Climate change: Implementing a resident-centered anonymous reporting tool to promote a safe & inclusive learning climate.
Cuervo, I; Mostow, J; Muralles, S; Priyam*, P;  Richardson, E;  Saho, F; Younge, M; HollandBerry, K; Echiverri, A. 

Context & Objective: Cultivating a safe and inclusive learning climate is a critical component in the recruitment and retention of residents under-represented in medicine into faculty and leadership roles. A focus on learning climate will lift up challenging issues related to bias, microaggressions, racism and oppression experienced by learners. We aim to address this by implementing an anonymous reporting tool for learners to identify harms that occur, and develop mechanisms to address and prevent harm.

Setting/Populations: The Contra Costa Family Medicine Residency is a community-based program embedded within a county health system that prioritizes full spectrum family medicine training to address the needs of under-resourced communities. Our program has deepened our work around diversity, equity, inclusion and antiracism (DEIA), with learning climate as a key priority.

The Learning Climate Committee leads this work and is composed of 7 resident leaders representing our Diversity Council and Leadership Board, and 2 faculty representing different departments.

Intervention/Study Design: The Learning Climate Committee has met weekly since November to identify shared goals and vision, evaluate resources related to reporting platforms, garner critical support from residency and system leaders, and structure a pilot for tool implementation. With gratitude to colleagues at Sutter Santa Rosa, we adapted their bias incident tool and tailored it to meet program needs. We implemented a pilot with limited scope to gather data, provide support, prioritize safety and develop tools to mitigate learning climate issues.

Outcomes/Results: The anonymous reporting tool pilot was implemented in February 2022 focused on data gathering, developing standardized protocols to address harms, and considering ways to prevent harms through residency-wide education and training, and adapting departmental policies and practices.

The Learning Climate Committee has navigated the change management process by incorporating the perspectives of multiple key stakeholders, grounded our work with shared values and vision, garnered critical support from leadership, and deepened our purpose in cultivating safe and inclusive spaces for residents.

Conclusions: Cultivating a safe and inclusive learning climate is a critical component to the deepening of our program’s DEIA work. The anonymous reporting tool centers the experiences of learners and will help us address and prevent harms, and foster spaces of belonging overall.

---

Development of a novel online mentorship program for URM students
Cevallos*, J; Mora*, V; Sanchez*, N; Tapia, M.

Context & Objective: Latinx and Black students have been historically underrepresented among medical school applicants and matriculants relative to US population.  Leveraging collaboration between two prominent national organizations dedicated to matriculation of these students into medical school, Latino Medical Student Association (LMSA) and the Student National Medical Association (SNMA), we developed a novel online mentorship program providing individual virtual appointments with diverse medical student mentors. Mentorship programs are effective imperatives; yet, labor intensive and inaccessible for some.  This model can be a tool to help equitably reach students.

Setting/Populations: Mentors were recruited from 10 medical schools. Mentorship topics included: general pre-medical advice, AMCAS assistance, practice interviews, or written narrative review.

Intervention/Study Design: A 5-point Likert scale assessed student confidence, comfort, satisfaction, and sense of preparedness. A qualitative component queried thematic areas to be included in future sessions. We plan to identify qualitative response themes to elicit deeper understanding of specific concepts that led to success.

Outcomes/Results: In one month, 734 appointments were completed out of 846 booked (89%) nationwide. 498 unique participants were reached; 20% scheduled more than one appointment. Appointments booked were 55% general pre-medical advice, 22% AMCAS assistance and 20% practice interviews. 90% of respondents (n=80) strongly agreed to feeling more prepared and confident in applying and would recommend to other URM students.

Conclusions: The virtual nature of the program allowed connection to a high volume of often under-resourced mentees across different time zones.

---

Centering equity: creating a family medicine resident population health curriculum with a diversity, equity, inclusion and anti-racism lens
Toub, D*; Mayeda, M. 

Context & Objective: Sutter Santa Rosa Family Medicine Residency (SSRFMR)’s population health curriculum has historically focused on clinical quality measures (CQMs) within the teaching clinic. A data analysis on health disparities revealed: 1) lack of insurance as the largest driver in disparate CQM outcomes and 2) poor fidelity in collecting race (>25% unknown or unreported) data.

Setting/Populations: SSRFMR is a UCSF-affiliated community-based residency at a large FQHC 60 miles north of San Francisco.

Intervention/Study Design: We aligned curriculum goals and objectives with Accreditation Council for Graduate Medical Education (ACGME) Program Requirements and Association of Family Medicine Residency (AFMRD) Diversity, Equity and Inclusion (DEI) milestones. Residents will: 1) analyze their panels (and county-wide community data) for health disparities with CQMs using an ecological framework, reflecting on factors driving disparities 2) screen hyper-marginalized (non-English/non-Spanish speaking and minority) patients who are not meeting a CQM for Structural Drivers of Health (SDoH), then 3) connect those patients to community resources and to health insurance. Residents will self-assess using the AFMRD SDoH Milestone, and SSRFMR will use Entrustable Professional Activities (EPAs) for measuring and analyzing CQM disparities developed as part of this curriculum. Patient-level outcomes for curriculum evaluation will include: 1) reducing the number of uninsured resident patients and 2) reducing the number of resident patients with unknown or unreported race, ethnicity and primary language (REL) data. With time, another evaluation tool will be measuring EPA scores as the number of SSRFMR QI projects that directly address DEI and community engagement.

Outcomes/Results: We reviewed the draft curriculum with clinic and residency stakeholders and piloted self-assessment with the AFMRD SDoH Milestone and the EPAs with residents. An external DEI consultant added readings in order to reflect on the historical and sociopolitical context of these disparities. Our curriculum launches June 2022 with a QI project addressing barriers to insurance enrollment as an anti-racism education tool and promoting standardized collection of REL data.

Conclusions: Implementing resident QI projects without a connection to structural issues is no longer acceptable in family medicine resident education. Focusing a resident curriculum on population health equity is necessary and feasible.

Improving care for patients with limited English proficiency in a community residency program
Jordan, V.

Context & Objective: Limited English proficiency (LEP) has negative impacts on health, including lower rates of preventive services, higher acuity of illness at presentation to the hospital, and longer hospital stays. There have been frequent reports, amplified by residents of color, of hospitalized patients with LEP not being communicated with in their preferred language. While video remote interpreter services (VRI) have become increasingly available, there has been no formal assessment of the LEP patient population or of the provision of language-appropriate services by hospital staff. The COVID pandemic magnified these concerns and the need for systemic change.

