Academic practices and departments are defined by a tripartite mission of care, education, and research, conceived as being mutually reinforcing. But in practice, academic faculty have often experienced these 3 missions as competing rather than complementary priorities. This siloed approach has interfered with innovation as a learning health system in which the tripartite missions reinforce each other in practical ways. This paper presents a longitudinal case example of harmonizing academic missions in a large family medicine department so that missions and people interact in mutually beneficial ways to create value for patients, learners, and faculty. We describe specific experiences, implementation, and examples of harmonizing missions as a feasible strategy and culture. \"Harmonized\" means that no one mission subordinates or drives out the others; each mission informs and strengthens the others (quickly in practice) while faculty experience the triparate mission as a coherent whole faculty job. Because an academic department is a complex system of work and relationships, concepts for leading a complex adaptive system were employed: (1) a \"good enough\" vision, (2) frequent and productive interactions, and (3) a few simple rules. These helped people harmonize their work without telling them exactly what to do, when, and how. Our goal here is to highlight concrete examples of harmonizing missions as a feasible operating method, suggesting ways it builds a foundation for a learning health system and potentially improving faculty well-being.

BACKGROUND: Geopolitical and socioeconomic challenges limit faculty development and clinical teaching in Palestine and many other developing countries. The first, and still only, Family Medicine (FM) residency program is a four-year program based out of An-Najah University in the West Bank. Training in primary care clinics occurs in the final two years and there are many challenges to adequate supervision in the clinical setting that were exacerbated during the pandemic. To improve the readiness for practice skills of 13 Palestinian FM residents a three-month tutorial program was organized in 2020. A nongovernmental organization (NGO) that has worked to support Family Medicine development in the region engaged experienced British and American General Practitioners trained as tutors to offer online tutorials. We examined the program as a case study to understand the factors that facilitated or impaired a positive virtual learning environment in a middle/low income country.
METHODS: The tutors and residents were divided into groups and met virtually between June and September 2020. Evaluations and session reports collected during the program, the text of an online chat, and responses to an online survey two years later were collected. Using thematic analysis techniques, we evaluated the value for the residents at the time and two years later and identified factors that facilitated or impaired a positive virtual learning environment.
RESULTS: Themes of knowledge, skills, attitudes, cultural disconnects, and tutorial logistics emerged. The group with the most stable tutor pairing, including one Arabic-speaker familiar with the context, was the most engaged. The all-female group formed a chat group to share real-time case questions during clinical practice and focused on skills (e.g. conducting a thorough medication review) and attitudes (e.g. open to sharing and discussing uncertainties). Other groups were less cohesive.
CONCLUSIONS: Transnational tutorials that focused on clinical thinking and decision-making skills were most successful when the tutorial pair was stable, offered familiarity with the language and addressed cultural differences. Intrinsic factors such as lacking the motivation to participate and extrinsic factors such as unstable internet and rolling electric cuts, and clinical structures that made applying new skills challenging were more difficult to address but must be considered.

Teaching family medicine to medical students is primarily intended to aid in their understanding of the distinctive and significant role that the speciality performs within the healthcare system. Improving medical students\' comprehension of family medicine may have an impact on their decision to pursue family medicine as a speciality. It is important to use innovative evidence-based teaching and learning strategies and ensure that medical students receive extra learning opportunities in family medicine. This is a short report highlighting the use of audio-visual aids and case studies to enhance the understanding of family medicine principles among undergraduate medical students attending a private university in Ghana.Contribution: This short report offers family medicine teachers and educators at the undergraduate level an example of how to apply audio-visual aids and case studies to enhance the understanding of family medicine principles among students. The report contributes to the growth of family medicine as a speciality within the African context.

BACKGROUND: Consultation with primary healthcare professionals may provide an opportunity to identify patients at higher suicide risk.
OBJECTIVE: To explore primary care consultation patterns in the 5 years before suicide to identify suicide high-risk groups and common reasons for consulting.
METHODS: This was a case-control study using electronic health records from England, 2001 to 2019.
METHODS: An analysis was undertaken of 14 515 patients aged ≥15 years who died by suicide and up to 40 matched live controls per person who died by suicide (n = 580 159), (N = 594 674).
RESULTS: Frequent consultations (>1 per month in the final year) were associated with increased suicide risk (age- and sex -adjusted odds ratio [OR] 5.88, 95% confidence interval [CI] = 5.47 to 6.32). The associated rise in suicide risk was seen across all sociodemographic groups as well as in those with and without psychiatric comorbidities. However, specific groups were more influenced by the effect of high-frequency consultation (>1 per month in the final year) demonstrating higher suicide risk compared with their counterparts who consulted once: females (adjusted OR 9.50, 95% CI = 7.82 to 11.54), patients aged 15-<45 years (adjusted OR 8.08, 95% CI = 7.29 to 8.96), patients experiencing less socioeconomic deprivation (adjusted OR 6.56, 95% CI = 5.77 to 7.46), and those with psychiatric conditions (adjusted OR 4.57, 95% CI = 4.12 to 5.06). Medication review, depression, and pain were the most common reasons for which patients who died by suicide consulted in the year before death.
CONCLUSIONS: Escalating or more than monthly consultations are associated with increased suicide risk regardless of patients\' sociodemographic characteristics and regardless of the presence (or absence) of known psychiatric illnesses.

