and are a potential partner of rural Graduate Medical Education (GME), which is associated with greater likelihood of service in rural and underserved areas. Currently, very little Medicare funding supports GME in the CAH setting, highlighting a missed opportunity to improve access to care in rural America.


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.

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.

Calling all scholars to the Council of Academic Family Medicine Educational Research Alliance (CERA) - July 2011
The mission of CERA is to set within family medicine a standard for medical education research that is rigorous and generalizable, to provide mentoring and education to junior researchers, to facilitate collaboration between medical education researchers, and to guide the specialty by providing leadership and vision in the arena of medical education research.

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.

An international health track is associated with care for underserved US populations in subsequent clinical practice - June 2011
Presence of an international health track (IHT) was associated with increased care of underserved populations. After the institution of an IHT track, this association was seen among IHT participants and nonparticipants and was not associated with increased long-term service abroad.

Accounting for Graduate Medical Education production of primary care physicians and general surgeons: Timing of measurement matters - May 2011
Residency expansion thresholds that do not account for production at least two to four years after completion of first residency overestimate eligibility. The overall primary care production rate from GME will not sustain the current physician workforce composition.

Family physician participation in maintenance of certification - May 2011
Large numbers of family physicians are participating in MOC. The significant association between practicing in underserved areas and lapsed board certification, however, warrants more research examining causes of differential participation. The penetrance of MOC engagement shows that MOC has the potential to convey substantial practice-relevant medical information to physicians. Thus, it offers a potential channel through which to improve health care knowledge and medical practice.

Rural-urban distribution of the U.S. geriatrics physician workforce - April 2011
Small numbers of geriatricians combined with a growing elderly population poses a challenge and an opportunity. Healthcare systems and policy-makers will need to modify care models to better use the skill of geriatricians in concert with other providers to provide quality care for older rural and urban Americans.

Seeking ethical approval for an international study in primary care patient safety - April 2011
Seeking ethics committee approval for research can be challenging even for relatively simple studies occurring in single settings. Complicating factors such as multicentre studies and/or contentious research issues can challenge review processes, and conducting such studies internationally adds a further layer of complexity. This paper draws on the experiences of the LINNAEUS Collaboration, an international group of primary care researchers, in obtaining ethics approval to conduct an international study investigating medical error in general practice in six countries.

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.

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.

Comparison between U.S. Preventive Services Task Force recommendations and Medicare coverage - January 2011
Medicare coverage for preventive services needs to be reassessed, with special focus on preventive coordination. Continuing previous practices will likely promote both inadequate and excessive delivery of preventive services. The new health care reform law has the potential to improve the provision of preventive services to Medicare beneficiaries.


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.

Use of measures of socioeconomic deprivation in planning primary health care workforce and defining health care need in Australia - October 2010
Using remoteness areas alone to prioritize workforce incentive programs and training requirements has significant limitations. Including measures of socioeconomic disadvantage and workforce supply would better target health inequities and improve resource allocation in Australia.

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.

The social mission of medical education: ranking the schools - June 2010
Medical schools vary substantially in their contribution to the social mission of medical education. School rankings based on the social mission score differ from those that use research funding and subjective assessments of school reputation. These findings suggest that initiatives at the medical school level could increase the proportion of physicians who practice primary care, work in underserved areas, and are underrepresented minorities.

Primary care and why it matters for U.S. health system reform - May 2010
We discuss the evidence for primary care's important functions and international experiences with primary care. We also describe how and why the United States has deviated from this fuller realization of primary care, as well as the steps needed to achieve primary care and health outcomes on a par with those of other developed countries.

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.

State tort reforms and hospital malpractice costs - March 2010
This study explored the relation between state medical liability reform measures, hospital malpractice costs, and hospital solvency. It suggests that state malpractice caps are desirable but not essential for improved hospital financial solvency or viability.

Does graduate medical education also follow green? - February 2010
Our findings support the concern expressed by the COGME that instead of responding to policy aims to correct shortage in the primary care pipeline, hospitals are instead training to meet hospital goals.