Setting/Populations: Sutter Santa Rosa Regional Hospital administration, departmental leaders, hospital staff, med staff, and family medicine faculty and residents

Intervention/Study Design: We used electronic medical record data to quantify the patient population, interpreter usage data to examine trends, and documentation of interpreter use to understand how often patients were being communicated with in their preferred language. We presented this data to hospital leadership and asked for administrative attention to this important health equity issue.

Outcomes/Results: Almost 12% of the 6,883 patients hospitalized in 2021 prefered a language other than English; in fact, 13.2% of all hospitalized patients designated Spanish as their preferred language. VRI usage in the hospital increased 413% between 2018 and 2021; however, in 2021 documented use of interpreters per hospital encounter was low– only 25.3%. There was variability across departments, ranging from 15.4% (ED) to 40.9% (L&D) to 77.8% (Telemetry). This data was presented at Grand Rounds, shared with administration and departmental leaders, and formally added to the hospital safety dashboard.

Conclusions: We have the legal/ethical obligation and tools to ensure that medical interpretation is standard of care for every LEP patient encounter by every healthcare worker. Extracting and disseminating local data was a powerful tool to advocate for change, and nursing leaders were particularly interested in sharing this with their staff. Linking the use of interpretation to administrative metrics (e.g. length of stay and sepsis goals) gave leverage with hospital leadership. Adding a note template with preferred language and method of communication inspired behavior change in other departments. One important ongoing challenge is ensuring that physicians are held to the same standards as the hospital employees.

---

Impacts of the COVID-19 pandemic on chronic disease self-management
Olmos-Rodriguez, M*; Garcia, R; Cabrera, A; Najmabadi A; Dedhia, M; Su, G; Willard-Grace, R.

Context & Objective: The COVID-19 pandemic has had profound impacts on physical and psychological well-being and has exacerbated inequities for many vulnerable groups. People living with chronic lung conditions, such as asthma and Chronic Obstructive Pulmonary Disease (COPD), have been at greater risk for severe COVID, which has contributed to challenges accessing care and social support. We sought to understand how patients perceived that the pandemic had impacted their ability to care for themselves.

Setting/Populations: English- and Spanish-speaking adult participants with uncontrolled asthma or COPD from the San Francisco Health Network responded to questions regarding their engagement and changes in difficulty toward self-management behaviors as part of a randomized control study of health coaching.

Intervention/Study Design: English- and Spanish-speaking adult participants with uncontrolled asthma or COPD from the San Francisco Health Network responded to questions regarding their engagement and changes in difficulty toward self-management behaviors as part of a randomized control study of health coaching.

Outcomes/Results: Many respondents indicated that COVID-related efforts have made it either difficult or much more difficult to carry out essential and normative tasks in their health management. For example, 49% said that getting an appointment with a primary care provider was more difficult, while 57% said that being physically active was also more difficult. More than 40% indicated a neutral observation (neither easier or difficult) as part of their response, 48% of these neutral responses indicating no change in accessing medications and 45% reporting no change in healthy eating habits. The data points toward barriers in health maintenance for chronic lung conditions.

Conclusions: For this group of low income, publicly insured patients with chronic lung conditions, the pandemic posed a major barrier to self-care and management for their chronic conditions. These findings suggest that outreach to support groups that could provide patient-focused resources such as reliable social support through patient advocacy or health coaching, internet access, and remote communication access to healthcare teams during periods of sudden or unforeseen healthcare workflow disruption may be critical to the ongoing maintenance of patient health.

---

Implementation of Team-Based Care at a Family Practice Residency Clinic
McBride, T*; Mendoza, B; Nishiki, Y.

Context & Objective: Lifelong Medical Care has developed a clinic-focused residency training experience that aims to produce a workforce of family physicians equipped to practice full-spectrum primary care in underserved communities. When creating a clinic experience aligned to this mission, we have prioritized the development of a clinic culture that centers on high-quality patient care and effective team-based coordination.

Setting/Populations: We are a family medicine residency program based out of an urban teaching health center in Richmond, California, currently training six residents per class and welcoming our third class in 2022.

Intervention/Study Design: We initially developed residency competencies in this domain based on a combination of ACGME requirements and interviews with clinical staff and leadership across our organization reflecting on strengths and gaps of team-based care. Resident and medical assistant dyads participate in a longitudinal “Getting to the Heart” series designed to improve team communication, breakdown power dynamics in the clinic setting, and reflect on team experiences and areas for improvement.  Clinic staff collaborated to develop a ‘Provider-MA Agreement’ that highlights expectations of chart preparation, huddle presentations and clinical workflows. Lastly, residents and medical assistants review patient panels, set quality goals, and trial PDSA cycles to implement clinical changes. All of these interventions have contributed to improved team-based care delivery, but challenges remain.

Outcomes/Results: As a program, we have successfully committed to 1-to-1 dyad pairing, and all residents have attained competency in team-based care during their practice management curricula. Medical assistant feedback has been integrated into our annual resident evaluation, and plays an important role in celebrating resident strengths and helping them to identify areas of growth. Moving forward, we hope to measure the impact on these interventions on staff engagement (satisfaction surveys, retention analysis, etc.) and on resident competency in team-based care.

Conclusions: We believe that a commitment to strong, equitable team-based care is a central goal towards developing competent and compassionate physician, and hope that our strategies in this domain can be useful to our partners across the FM Residency Alliance.

What I need to know: Designing for health and healthcare empowerment through youth engagement
Cliffe, A*; Wingo, E; Wilson, W; Onyekwere, C; Williams, L; Bell, A; Dehlendorf, C. 

Context & Objective: Youth have unique needs, desires, and challenges related to sexual and reproductive health and accessing healthcare services. Youth, particularly BIPOC youth, can feel patronized or disregarded in their sex education and healthcare experiences. We sought to create an online educational resource to support young people in navigating their sexual and reproductive lives and decision-making from a place of strengths and empowerment. To bolster the relevance and impact of the intervention, we formed a Youth Advisory Board (YAB).

Setting/Populations: We recruited twenty-five YAB members from San Francisco, Fresno, and Alameda counties through organizational outreach, social media advertisement, word of mouth, and a partnership with a community-based youth organization. Members were aged 14-18 and predominately self-identified as women and Black/African-American or Latinx.

Intervention/Study Design: YAB members provided formative input and iterative feedback through a series of two-hour in-person and virtual focus groups throughout all stages of content and resource development. In partnership with our YAB, we created an extensive digital resource targeting youth engagement in sexual and reproductive health and healthcare, including reproductive anatomy and physiology, sex and relationships, mind and body wellness, as well as tools and resources to support healthcare engagement.

