In This Issue: Developing and Amplifying the Effectiveness of the Primary Care Workforce
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* Kurt C. Stange

In addition to a number of interesting clinical research studies and reflections, articles in this issue illuminate how the primary care workforce can be expanded and made more effective.

A shortage of primary care physicians and a shortfall in production rates is projected in analyses by Liaw and colleagues.1 Changing care delivery models toward small panel sizes substantially increases the shortage.

Willard-Grace et al show how the effectiveness of the primary care workforce can be enhanced by involving medical assistants as in-office health coaches.2

Medical assistant health coaches are effective in helping patients to meet goals for diabetes control and cholesterol reduction, but not blood pressure treatment. This article is this issue’s *Annals* Journal Club.3

Social networks within primary care practices, in terms of the density of interactions among team members, are associated with fewer hospital days and lower medical care costs for patients with cardiovascular disease, according to a study by Mundt and colleagues.4 This important relationship is mediated by the team’s degree of shared vision about goals and expectations.

For those evaluating change toward the patient-centered medical home, Goldman and colleagues provide a mixed methods roadmap that examines both patient and practice processes and outcomes.5

Jackson and colleagues provide information to guide how we arrange follow-up of patients to reduce hospital readmissions.6 They find that most patients do not benefit from early outpatient follow-up, and they identify a subgroup based on multimorbidity and risk that may benefit from early hospital follow-up.

A study of a large sample of older people with multiple medical conditions finds that continuity of care is associated with lower rates of hospital use, even in an integrated delivery system with shared electronic medical records that provide continuity of information to different health care providers.7

Another study of patients with multiple chronic medical conditions, by Mercer and colleagues, finds that multimorbidity is strongly associated with hospitalization across 3 widely different health care systems, but the relationship between socioeconomic deprivation, multimorbidity, and hospital admission varies across different systems in ways that give insights into how systems might be made equitable and effective.8

Inviting people to be screened for type 2 diabetes turns out to have a limited effect on cardiovascular morbidity, self-rated health, or health behavior after 7 years of follow-up, in a study by Griffin and colleagues.9

A longitudinal study of chronic abdominal pain in children finds that pain persists for at least 1 year in one-third of children. The study identifies some modestly useful but practical predictors of persistent pain.10

Two essays hit hard with personal reflections on challenging interpersonal relationships. Vidal asks why medical schools tolerate unethical behavior by their faculty11 and Hughes shares her personal struggle after witnessing a man commit suicide.12

Finally, a pair of Point-Counterpoint articles argue the question: is secondhand smoke exposure a form of child abuse?13,14

We welcome your reflections at [http://www.AnnFamMed.org](http://www.AnnFamMed.org).

*   © 2015 Annals of Family Medicine, Inc.

## References

1.  Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the residency expansion required to avoid projected primary care physician shortages by 2035. Ann Fam Med. 2015;13(2):107–114.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xMDciO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  Willard-Grace R, Chen EH, Hessler D, et al. Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial. Ann Fam Med. 2015;13(2):130–138.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xMzAiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  Rohrberg T. *Annals* Journal Club. Impact of medical assistants as health coaches. Ann Fam Med. 2015;13(2):iii.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMS9paWkiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  Mundt MP, Gilchrist VJ, Fleming MF, Zakletskaia LI, Tuan W-J, Beasley JW. Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease. Ann Fam Med. 2015;13(2):139–148.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xMzkiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

5.  Goldman RE, Parker DR, Brown J, Walker J, Eaton CB, Borkan JM. Recommendations for a mixed methods approach to evaluating the patient-centered medical home. Ann Fam Med. 2015;13(2):168–175.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xNjgiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

6.  Jackson C, Shahsahebi M, Wedlake T, DuBard CA. Timeliness of outpatient follow-up: an evidence-based approach for planning after hospital discharge. Ann Fam Med. 2015;13(2):115–122.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xMTUiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

7.  Bayliss EA, Ellis JL, Shoup J, Zeng C, McQuillan DB, Steiner JF. Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system. Ann Fam Med. 2015;13(2):123–129.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xMjMiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

8.  Wang HHX, Wang JJ, Lawson KD, et al. Relationships of multimorbidity and income with hospital admissions in 3 health care systems. Ann Fam Med. 2015;13(2):164–167.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xNjQiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

9.  Echouffo-Tcheugui JB, Simmons RK, Prevost AT, et al. Long-term effect of population screening for diabetes on cardiovascular morbidity, self-rated health, and health behavior. Ann Fam Med. 2015;13(2):149–157.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xNDkiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

10. Spee LAA, Lisman-van Leeuwen Y, Benninga MA, Bierma-Zeinstra SMA, Kollen BJ, Berger MY. Predictors of chronic abdominal pain affecting the well-being of children in primary care. Ann Fam Med. 2015;13(2):158–163.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xNTgiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

11. de Oliveira Vidal EI, dos Santos Silva V, dos Santos MF, Jacinto AF, Villas Boas PJF, Fukushima FB. Why medical schools are tolerant of unethical behavior. Ann Fam Med. 2015;13(2):176–180.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xNzYiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

12. Hughes LS. You can’t hide the bridges. Ann Fam Med. 2015;13(2):181–183.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xODEiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

13. Goldstein AO. Is exposure to secondhand smoke child abuse? Yes. Ann Fam Med. 2015;13(2):103–104.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xMDMiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

14. Lindhorst T. Is exposure to secondhand smoke child abuse? No. Ann Fam Med. 2015;13(2):105–106.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTMvMi8xMDUiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzEzLzIvMTAyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)