Avertable deaths associated with household income in Virginia - February 2010
If the mortality rates of the reference population had applied to the entire state, 24.3% of deaths in Virginia from 1990 through 2006 (range=21.8%–28.1%) would not have occurred. Further research must clarify the extent to which individual-level factors (e.g., earnings, education, race, health insurance) and community characteristics can improve health outcomes.

The impact of a clinic move on vulnerable patients with chronic disease: A geographic information systems (GIS) analysis - January 2010
Maps created from practice management data revealed a shift in patients when a clinic moved. Geographic information systems tools are valuable aids in defining changing service areas of primary health care clinics.

American Board of Family Medicine (ABFM) Maintenance of Certification: Variations in Self-Assessment Modules uptake within the 2006 cohort - January 2010
More than two-thirds of eligible, certified family physicians completed stage-one MC-FP requirements. Concerns that technical aspects of the new MC-FP paradigm would leave parts of a widely distributed, poorly resourced primary care workforce disadvantaged may hold true for providers in some underserved areas, but differential completion among rural and remote physicians was not found. Understanding barriers to uptake is essential if the specialty boards are to meet their obligations to the public to promote quality of care through Maintenance of Certification for all physicians.

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.


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.

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.

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.

Family medicine, the NIH, and the medical-research roadmap: Perspectives from inside the NIH - March 2009
NIH key informants generally appreciated family medicine clinically but viewed family medicine research as underdeveloped. Some identified opportunities for family medicine to lead, particularly CTSAs. Greater self-advocacy, research training,and developing areas of expertise may improve family medicine’s engagement with NIH.

How can primary care cross the quality chasm? - March 2009
The chasm between knowledge and practice decried by the Institute of Medicine (IOM) is the result of other chasms that have not been addressed. If we are to facilitate the production and use of the knowledge needed for primary care to cross IOM’s chasm, major changes are needed.


Off the roadmap? Family medicine's grant funding and committee representation at NIH - November 2008
Departments of family medicine, and family physicians in particular, receive a miniscule proportion of NIH grant funding and have correspondingly minimal representation on standing NIH advisory committees. Family medicine's engagement at the NIH remains near well-documented historic lows, undermining family medicine's potential for translating medical knowledge into community practice, and advancing knowledge to improve health care and health for the US population as a whole.

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.

Navigating general practice. The use of geographic information systems - October 2008
Geographic information systems (GIS) are powerful tools for managing, analysing and mapping geographical and associated data. In the health care setting, GIS can be used to map and graph health care provider and social and environmental data.

Primary care's eroding earnings: is congress concerned? - September 2008
Issues in primary care are not high on the congressional agenda, and Medicare's Sustainable Growth Rate (SGR) is the physician-payment issue on the minds of congressional staff members. Attempts to solve primary care's reimbursement difficulties should be tied to SGR reform.

Impact of Title VII training programs on community health center staffing and national health service corps participation - September 2008
Continued federal support of Title VII training grant programs is consistent with federal efforts to increase participation in the NHSC and improve access to quality health care for underserved populations through expanded CHC capacity.

Testing process errors and their harms and consequences reported from family medicine practices - June 2008
Errors occur throughout the testing process, most commonly involving test implementation and reporting results to clinicians. While significant physical harm was rare, adverse consequences for patients were common. The higher prevalence of harm and adverse consequences for minority patients is a troubling disparity needing further investigation.

Residency footprints: Assessing the impact of training programs on the local physician workforce and communities - May 2008
The effect of closing family medicine residency programs is likely to go undetected for many years. Decisions regarding the fate of family medicine programs are often made without benefit of a full assessment. Local and regional effects on physician access are often recognized only after the fact. Novel approaches to analysis and display of local effects of closures are essential for policy decisions concerning physician workforce training.

Nonemergency medicine-trained physician coverage in rural emergency departments - April 2008
Nonemergency physicians provide a significant portion of emergency department care, particularly in rural areas. Medical specialties must cooperate to ensure the availability of high-quality emergency department care to all Americans regardless of physician specialty.


Going global: Considerations for introducing global health into family medicine training programs - October 2007
Several hurdles can be anticipated in developing global health programs, including finances, meeting curricular and supervision requirements, and issues related to employment law, liability, and sustainability.