Outcomes/Results: Youth engagement informed both what we decided to include on the website and how we went about including it. The YAB input drove revision of written materials for clarity/accessibility, tone, validating appropriateness and relevance of content, and content area prioritization. The YAB also informed website design and branding, features, and qualities of illustrations used on the site.

Conclusions: Youth have valuable insight about youth-specific needs, desires, and experiences in the context of sexual and reproductive health education and healthcare access. When designing tools and resources with a community or population in mind, early and consistent engagement with that community is essential to ensure their relevance and utility.

---

​Community medicine fellowship as a strategy to improve access to care, reduce health disparities, and increase collaboration among service providers
Farrier-Nolan, O.*; Vela, A.*; Nothnagle, M. 

Context & Objective: Community Medicine (CM) Fellowship prepares Family Physicians to provide comprehensive care that meets medical and psychosocial needs of underserved and unsheltered patients.

Objectives:

1. Identify gaps in care for underserved/unsheltered populations and use public health approaches to reduce health disparities

2. Facilitate collaboration across agencies and implement service models that improve access to care for patients in need

3. Develop clinical skill set to care for the most vulnerable– mobile/street medicine, Hep C care, HIV care, addiction medicine, wound care, LGBTQ+ care, behavioral health and psychiatric care, and coordination with case management/social work

4. Advocate for policies and resources to benefit underserved populations at local and state level

5. Attract new providers to the area and improve provider continuity and retention at mobile clinics

Setting/Populations: Fellowship partners include:

FQHC

Family Medicine Residency

Harm Reduction Programs

Homeless Services

CM Fellow is employed and paid by the FQHC. Residency provides training and mentorship and community programs collaborate with outreach, case management, and harm reduction services. The fellow attends 2 days/week at mobile clinic, 1 day/week at a rural brick and mortar clinic, with 2 days for training, academics and special projects, including a new street medicine initiative.

Intervention/Study Design: The inaugural fellow conducted a needs assessment with unsheltered communities and service providers and determined that there was both need and capacity for street medicine. Outreach services have improved relationships and trust with these communities, increasing patient visits and continuity both within and outside of mobile clinic. Barriers to pharmacy access are being addressed with a medication dispensary.

Outcomes/Results: The fellow acquired new clinical skills and greater understanding the barriers to care for people experiencing homelessness and poverty. Partnerships across agencies were enhanced, improving access to care for our most vulnerable communities. Hundreds of patients have been served with vital care and medical attention in their own neighborhood, without having to travel or navigate insurance and other barriers.

Conclusions: Community medicine fellowship is an effective strategy for improving partnership, access to care, and recruitment of new providers. More research is needed to determine the impact of this fellowship on health disparities and other outcomes of interest.

---

​Exploring the impact of a produce prescription program on healthy eating- knowledge, attitudes, and behavior
Lin, N*, Miller, D.

Context & Objective: Poor diet is the leading cause of mortality in the United States. Diet-affected chronic health conditions cost our nation over a trillion dollars in direct medical expenses each year. As of October 2020, food insecurity was experienced by about 15.6% of the population. Food insecurity and the subsequent diet-related diseases, and opportunities for food sovereignty and land ownership are disparately experienced along racial lines. Produce Prescription Programs (PPP) improve health outcomes, reduce food insecurity, and decrease long-term healthcare costs.

Setting/Populations: Food insecurity is a high priority area of need in Richmond, California, as identified by community members. In collaboration with Urban Tilth (UT), a local farm, Lifelong William Jenkins Health Center (LL WJHC), an FQHC in Richmond, recently launched a PPP which involves a six-week healthy eating curriculum including cooking demonstrations and medically supportive food (MSF) distribution supplied by UT.

Intervention/Study Design: The main purpose of this project was to evaluate the impact of a PPP and healthy eating curriculum on patients’ attitudes, knowledge, and behavior in relation to healthy eating. A pre- and post-survey utilizing Likert scales to explore these themes was administered to patients. Additionally, a unique method of funding the PPP through Contra Costa Health Plan, the county’s primary Medicaid health insurance option was undertaken, to ensure sustainability and longevity for the partnership.

Outcomes/Results: At this point in time, no data has yet been collected. Due to putting group visits on hold and then converting them to a virtual setting in response to social distancing guidelines, there was a delay in delivering the survey. Anticipated results include behavior change including increased preparation and consumption of whole foods, improved understanding of barriers to healthy eating experienced by Richmond residents, increased access to MSF for participants in the PPP, and a more sustainable partnership between UT and LL WJHC.

Conclusions: PPPs may increase the preparation and consumption of whole foods and patients’ satisfaction with their interactions with the medical system.

Covering MSF produced by local farms and distributed at community health centers as a health benefit may increase access to healthy food and sustain partnerships that promote mutual growth.

---

​Adapting health coaching skills to discuss the COVID-19 vaccine across the spectrum of vaccine readiness: Learnings from a community-based participatory research project in partnership with a multi-partner virtual training academy (VTA) COVID vaccine communications training
Cabrera, A*; Harris, O; Maher, A; Taylor, K; Westfall, M; Carson, M; Rios-Fetchko, F; Burra, A; Willard-Grace, R.

Context & Objective: The COVID-19 vaccines have become one of the best preventative measures to prevent serious illness or death from SARS-CoV-2 and its variants. Although publicly available at no cost, there are many reasons that an individual may not elect to get vaccinated. This lecture-discussion presents a training model developed through a novel partnership between a community-based participatory research (CBPR) program  to create the Share, Trust, Organize, Partner COVID-19 project (STOP COVID) and a state-academic partnership (the Virtual Training Academy) to train over 14,000 vaccine outreach workers across all public health jurisdictions in the State of California. Using a model of Vaccine Readiness and Acceptance developed by Dr. Orlando Harris, the coalition matched health coaching skills at each stage of the readiness cycle. Vaccination readiness is a dynamic and deliberative process ranging from Antivaccine to Vaccine skeptical to Vaccine Questioning to Vaccine Confident. This workshop, co-led by one of the community partners, will share facilitators of success of this novel partnership as well as present skills developed through the training.

In response to the COVID-19 pandemic and its disproportionate impacts on communities of color, eleven institutions from California formed the STOP COVID-19 California Alliance. The institutions collaboratively addressed gaps in COVID-19 information and vaccination accessibility for all Californians, using community engagement techniques to focus on those most at risk for COVID-19 infection and complications. The UCSF STOP COVID-19 CA team sought to explore community views about COVID-19 vaccination, including barriers, facilitators, trusted messengers, and other issues affecting interest in and access to vaccination.  The team included UCSF faculty, staff, individuals from the Latinx Center of Excellence, and community partners from three San Francisco community-based organizations representing the Black and African American, Latinx, and Chinese American communities (Rafiki Coalition for Health and Wellness, Instituto Familiar de la Raza, and NICOS Chinese Health Coalition). The UCSF STOP COVID-19 team conducted multiple focus groups and interviews between January and June 2021 in English, Spanish, and Cantonese. Based on findings from the study, a total of four practice and policy briefs were developed and disseminated: 1) Barriers and Facilitators; 2) Knowledge, Concerns, and Benefits; 3) Trusted Messengers; and 4) Young Adult Views on Vaccination.