BACKGROUND: Despite longstanding problems of access to general practice, attempts to understand and address the issues do not adequately include perspectives of the people providing or using care, nor do they use established theories of access to understand complexity.
OBJECTIVE: To understand problems of access to general practice from the multiple perspectives of service users and staff using an applied theory of access.
METHODS: A qualitative participatory case study in an area of northwest England.
METHODS: A community-based participatory approach was used with qualitative interviews, focus groups, and observation to understand perspectives about accessing general practice. Data were collected between October 2015 and October 2016. Inductive and abductive analysis, informed by Levesque et al\'s theory of access, allowed the team to identify complexities and relationships between interrelated problems.
RESULTS: This study presents a paradox of problems in accessing general practice, in which the demand on general practice both creates and hides unmet need in the population. Data show how reactive rules to control demand have undermined important aspects of care, such as continuity. The layers of rules and decreased continuity create extra work for practice staff, clinicians, and patients. Complicated rules, combined with a lack of capacity to reach out or be flexible, leave many patients, including those with complex and/or unrecognised health needs, unable to navigate the system to access care. This relationship between demand and unmet need exacerbates existing health inequities.
CONCLUSIONS: Understanding the paradox of access problems allows for different targets for change and different solutions to free up capacity in general practice to address the unmet need in the population.

The COVID-19 pandemic led to the widespread and continuing use of telemedicine in primary care. Despite telemedicine\'s benefits, it threatens to reduce the role of family physician to that of gatekeeper and case manager, nullifying decades of experience and medical intuition that is more difficult to develop and apply virtually. Additionally, many values of family medicine have eroded during this global process. The narrative presents 3 vignettes that illustrate different ways in which we contend with this complex issue. The challenges presented by telemedicine require us to re-examine our professional and personal values such as maintaining the centrality of the therapeutic relationship with patients. The greatest concern, however, relates to the future of the profession and the ability of new family doctors to overcome the challenges of telemedicine in an increasingly digital world.

UNASSIGNED: Although people with a migration background (MB) have more unmet mental health needs than the general population, patients with a MB are still underrepresented in mental health care services. Provider bias towards these patients has been evidenced repeatedly but its driving factors remain elusive. We assessed the moderating effect of the individual (e.g. age and ethnicity), interpersonal (e.g. healthcare provider trust), and organisational (e.g. perceived workload) factors on general practitioners (GPs) differential decision-making regarding diagnosis, treatment, and referral for a depressed patient with or without a MB.
UNASSIGNED: An experimental study was carried out in which GPs were shown one of two video vignettes featuring adult male depressed patients, one with a MB and the other without. Belgian GPs (n = 797, response rate was 13%) had to decide on their diagnosis, treatment, and referral. Analysis of variance and logistic regression were used to analyse the effect of a MB, adding interaction terms for the explanatory variables.
UNASSIGNED: Overall, we found that there were ethnic differences in GPs\' decisions regarding diagnosis and treatment recommendations. GPs perceived the symptoms of the patient with a MB as less severe (F = 7.68, p < 0.01) and demonstrated a reduced likelihood to prescribe a combination of medical and non-medical treatments (F = 11.55, p < 0.001). Those differences increased in accordance with the GP\'s age and perceived workload; at an interpersonal level, we found that differences increased when the GP thought the patient was exaggerating his distress.
UNASSIGNED: This paper showed that lower levels of trust among GPs\' towards their migrant patients and high GP workloads contribute to an increased ethnic bias in medical decision-making. This may perpetuate ethnic inequalities in mental health care. Future researchers should develop an intervention to decrease the ethnic inequities in mental health care by addressing GPs\' trust in their migrant and ethnic minority patients.