The Shoulder to Shoulder Model: Channeling medical volunteerism toward sustainable health change - October 2007
The Shoulder to Shoulder model allows health care professionals to channel short-term medical volunteerism into sustainable health partnerships with resource-poor communities. The resulting network of partnerships offers a powerful resource available to governments and foundations, poised to provide innovative interventions and cost-effective services directly to poor communities.

Seeking a replacement for the Medicare physician services payment method: A new approach improves health outcomes and achieves budgetary savings - July 2007
Key findings are that the single-payment rate is relatively inelastic to the Sustained Growth Rate (SGR) and expenditure levels and that the proposed service-specific payment rate promotes primary care, controls spending, and saves money.

Democratizing and displaying health data: Introducing - June 2007
A collaborative effort of the American Academy of Family Physicians, the Robert Graham Center for Policy Studies, the Health Foundation of Greater Cincinnati, and the University of Cincinnati, this site has three components: 1) Community Health View, 2) the Primary Care Atlas, and 3) the Health Center Mapping Tool. We describe the development and applications of this innovative platform, and how HealthLandscape helps its users to understand health and health needs in their community, evaluate programs, and influence policy.

The Canadian contribution to the U.S. physician workforce - April 2007
Minimizing emigration, and perhaps recruiting physicians to return to Canada, could reduce physician shortages, particularly in subspecialties and rural areas. In light of competing physician shortages, it will be important to consider policy options that reduce emigration, improve access to care and reduce reliance on physicians from developing countries.

Giving everyone the health of the educated: An examination of whether social change would save more lives than medical advances - April 2007
Higher mortality rates among individuals with inadequate education reflect a complex causal pathway and the influence of confounding variables. Formidable efforts at social change would be necessary to eliminate disparities, but the changes would save more lives than would society’s current heavy investment in medical advances. Spending large sums of money on such advances at the expense of social change may be jeopardizing public health.

Congruent satisfaction: Is there geographic correlation between patient and physician satisfaction? - January 2007
Despite geographic variation, there is a strong correlation between physician and patient satisfaction living in similar geographic locations. Further analysis of this congruence and examination of areas of incongruence between patient and physician satisfaction may aid in improving the healthcare system.

How well do family physicians manage skin lesions? - January 2007
This study demonstrates that most skin lesions seen by office-based family physicians resolve within three months, patients are generally satisfied with the care they receive, and the diagnostic and treatment decisions made by primary care physicians are not significantly different from those of their dermatologic colleagues.


Training on the clock: Family medicine residency directors' responses to resident duty hours reform - December 2006
Many FMPDs cited increased faculty burden and the risk of lower-quality educational experiences for their trainees. Innovations for increasing the effectiveness of teaching may ultimately compensate for lost educational time. If not, alternatives such as extending the length of residency must be considered.

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.

Learning from different lenses: Reports of medical errors in primary care by clinicians, staff, and patients - September 2006
Clinicians and staff offer different and independently valuable lenses for understanding errors and their outcomes in primary care, but both predominantly reported process- or system-related errors. There is a clear need to find more effective ways to invite patients to report on errors or adverse events. These findings suggest that patient safety organizations authorized by recent legislation should invite reports from a variety of health care workers and staff.

National Health Service Corps staffing and the growth of the local rural non-NHSC primary care physician workforce - September 2006
These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s.

International medical graduates in family medicine in the United States of America: An exploration of professional characteristics and attitudes - July 2006
There are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States.

The US medical liability system: Evidence for legislative reform - June 2006
Significant reductions in malpractice payments could be realized if total or noneconomic damage caps were operating nationally. Hard noneconomic damage and total damage caps could yield lower premiums. If tied to a comprehensive plan for reform, the money saved could be diverted to implement alternative approaches to patient compensation or be used to achieve other systems reform benefiting patients, employers, physicians, and hospitals.


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.

Using the ecology model to describe the impact of asthma on patterns of health care - May 2005
The ecology model confirmed that having asthma changes the likelihood and pattern of care for Americans. More importantly, the ecology model identified a subgroup with asthma who sought only emergent or hospital services.