Setting/Populations: A training model was developed through a novel partnership between a community-based participatory research (CBPR) study, the Share, Trust, Organize, Partner COVID-19 project (STOP COVID) and a state-academic partnership (the Virtual Training Academy).

The partnership between the UCSF STOP COVID-19 team and the VTA’s vaccine communications training is rooted in the mission of the department of family and community medicine. Community partnerships from the STOP COVID study informed curriculum of VTA vaccine communications training, and the community partners from the COVID-19 Patient and Community Advisory Board (PCAB) helped by serving as facilitators of the training. This partnership provided comprehensive information to thousands of learners by providing the skills to addresses various states of vaccine readiness.

The training launched in April 2021, during a time of public access to the COVID-19 vaccine. We invited and trained community partners from STOP COVID-19 community-based organizations  and the UCSF COVID Patient and Community Advisory Board (PCAB) to facilitate breakout sessions. The training continues to be a free resource available to community partners, students, health centers and departments, and more.

Intervention/Study Design: Community partnerships from the STOP COVID study informed curriculum of VTA vaccine communications training, and the community partners from the COVID-19 Patient and Community Advisory Board (PCAB) helped by serving as facilitators of the training. This partnership provided comprehensive information to thousands of learners by providing the skills to addresses various states of vaccine readiness.

The training used the HEAR technique (Hear, Express gratitude, Ask about pros & cons, Respond) to discuss the COVID-19 vaccine with individuals in the stage of Vaccine Skepticism, as well as using the health coaching skill Ask-Tell-Ask to discuss with individuals in the stage of Vaccine Curiosity.

We invited and trained community partners from STOP COVID-19 community-based organizations and the UCSF COVID Patient and Community Advisory Board (PCAB) to facilitate breakout sessions. The training continues to be a free resource available to community partners, students, health centers and departments, and more. 

Outcomes/Results: The training launched in April 2021, during a time of public access to the COVID-19 vaccine. This novel partnership trained over 14,000 vaccine outreach workers across all public health jurisdictions in the State of California.

Using the HEAR technique and health coaching skills provide a way to respectfully engage individuals in a person-centered approach. There are many ways to adapt the HEAR technique and health coaching skill beyond the COVID vaccine and into the clinic to address chronic diseases and other preventative measures.

Conclusions: The contribution of learnings from the STOP COVID-19 CBPR to the curriculum and delivered by community partners is an example of an inclusive and collaborative way towards achieving racial and ethnic equity in COVID-19 vaccination. Using the HEAR technique and health coaching skills provide a way to respectfully engage individuals in a person-centered approach. There are many ways to adapt the HEAR technique and health coaching skill beyond the COVID vaccine and into the clinic to address chronic diseases and other preventative measures.

Technology impacts human rights and equity practice
Kivlahan C*; Frazier, R; Stephens, D; Vu, M; Romero, S; DeFries, T. 

Context & Objective: At a time of unprecedented climate change, conflict and forced migration, asylum seekers leave their homes to seek legal protection from torture and ill-treatment in a safe country. One of the best ways to enhance the likelihood of legal protection is by corroborating the client’s claim of persecution using medicolegal evidence from trained clinicians. But collecting and documenting medicolegal evidence takes many hours.

Setting/Populations: Interventions to minimize time spent can reduce barriers to clinician engagement in this pro bono work, and speed data collection that informs best practices and emergent trends in human right violations. The UCSF HHRI developed and tested an electronic FME standard form, reviewed by expert forensic evaluators, attorneys and judges.  Project partners included UCSF IT REDCap and Tableau teams, UCSF medical students and HHRI team members.

Intervention/Study Design: Child and adult specific forms were created for use by primary care and mental health clinicians. The REDCap form is completed live in the exam room, or in a remote video room, while reducing documentation time, maintaining trust and improving quality and data capture. We selected REDcap as our vehicle for this work, a tool designed to capture data for clinical trials.  There is no other electronic forensic standard form in the world, and none in REDCap. REDCap data entry is converted to a Word document which serves as the forensic affidavit for Immigration Court.

Outcomes/Results: Our digitized data entry system is revolutionizing the way forensic medical evaluations are performed at UCSF: our clinicians have already reduced documentation time and improved data capture. Outcome metrics include: asylum grant rate, sustained clinician engagement and increase in research activity using our data. A survey of clinicians is underway to determine level of adaptation and acceptance of the form, as well as perception of change in documentation time.

Conclusions: This combination of tools, used primarily in clinical trials, can collect data and improve quality in human rights and equity projects in primary care settings, while the program is catalyzing our training program for students, trainees and clinicians.

---

Prevalence of anemia and assessment of growth development of children in rural villages of the Comayagua Region of Honduras
Melendez-Muniz, V*; Stecker, T; Sevilla, J.

Context & Objective: The global burden of anemia is disproportionately born among children in developing countries. In Honduras, anemia is a nationwide issue. Those living within the lowest quintile of wealth are at highest risk. Anemia in children is of particular interest since it can negatively and irreversibly impact their growth and neurodevelopment. The objective of this project was to measure the prevalence of anemia and describe the growth development of children in the rural Comayagua Region of Honduras.

Setting/Populations: This prospective cohort study was conducted at two rural villages in the Comayagua Region of Honduras in February 2022.

Intervention/Study Design: All children  between the ages of 1 month-12 years old qualified for a comprehensive exam including hemoglobin (Hg) screening, weight, and height measurement. Hemoglobin measurements were completed by using HemoCue Hb 201 DM point of care system. Anemia was defined as less than 2 standard deviations from the mean. Using WHO definitions of stunting, underweight and overweight, we sought to determine the prevalence of each in the population. A total of 71 children were seen during the visits. A descriptive data analysis was performed. Patients diagnosed with anemia were given a 3-month supply of vitamins with iron and will be followed in July 2022.

Outcomes/Results: Results showed that 35% of the children were found to have anemia in this study, a high prevalence but comparable to other studies done in the Honduran population. Anemia was slightly seen more in females than males. Half of children who were stunted, wasting, or underweight were also anemic. More than 40% of the children in this study were underweight or wasting and 4% of the children were stunted. 4% were overweight in Village 2, however, no children were found to be overweight in Village 1.