BACKGROUND: The concept of Care Assistant in General Practice (VERAH) was developed in order to integrate non-medical staff more strongly into primary care and thus to meet the increasing demand for care and the simultaneous shortage of medical staff. VERAHs are increasingly responsible for software-supported case management and are thus confronted with new tasks. The aim of this study was therefore to explore the role of the VERAH in primary care practices.
METHODS: The present study is a qualitative secondary data analysis; the data collection took place within the projects VESPEERA and TelePraCMan. Twenty individual interviews and two focus group meetings were conducted with a total of 30 physicians, VERAHs and medical assistants from primary care. The data were analysed qualitatively according to Emerson. Contextual and socio-demographic data were collected with an accompanying questionnaire.
RESULTS: The VERAHs of all primary care practices from which interview partners participated performed tasks within software-supported case management. Concerning the role of the VERAH, three themes were identified in the interviews: a) concrete tasks of the VERAH in software-supported case management within the practice team, b) relevance of software-supported case management within the activities of the VERAHS and c) relationship between VERAHs and patients.
CONCLUSIONS: Taking over tasks in software-supported case management can contribute to strengthening and expanding the role of the VERAH. In the future, more attention should be paid to a clear description of the new role, and the conditions of the VERAHs\' task fulfilment should be considered.
UNASSIGNED: Das Konzept der Versorgungsassistentin in der Hausarztpraxis (VERAH) wurde entwickelt, um nicht-ärztliches Personal stärker in die hausärztliche Versorgung einzubinden und somit dem steigenden Versorgungbedarf und der gleichzeitigen Verknappung von ärztlichem Personal zu begegnen. VERAHs werden zunehmend auch im softwaregestützten Case Management eingesetzt und sind somit mit neuen Aufgaben und Verantwortungsgefügen konfrontiert. Das Ziel dieser Studie war es daher, zu explorieren, wie sich die Rolle der VERAH in hausärztlichen Praxen darstellt.
METHODS: Bei der vorliegenden Studie handelt es sich um eine qualitative Sekundärdatenanalyse im Rahmen der Projekte VESPEERA und TelePraCMan. Es wurden 20 Einzelinterviews und 2 Fokusgruppen mit insgesamt 30 Ärzt:innen, VERAHs und Medizinischen Fachangestellten aus der hausärztlichen Versorgung durchgeführt. Die Analyse der Daten fand qualitativ in Anlehnung an Emerson statt. Kontext- und soziodemographische Daten wurden mit einem begleitenden Fragebogen erhoben.
UNASSIGNED: Die VERAHs aller Hausarztpraxen, aus denen Interviewpartner:innen teilnahmen, nehmen Aufgaben innerhalb des softwaregestützten Case Management wahr. In den Aussagen zur Rolle der VERAH ließen sich drei Themen identifizieren: a) Beschreibung der konkreten Aufgaben der VERAH im softwaregestützten Case Management innerhalb des Praxisteams, b) Stellenwert des softwaregestützten Case Managements innerhalb der Tätigkeiten der VERAHS und c) Beziehung der VERAHs zu den Patient:innen.
UNASSIGNED: Die Wahrnehmung von Aufgaben des softwaregestützten Case Managements kann zu einer Stärkung und Erweiterung der Rolle der VERAH beitragen. Künftig sollte verstärkt auf eine klare Beschreibung der neuen Rolle geachtet und die Rahmenbedingungen der Aufgabenerfüllung der VERAH berücksichtigt werden.

Introduction Healthcare inequity disproportionately affects minority populations in Aotearoa New Zealand. Healthcare providers may contribute to inequity due to their biases. Medical education can unintentionally promote biases by reinforcing stereotypes or limiting exposure to diversity. Teaching staff from the Department of General Practice and Rural Health suggested a need to review current teaching materials to ascertain if they have the potential to contribute to this bias. Aim The aim of this study was to review case-based teaching material to determine its representation of the New Zealand population, and whether there is potential to contribute to implicit bias. Methods Document analysis of 135 cases used to teach fourth- and fifth-year medical students in the Department of General Practice and Rural Health, Otago Medical School was performed. Demographic, clinical and social features of each case were recorded and analysed. Results Cases typically included patient age (129/135, 95.6%), sex (127/135, 94.1%) and occupation status (91/136, 66.9%). Ethnicity (31/135, 23.0%), living situation (55/135, 40.7%), relationship status (57/135, 42.2%) and sexual orientation (52/135, 40.0%) were less frequently defined. Cases typically represented the population majority norms. Discussion Case-based teaching materials require regular review and updating to match population demographics. There is potential to improve representation of diversity, and hence cultural safety, though review and revision of written teaching cases.

Social and structural factors play a critical role in driving inequitable health outcomes, resulting in the need for undergraduate medical education to include important care components such as team-based care to address social determinants of health. Research shows that learning strategies such as case-based initiatives are valuable opportunities to impact knowledge of population health, health disparities, and social determinants that impact care. The purpose of this study was to assess the impact of a clinical case-based experience on medical students\' self-efficacy and future intent to use the team-based care necessary to address social determinants of health.
We used a retrospective analysis of program data from 640 third-year medical students who engaged in a case-based experience and small-group debriefing around the impact of team-based care and social determinants of health on patient care during their family medicine clerkship between July 2020 and April 2022.
We found a statistically significant improvement in students\' reported self-efficacy and intent to collaborate with other health care workers (team-based care) to address patient care needs in rural and urban underserved community settings.
Our students reported that a case-based experience coupled with a small-group debriefing was an effective method for teaching them how to use a team-based approach to address social determinants of health.