What if we were equal? A comparison of the black-white mortality gap in 1960 and 2000 - March 2005
Using 2002 data, an estimated 83,570 excess deaths each year could be prevented in the United States if this black-white mortality gap could be eliminated.

Changes in age-adjusted mortality rates and disparities for rural physician shortage areas staffed by the National Health Service Corps: 1984-1998 - March 2005
From the early 1980s through the mid-1990s, the National Health Service Corps's goal to see health improve in rural health professional shortage areas was met, but its goal to diminish geographical health disparities was not. Because age-adjusted mortality rates improved in all county groups, the authors conclude that improvement was likely due to a variety of factors, including decreasing poverty and unemployment rates and increasing primary care physician-to-population ratios, to which the National Health Service Corps may have contributed.

Patients' beliefs about racism, preferences for physician race, and satisfaction with care - March 2005
Many African Americans and Latinos perceive racism in the health care system, and those who do are more likely to prefer a physician of their own race or ethnicity. African Americans who have preferences are more often satisfied with their care when their own physicians match their preferences.

Avoiding and fixing medical errors in general practice: Prevention strategies reported in the Linnaeus Collaboration's Primary Care International Study of Medical Errors - January 2005
In general practitioners’ medical errors reports, a culture of individual blame is more evident than recognised need for systems design. A minority of reports contained specific, pragmatic suggestions for changing healthcare systems to protect patients’ safety. Error reporting systems may be a practical way to generate innovative solutions to potentially harmful problems facing general practice patients.


The health impact of resolving racial disparities: An analysis of US mortality data - December 2004
Achieving equity may do more for health than perfecting the technology of care.

When do older patients change primary care physicians? - November 2004
Older patients, and particularly those who are older and have more education and income, tend to stay with their PCP until they are forced to change. The longer they stay in the relationship, the better they feel about the quality of the primary services they receive. Changes in the health care system may have increased the number of patients forced to change PCP.

Variation in participation in health care settings associated with race and ethnicity - October 2004
Fewer blacks and Hispanics than whites received healthcare in physicians’ offices, outpatient clinics, and emergency departments in contrast to hospitals and home care. Research and programs aimed at reducing disparities in receipt of care specifically in the outpatient setting may have an important role in the quest to reduce racial and ethnic disparities in health.

Modifiable determinants of healthcare utilization within the African-American population - September 2004
The three modifiable factors of poverty, uninsurance, and having a primary care medical home have a dramatic effect on patterns of care for African-American patients, and could be independently targeted for intervention

Follow-up on family practice residents' perspectives on length and content of training - September 2004
Although most surveyed residents favored a 3-year residency program, a substantial minority still supported extending training to 4 years, and the majority would still choose to enter family mdicine programs if theyr were extended. Given a lack of consensus about specific content areas, family medicine should consider a period of experimentation to determine how to best prepare future family physicians.

A string of mistakes: The importance of cascade analysis in describing, counting, and preventing medical errors - August 2004
Cascade analysis of physicians’ error reports is helpful in understanding the precipitant chain of events, but physicians provide incomplete information about how patients are affected. Miscommunication appears to play an important role in propagating diagnostic and treatment mistakes.

Future of family medicine recommendations confirm need for increased research from family physicians - June 2004
No abstract available.

Geographic retrofitting: A method of community definition in community-oriented primary care practices - June 2004
This paper describes a technique called "geographic retrofitting" that has proved useful in establishing a rigorous definition of a practice's community based on current patterns of health care by the community. It also demonstrates how this approach, used in conjunction with geographic information systems software, facilitates more-powerful capabilities in community characterization and intervention.

The research domain of family medicine - May 2004
The domain of family medicine research is important and ripe for fuller discovery, and it invites the thinking and imagination of the best investigators. It seems unlikely that medical research can ever be complete without a robust family medicine research enterprise. As the domain of family medicine research is explored, not a few, but billions of people will benefit.

Who are the uninsured elderly in the United States? - April 2004
This study reveals important gaps in the availability of health insurance for the elderly, gaps that are likely to affect an increasing number of older Americans in the coming decade.

Learning from malpractice claims about negligent, adverse events in primary care in the United States - April 2004
Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error-related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.

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.