Conclusions: The high prevalence of anemia and abnormal growth development rates seen in this study could be attributed to accessibility to resources and nutrition status in each village. These findings are concerning for the long-term health effects of these children. Thus, treatment of anemia is imperative. Further studies are needed to evaluate the community’s potential for an anemia screening program and to assess plausible and correctable causes.

---

COVID-19 and immigration detention: how can we learn from letters?
Kane, M*; Ivey, S; Holmes, S; Halpern, J.

Context & Objective: Thousands of people are detained annually by the US immigration enforcement system, which enacts physical, legal, and emotional injury through explicit connections with criminal justice and legal systems. Narratives created by law, the state, media, and politics directly shape these structures while narratives from within, though infrequently public, may offer alternatives and resistance.

COVID-19 increased existing structural violence in detention facilities, as highlighted by community members, activists, and journalists. Letters from detained people provide a testimonio (witnessing) of COVID-19’s impacts and underscore the limits of written forms and resultant research ethics.

Setting/Populations: Letters and drawings from ICE detention sites were sent to three community-based organizations (national and California-focused), which informally collected letters over several years. I learned of these through grassroots organizers.

Intervention/Study Design: I examined 60 de-identified letters in English and Spanish from February – August 2020, using blended convenience and purposive sampling. Grounded in interdisciplinary theory, I coded letters using descriptive and comparative codes, followed by close textual analysis for selected letters.

Outcomes/Results: Coding:

Letters were typified by various characteristics, e.g., length and fluency. Initial thematic domains (deprivation, power, coping, and deservingness) were intensified by COVID-19 leading to heightened deprivation, uncertainty, and powerlessness to implement prevention, e.g., proper hygiene and social distancing. Letters consistently outlined solutions, especially release and/or abolition.

‘Against the Grain’:

Close textual analysis generates multiple possibilities from the unsaid, destabilizing generalizability and certainty. For example, repeated pleas for help could imply fear, disempowerment, difficulty with language, or fierce determination. Such analysis centers the unknowable in narrative as a strength, resistance, and humanity.

Conclusions: Writers noted the dissonance between perceived American values and the reality of detention while comparing and refuting narratives of criminality. To mitigate COVID-19, they explicitly call for decarceration and improved protection measures. These letters further serve as testimony of injustices faced, advocacy, analysis, and connection. Letters also demonstrate inherent constraints in the written form and the complex humanity contained within. Informed consent is fraught in such settings. Readers witnessing these experiences must attend to silences as much as the words of those detained and to match their calls with abolitional praxis, addressing root causes and justice for writers.

Climate change: How microaggressions in graduate medical training affect learning climate
HollandBerry, K*; Priyam, P; Saho, F; Echiverri, A.

Context & Objective: Learning climate directly affects resident learning and the quality of patient care. Microaggressions create a negative learning climate and contribute to burnout. Graduate medical education lacks formal systems to address burnout. We need to understand more about resident experience of microaggressions to improve learning climate, prevent burnout, and improve patient care.

Setting/Populations: We seek to describe the experience of residents regarding microaggressions at a community-based Family Medicine residency program housed in a diverse county healthcare system.

Intervention/Study Design: Thirty-nine residents were invited to complete an anonymous online survey, customized for this learning context, that included both multiple choice and free text questions regarding how microaggressions affect their ability to learn and provide patient care.  Twenty-three residents (59%) responded.

Outcomes/Results: The survey results revealed negative effects of microaggressions. 100% had witnessed microaggressions and 87% have experienced them.  19 of 23 respondents wrote free form about their experience with microaggressions. Respondents reported that witnessing or experiencing microaggressions “shook their confidence,” made them feel “threatened,” “not worthy,” “distracted,” and led them to ask fewer questions of educators. 91% of respondents felt that the current system is not providing adequate ways to process these experiences, nor is there an avenue for safely giving feedback to the microaggressor. One respondent reported considering leaving residency due to microaggressions they had experienced.

The survey was voluntary, completed at a specific point in time at a single residency program. Questions were written by the study author; bias is possible. Online surveys cannot articulate the nuance and complexity that more in depth interviews may.

Conclusions: Overall, residents want an improved learning climate by limiting microaggressions and are seeking formal pathways for reporting and debriefing these experiences. The residency program will be implementing and evaluating a tool for anonymous reporting of microaggressions. Data from this tool will help guide next steps, be it educating our residency community, individuals who have caused harm, or working to change departmental culture. Reducing microaggressions is a critical way to improve learning environment and the quality of patient care.

---

Zoom vs In the Room: Comparing the experiences of in person and virtual residency applicants in a family medicine residency program
Simon-Weisberg, D*; Radosevich, J*; Miller, D; Richardson, T.

Context & Objective: We sought to review our 2021-2022 recruitment process and evaluate if in-person vs virtual interviews affected the experience of applicants and interviewers and the Match outcome. We conducted 50% of our interviews in-person and 50% virtually. Applicants selected which format of interview they preferred. We sought to assess if there was a trend to choose one format or another by “Underrepresented in Medicine” (URM) identity, hometown, or location of medical school. We wanted to learn if the virtual vs in-person format affected the interviewers’ experience of assessing applicants, and to assess whether the interview format affected our rank list.

Setting/Populations: We are a new teaching health center residency in Northern California. During the 2021-2022 recruitment season we were recruiting for our 3rd class of residents into a 6-6-6 program.

Intervention/Study Design: We offered in-person or virtual options for all selected applicants on a rolling basis. We identified two virtual and one in-person days as URM focused days and encouraged applicants who identify as URM to choose these days if they wished.

We sent out surveys to all applicants and interviewers after the interview season to evaluate their experience.

Outcomes/Results: We are in the process of collecting and reviewing data including the demographics of the applicants who selected each interview format, representation of in-person vs virtual interviewees on the final rank list and in-person vs virtual interviewees among our matched interns. 53% of URM applicants chose virtual and 47% chose in-person interviews. On our final rank list, the top third included 42% in-person and 58% virtual interviewees. The middle third was 55% in-person and 45% virtual interviewees. The lower third included 50% in-person and 50% virtual interviewees.

Conclusions: In our discussion and conclusions, we’ll explore whether virtual vs in-person interviews affected the position of an applicant on our rank list; whether interviewees and interviewers had a better experience doing virtual vs in-person interviews; and how our ability to recruit a diverse body of residents was affected by interview format.

---

Strengthening community-based relationships: Creating a community engagement rotation utilizing a community-engaged curriculum development process
Griffiths, E; Dennison, S; Boyer-Chu, L; Owens, L; Beck-Pancer, D; Bouagnon, A; Wortis, N.* 

Context & Objective: The Liaison Committee on Medical Education requires US medical schools to support “service-learning and/or community service activities.” Few schools require community engagement curricula. In 2016, UCSF School of Medicine’s (SOM) launched the new Bridges curriculum, which included a vision for a 4th year required community engagement rotation. We used a community-engaged curriculum development process to design and pilot a community engagement rotation that benefits both communities and medical students.

Setting/Populations: We focused on community engagement opportunities in San Francisco. Four community partners joined us in developing and implementing the curriculum. These partners were from Faithful Fools (Tenderloin), Mission Neighborhood Health Center, the San Francisco Unified School District, and YMCA of San Francisco.

Intervention/Study Design: We used Kern’s curricular design framework, beginning with a review of relevant best practices. We conducted targeted needs assessment with medical students and community partners. We formed a working group, with 4 stipended community partners and 2 students, to collectively determine goals and objectives, choose educational strategies, and guide implementation. Students and community hosts provided quantitative and qualitative evaluation.

Outcomes/Results: Learning objectives relate to community engagement and partnership, cultural humility, policy advocacy, and public health. The 4-week rotation includes 1 day/week of group engaged learning and 4 days/week for student work at community sites. We piloted the rotation 4 times since 2020, with 17 student participants and 12 community hosts. Students rated rotation quality at 4.86 on a 5-point Likert scale (82% response). Qualitative feedback from students and hosts speaks to the impact on students’ career aspirations and community health.

Conclusions: Students and community partners valued the rotation. Community partner engagement in all aspects of this process has been critical to its success. During the pandemic, it was difficult to recruit large numbers of students for the pilots and to identify stable funding to compensate community partners. The rotation remains an elective, as SOM shifts resources to other curricular efforts. Students and community partners suggest longitudinal community engagement starting earlier in medical school. We proposed a longitudinal community engagement curriculum that SOM curricular leaders may incorporate as part of the Anti-Oppression Curriculum.

Street medicine outreach in Salinas, CA
Musselman, M; Vela, A. 

Context & Objective: Many people live in tents on sidewalks or next to railroad tracks in Salinas, CA.  Individuals or families face enormous structural vulnerability in their day-to-day survival related to exposure to natural environmental elements, seizure of their property, high prevalence of substance use disorder, food insecurity, trauma from violence, and unreliable access to healthcare and other services. There is an ongoing Housing First initiative within Monterey County, however the wait time to be placed into housing is long, cumbersome, and dependent on multiple contingencies. Street medicine outreach is one method to circumvent the extraordinary barriers patients who are unhoused face in attempting to access the healthcare system.

Setting/Populations: We sought to provide basic outreach and healthcare access to individuals living in encampments and areas populated with unhoused individuals in Salinas, CA

Intervention/Study Design: Through a snowball sampling technique, we conducted basic interviews with folks who were open to talking with us. We provided incentives that were not contingent on participants’ participation in our interviews, such as clean socks, baked goods, wound care supplies, clean needles / pipes, narcan, etc. We sought to understand individuals’ stories and provide them with reliable and trusted points of contact within the healthcare system.

Outcomes/Results: There is a growing population of unhoused individuals residing in Salinas, CA who suffer from a wide array of health conditions that would benefit from regular access to primary care services. These individuals come from a wide variety of backgrounds, although most of them either originally lived in Salinas or found themselves in the area due to seasonal agricultural work availability. Due to barriers such as transportation, substance use, interpersonal conflicts, or other considerations for basic survival, it is often impossible for unhoused individuals to schedule and attend regular medical appointments at typical safety net clinics. A simple conversation can open the door to a trusted therapeutic relationship with a clinician.

Conclusions: Street medicine is a valuable strategy to provide supportive services to individuals facing housing insecurity or homelesness. By approaching this population with humility and kindness, it is possible to cultivate meaningful relationships and build trust.

---

COVID-Associated misinformation across the South Asian diaspora: A qualitative study of WhatsApp messages
Potharaju, K*; Khosla, K; Mukherjea, A; Sharma, A; Sarkar, U.

Context & Objective: COVID-19 misinformation is a global public health crisis. Little is known about COVID-related misinformation specific to the South Asian community on WhatsApp, which plays a major role in transnational communication. Understanding communication among the South Asian diaspora on this popular platform may improve public health messaging to address COVID-19 disparities. The COVID Associated misinfoRmation On Messaging (CAROM) Apps Study examined messages containing misinformation about the coronavirus pandemic transmitted via WhatsApp.

Setting/Populations: We engaged with self-identified South Asian community members over the age of 18 globally through major social media platforms such as Twitter, Facebook, and Instagram.

Intervention/Study Design: We collected de-identified WhatsApp messages containing misinformation about COVID-19 transmission and prevention between March 23 and June 3, 2021. We excluded messages that were in languages other than English, that did not contain misinformation, or were not relevant to COVID-19. We coded each message to capture message content, the type of media (video, image, text) and tone (e.g. fearful, well-intentioned). We performed a qualitative content analysis to arrive at key themes of COVID misinformation.

Outcomes/Results: We received 108 messages; 55 messages met inclusion criteria for the final analytic sample. Content analysis revealed the following themes: “community transmission” relating to misinformation on how COVID-19 spreads in the community; “prevention” and “treatment” referring to Ayurvedic and traditional remedies and recommendations for how to prevent or treat COVID-19 infection; and messaging attempting to sell products to prevent or cure COVID-19. While some messages were targeted to the general public, others were aimed at South Asians specifically, at times speaking to South Asian pride and solidarity. Scientific jargon and references to major organizations and leaders in healthcare were included to provide credibility. Tone was often pleading to encourage forwarding of messages to friends or family.

Conclusions: Misinformation in the South Asian community on WhatsApp spreads erroneous ideas regarding disease transmission, prevention, and treatment. Content evoking solidarity, “trustworthy” sources, and encouragements to forward may increase misinformation spread. Public health outlets and social media companies must actively combat misinformation in order to address health disparities among the South Asian community during the COVID-19 pandemic.

---

Are you ready for disaster?
Scott, T*; Mc Dermott, S; Hiserote, P.

Context & Objective: Across the state, climate-related disasters such as fire and flood can put vital primary care training programs at risk either due to physical destruction of  training facilities or through attrition of residents due to emotional impacts or fear of lost training opportunities.    

Setting/Populations:  We surveyed residents and faculty from five Family Medicine residency programs across California that experienced catastrophic fire in their communities between 2017 and 2021 to understand participant experience of living, learning, and working in a community that experienced a major wildfire event.