The Balanced Budget Act of 1997 and the financial health of teaching hospitals - January 2004
Teaching hospitals realized deep cuts in profitability between 1996 and 1999; however, these cuts were not entirely attributable to the Balanced Budget Act of 1997. The role of Medicare in supporting GME has been substantially reduced and needs special attention in the overall debate.


A study of closure of family practice residency programs - November 2003
The rate of program closure is increasing, affecting programs that meet most measures of high quality. Quality programs are being lost, and the ultimate impact is yet to be seen. Program directors offer warning signs and advice that is generally applicable to other family practice residency programs.

Exploring residency match violations in family practice - November 2003
Real and potential Match violations did occur, but there is also considerable confusion about what constitutes a violation. There are opportunities to investigate violations, train students to recognize and deal with violations, and clarify actual violation definitions and for programs to avoid the real and perceived violations that affect their recruiting.

Disparities in health care in the United States apparent in the ecology of medical care - October 2003
No abstract available.

The need for research in primary care - October 2003
The knowledge base for family practice must be expanded by integration of multiple methods of comprehension, so we can bridge the gap between evidence and practice.

Variation in the ecology of medical care - July 2003
Frequency and location of health care delivery varies substantially with sociodemographic characteristics, insurance, and having a usual source of care. Understanding this variation can inform public consideration of policy related to access to care.

Oral Vitamin D3 decreases fracture risk in the elderly - June 2003
The 5-year overall, age-adjusted fracture risk was lower for the patients receiving vitamin D (relative risk [RR]=0.78; 95% confidence interval [CI]=0.61–0.99). Important fractures were also significantly lower—that is, those occurring at the hip, wrist, forearm, or vertebrae (RR=0.67; 95% CI=0.48–0.93) Hip fractures, a known cause of severe morbidity in the elderly, were not significantly lower in the treated group; again, the study was probably too small or too brief to find a difference if one existed. With respect to secondary outcomes, the vitamin D group, compared with the placebo group, had no statistically significant difference in self-reported health and falls, or mortality from cardiovascular disease, cancer, or all causes.

Receipt of preventive care among adults: Insurance status and usual source of care - May 2003
Having a usual source of care and health insurance are both important to achieving national prevention goals.

The ecology of medical care for children in the United States - May 2003
The ecology of children's medical care is similar to that of adults in the United States in that a substantial proportion of children receive health care each month, mostly in community-based, outpatient settings. In all settings except emergency departments, receipt of care varies significantly by children's age, race, ethnicity, income, health insurance status, and whether they have a usual source of care.

International medical graduates and the primary care workforce for rural underserved areas - March 2003
IMGS appear to have been no more likely than USMGs were to practice primary care in RUAs, but the distribution by specialty differs.

The effects of the 1997 Balanced Budget Act on family practice residency training programs - February 2003
The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue.


Classification of medical errors and preventable adverse events in primary care: A synthesis of the literature - November 2002
Original research on medical errors in the primary care setting consists of a limited number of small studies that offer a rich description of medical errors and preventable adverse events primarily from the physician's viewpoint. We describe a classification derived from these studies that is based on the actual practice of primary care and provides a starting point for future epidemiologic and interventional research. Missing are studies that have a patient, consumer, or other health care provider input.

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.

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.

Accounting for graduate medical education funding in family practice training - September 2002
More than half of family practice training programs do not know how much GME they receive. These findings call for improved accountability in the use of Medicare payments that are designated for medical education.

A preliminary taxonomy of medical errors in family practice - September 2002
This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

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.

An international taxonomy for errors in general practice: A pilot study - July 2002
This pilot study indicates that errors are likely to affect primary care patients in similar ways in countries with similar primary healthcare systems. Further comparative studies are required to improve our understanding of general practice error differences between Australia and other countries.

First morning back - June 2002
This diary-based report documented the increasing difficulty of practicing in primary care settings. Medical knowledge and skills are, in general, the easy part; getting into a position to apply them is the challenge.

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.

The association of Title VII funding to departments of family medicine with choice of physician specialty and practice location - June 2002
Title VII has been successful in achieving its stated goals and legislative intent and has had an important role in addressing US physician workforce policy issues.

Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care? - March 2002
An inability to care for patients is significantly associated with career dissatisfaction. This relationship has implications for the achievement of policy objectives related to access, having a usual source of care and quality.

Length and content of family practice residency training - March 2002
Most respondents support the current three year model of training. There is considerable interest in changing both the length and content of family practice training. Lack of consensus suggests a period of elective experimentation may be needed to assure that family physicians are prepared to meet the needs and expectations of their patients.

Patients' rights in the United States: From 'down-under' the situation seems upside-down - February 2002
No abstract available. Free full text version available.

The role of family practice in different health care systems: A comparison of reasons for encounter, diagnoses, and interventions in primary care populations in the Netherlands, Japan, Poland, and the United States - January 2002
Even under different conditions there was substantial overlap in the top 30 symptom/complaint reasons for encounter, incidence rates, and encounters per diagnosis in the 4 countries we studied. This striking resemblance supports the concept of the reason for encounter as a core element of the consultation with a family physician. Similarities between the databases are much better reflected by the way patients formulate their demand for care than in the diagnoses by the family physician. US patients also see providers other than family physicians for common problems; it remains unclear whether a limited group brings most of their health problems to a family physician or whether most people visit a series of primary care physicians. Possibilities to further develop episode-oriented epidemiology in family practice have considerably increased with this study. The potential for comparative studies has also increased with the introduction of complete electronic patient records based on the documentation of episodes of care with the ICPC and with its mapping to International Classification of Disease-10th revision (or the 9th revision clinical modification.)


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

Using geographic information systems to understand health care access - November 2001
Given the relative universality of such data collection from CHCs nationwide and recent political commitment to doubling the capacity of CHCs over the next five years, we suggest options for developing centralized processes for evaluating CHC service areas and local unmet health care access needs.

The ecology of medical care revisited - October 2001
No abstract available.

Family physicians' experiences of their fathers' health care - October 2001
Even patients with a knowledgeable physician family member face challenges in receiving optimal medical care. Patients might receive better treatment if health care systems reinforced the role of an accountable attending physician, encouraged continuity of care, and emphasized the value of knowing the patient as a person.

Role conflicts of physicians and their family members: Rules but no rulebook - October 2001
Conflicting rules of appropriate conduct, compounded by the inadequacies of modern health care, make the role of physician-family member especially challenging. The medical profession needs a clearer, more trenchant understanding of this role.

Hispanic versus white, non-Hispanic physician medical practices in Colorado - August 2001
These findings argue for special provision to admit ethnic minorities to undergraduate and graduate medical education programs.

Direct graduate medical education payments to teaching hospitals by Medicare: Unexplained variation and public policy contradictions - May 2001
Inherent inequities in DME funding seriously undermine the current Medicare GME payment system's capacity to contribute to US physician workforce reform and to improve access to care. There is actually a financial incentive to train residents in areas in which there is relatively less need for their services.

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.

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.

Shortchanging adolescents: Room for improvement in preventive care by physicians - February 2001
Adolescents visit physicians infrequently. When they do, few receive counseling on critical adolescent health issues. Both family physicians and pediatricians have room for improvement.


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.


The development and goals of the AAFP Center for Policy Studies in Family Practice and Primary Care - November 1999
In this article we describe the creation and role of the Center for Policy Studies in Family Practice and Primary Care established by the American Academy of Family Physicians in Washington, DC, this year. We recount the events leading to the decision to implement the Center, list its guiding assumptions, and explain its initial structure and function. We also identify the three themes that will guide the early work of the Center: sustaining the functional domain of family practice and primary care; investing in key infrastructures; and securing universal health coverage.

Multi-method assessment of access to primary medical care in rural Colorado - March 1999
The results of simultaneous application of distance-to-care and provider-to-population techniques unrestricted by geographic boundaries, depict access to primary medical care and corresponding consumer difficulty more fully than previously done. Further combination of methods of needs assessment such as those used in this analysis may better inform the future efforts of organizations mandated to address health care underservice in rural areas.

Health care transition counseling for youth with special health care needs -

Trends in Office-Based Care for Reproductive-Aged Women According to Physician Specialty: A Ten-Year Study -