Intervention/Study Design: Between March 1 and June 30th of 2021, we surveyed 160 residents and 66 faculty across our 5 programs.   Likert scale and open-ended narrative question formats were used. The survey focused on perceptions of program and community readiness for disaster, the role of Family Medicine and trainees in responding to disaster, reasons for considering leaving as well as reasons for staying.  Several questions explored different types of emotional support respondents found most useful for coping with the trauma of the disasters.  

Outcomes/Results: We had an overall response rate of 46% across all 5 programs.  Thirty-seven percent of respondents considered leaving the program or community but only 4% actually did. The most common reason people who considered leaving chose to stay was commitment to the program.  The three most helpful support mechanisms for residents and faculty during wildfires were peer support (78%); family (70%) and friends (70%).  The great majority of respondents believe that Family Medicine residencies should be involved in community disaster response, that trainees should have a choice about whether they are involved and that programs should teach basic disaster response to all trainees. 

Conclusions:In spite of the challenges, faculty and residents who have experienced fire disaster see value in the experience and think that basic disaster training should be included in all Family Medicine residencies.  Importantly, programs and communities in our survey that solidified plans and created annual orientation to disaster response were rated as more prepared and better able to respond and support trainees. 

Bringing sexuality and reproduction into wellbeing, and wellbeing into sexuality and reproduction
Dehlendorf, C*; Wingo, E; Williams, L; Wulf, S; Sarnaik, S.

Context & Objective: Sexuality and reproduction are core dimensions of the human experience that have wide ranging impacts across the life course, including on physical and mental health, and are central components of life satisfaction. While there has been increasing focus on subjective well-being and its measurement, relatively little attention has been paid to how to capture people’s lived experiences of sexuality and reproduction. Further, in the measurement of sexual and reproductive outcomes, most of the attention focuses on outcomes prioritized in public health and clinical care, as opposed to the degree to which individuals achieve the pregnancies and births they wish to have, as well as their experiences of reproductive health care. To address these gaps, the Coalition to Expand Contraceptive Access, the Person-Centered Reproductive Health Program, and the National Birth Equity Collaborative have embarked on an intensive process to explore a definition of Sexual and Reproductive Wellbeing (SRWB).

Setting/Populations: Multidisciplinary stakeholder engagement in the United States, including experts in reproductive epidemiology, maternal and child health, reproductive health care, economics, and Reproductive Justice.

Intervention/Study Design: We are conducting a review of existing measurement and conceptual literature to inform stakeholder meetings between May 2022 and May 2023.

Outcomes/Results: To develop a definition of SRWB and its subdomains, as well as a strategy for developing measures of this construct.

Conclusions: Developing an inclusive understanding – and ultimately measurement(s) - of SRWB will facilitate increased focus on equity and people’s lived experiences in sexual and reproductive health policy and practice.

---

How can self-injection promote contraceptive agency?: A qualitative study of the potential of self-injection from the perspective of women in Kenya, Malawi, Nigeria, and Uganda
Holt, K*; Nyando, M; Omoluabi, E; Gitome, S; Kayego, A; Kamanga, M; Jumbe, T; Suchman, L; ICAN research group 

Context & Objective: We sought to fill an evidence gap for the often-touted “empowering” potential of self-injectable contraception through this study of how self-injection may promote contraceptive agency from women’s perspective. Data were collected as part of the Innovations in Choice and Autonomy (ICAN) study.

Setting/Populations: Participants were reproductive-aged women of purposively sampled to ensure diversity by age and prior contraceptive use. Study sites include Nairobi and Kisumu, Kenya; Oyam and Mayuge, Uganda; Ntchisi and Mulanje, Malawi; and Enugu and Plateau, Nigeria.

Intervention/Study Design: We conducted 241 in-depth interviews (approximately 60 per country). Data were analyzed collaboratively among teams from the five countries.

Outcomes/Results: We identified four ways in which self-injection has the potential to promote contraceptive agency. First, the privacy self-injection offers can enable a decision to use contraception among women interested but hesitant to use it in unsupportive social contexts: “The negative sayers [people in her community mistrustful of contraception], they make me feel fear” (Ugandan participant). Second, the ability to take multiple doses home makes self-injection more convenient than other contraceptive methods because of time savings, less red tape (e.g., required pregnancy tests that can accompany re-injection visits), and more reliable access given the ability to stock up on doses in the context of method stock-outs or economic instability: “I can always inject myself at my convenient time. Even at night, even when I have traveled” (Malawian respondent). Third, despite fear among those who had not tried it, some self-injection users describe a less painful experience than provider-administered injections: “The pain feels different compared to when someone [else] is injecting [you]” (Malawian respondent). Fourth, self-injection users describe a sense of control or elevation in status: “I now have myself for myself. I am the master of myself. It’s only God that has me” (Nigerian respondent).

Conclusions: Programs to support contraceptive decision-making and desired use of self-injection have potential to promote contraceptive agency among women in contexts unsupportive to contraceptive use, with limited time or resources, or who desire a more independent experience. More research is needed to document whether self-injection does change contraceptive agency—a question ICAN will study quantitatively through a cohort study.

---

Desire for pregnancy or interest in using contraception? Development of a service needs question to assess contraceptive need
Kriz, R *; Wingo, E; Gibson, L; Michel, M; Dehlendorf, C. 

Context & Objective: Measures of pregnancy intention, like One Key Question (OKQ), have been used assess patients’ need for contraceptive services at the time of clinic visits. In this paradigm, patients who indicate that they intend to become pregnant in the next year would be provided preconception care and not services related to pregnancy prevention. However, while a person may hope to become pregnant in the next year, they may also be interested in pregnancy prevention today. Data from several statewide surveys have documented that asking people about desire to prevent pregnancy identifies more people interested in contraceptive care than do pregnancy intention questions.

Setting/Populations: Community Health Centers

Intervention/Study Design: Through engagement with Reproductive Justice consultants and industry stakeholders, UCSF has created a screening question and standardized EHR data element that assesses contraceptive service needs. The Self-Identified Need for Contraception (SINC) screening question can be used in routine care to allows patients to self-identify whether they want to talk about contraception during their visit. In addition to facilitating patient-centered clinical workflows, the implementation of SINC as a standard data element in the EHR can improve the patient-centeredness of performance measures assessing contraceptive provision by allowing those that self-identify as not wanting to discuss contraception to be excluded from the denominator.

Outcomes/Results: We found that CHCs needed clinic- and provider-focused education centered in Reproductive Justice to support incorporating SINC into practice, and health information technology (HIT) support to implement SINC into their EHRs. We also found an interest by stakeholders, including government agencies, to support the adoption of SINC more broadly.

Conclusions: Adoption of SINC by CHCs may improve patient experience and contraceptive care by prompting providers to ask patients about their service needs, while refining calculation of eCQMs of contraceptive provision. Educational programs, training, and HIT support are needed to ensure successful SINC implementation and improve contraceptive provision measurement. Engagement with various stakeholders including government agencies, health plan, patient and provider groups, and others is needed to further socialize and support dissemination of SINC.

---

Evaluating the association between Centering Pregnancy and adverse pregnancy outcomes among Kaiser Permanente Northern California patients
Salow, A*; Maes, W; Samiezade-Yazd, Z; Villa, J; Winninghoff, H; Behizad, K; Perry, E;  Flaxman, G.

Context & Objective: CenteringPregnancy (CP) group prenatal care has been linked to decreased preterm birth (PTB) rates. Kaiser Permanente Northern California (KPNC) began offering CP in 2016. We assessed the association between CP and adverse pregnancy outcomes.

Setting/Populations: KPNC patients with a singleton delivery between 2016 to 2019 were eligible for inclusion. Patient characteristics and pregnancy outcomes were identified from electronic records.

Intervention/Study Design: This was a retrospective cohort study. We assessed two cohorts: an unmatched cohort of randomly sampled TPC patients and all eligible CP patients, and a propensity score matched cohort of TPC patients and all eligible CP patients. The propensity score accounted for patient demographic and preexisting clinical factors. To control for immortal time bias, deliveries before 28 weeks were excluded. Patients with 0 CP visits were assigned to the traditional prenatal care (TPC) group. Patients with > 3 CP visits were assigned to the CP group. Associations between CP and PTB, small for gestational age (SGA), and large for gestational age (LGA) were analyzed with logistic regression and conditional logistic regression for the unmatched and matched cohorts, respectively.

Outcomes/Results: We identified 3,008 eligible CP patients and 93,693 eligible TPC patients. Compared to the randomly sampled TPC patients, CP patients were less likely to be multiparous, or have a history of PTB, chronic diabetes, or obesity (p<0.05). CP patients had lower rates of PTB (5.4% vs 6.8%, p<0.05) and LGA (4.6% v 7.1%, p<0.05) and a higher rate of SGA (10.0% vs 7.1%, p<0.05). In multivariable analysis, CP patients had lower odds of PTB compared to the randomly sampled TPC patients. In the propensity score matched cohort, CP was not significantly associated with PTB, SGA, or LGA in unadjusted or multivariable models.

Conclusions: CP patients appear to have lower rates of PTB compared to TPC patients. However, these differences may be attributable to lower risk patients participating in CP for their prenatal care.

Rehumanizing medicine: promoting culture of mindfulness and compassion through discussion
Issaq, H*; Martinez, L*; Hartwig, K.

Context & Objective: Compassionate care is associated with improved patient outcomes and adherence. Physicians can develop compassionate skills by becoming more conscious of social inequities, social determinates of health, and the social dynamics of healthcare. As such, at the Kaiser San Jose Family Medicine Residency, we initiated a successful 21 Day Anti-Racism Campaign to begin this work, and this was well received. Because of this good response and to continue these important discussions, we developed a quarterly evening initiative to engage our residents and faculty in areas covering these topics, which we named Rehumanizing Medicine.

Setting/Populations: These 1.5 hour virtual sessions took place in the evening once a quarter and included residents and faculty.

Intervention/Study Design: For three quarters, we have chosen powerful documentaries showing the social, cultural, and historical dynamics that affect our patients’ lives. For this initiative, we have aired these documentaries and provided a time and space for dialogue. Discussion focused on applying lessons from these documentaries into clinical practice moving forward.

Outcomes/Results: We generated a survey to assess participants’ satisfaction and clinical change by participating. So far, responses have been positive with >90% indicating that these sessions have changed how they will practice, including becoming more conscious of the external factors that impact patients’ health. Suggestions included changing the time-of-day sessions are offered.

Conclusions: These concepts are imperative to learn early in training as clinical habits are forming. We created these sessions to promote and strengthen the relationship between the residency program and the diverse community we serve. Our focus has been to get both residents and faculty involved in order promote a collective culture.

---

Happiness and health: Contra Costa resident wellness assessment
Rodgers, A.* 

Context & Objective: Physician burnout is a major challenge within the healthcare system and can negatively affect physician well-being, patient care, and team collaboration. Addressing burnout begins in residency. In 2017, the ACGME revised its program requirements for all accredited residencies to directly address well-being. Most residencies are working on this but many do not have a formal process to evaluate resident wellness and incorporate their input. Incorporating resident voices can provide an important viewpoint and ensure sustainability of future implemented wellness programs. Before this study, there were no resident specific wellness surveys administered to Contra Costa Family Medicine Residency Program (CCFMRP) residents.

Setting/Populations: CCFMRP is located in Contra Costa County and serves more than 1 million patients from rural, suburban, and urban communities. It is an acute care focused 13-13-13 three-year family medicine residency serving historically marginalized communities.

Intervention/Study Design: An adapted validated resident wellness survey with a needs assessment component was provided to all CCFMRP residents. Demographic information was collected including identification as URM. There were 6 domains of wellness addressed including ability, personal growth, meaningful work, social support, institutional support, and life security.

Outcomes/Results: 18/39 residents completed the survey; 10/18 respondents identified as URM. URM residents had wellness scores that were similar to or higher than their non-URM colleagues. Ideas to improve resident wellness included the following categories: nutrition, physical activity, mental health, community building, and schedule changes. For example, 20% of survey participants requested healthier food options in the cafeteria.

Conclusions: Routine validated wellness surveys are essential to longitudinally track the wellness of family medicine residents. Needs assessments allow residents to give input and guidance on how programs can enhance resident well-being. We found higher URM wellness scores compared to non-URM, which seems counterintuitive based on current literature. However, recent residency investment in URM support could account for this difference. The formation of the CCFMRP Resident Diversity Council (RDC) and URM community gatherings have most likely served as protective factors against burnout. Continuing these efforts and tracking their impact are essential. Next steps include presenting results to residency leadership to help guide future wellness programing.

---

Ideals of Medicine: A Call to Conversation and Action
Waris, M. U; Musselman, M.

Context & Objective: Research has repeatedly shown that as medical students and residents progress through the training, there is a loss in the idealism that initially inspired their decisions to enter medicine. A variety of factors - rigor of training, student loan debt, administrative burden that deemphasizes patient connection, shifting focus on status over service in medical culture - have been posited for this trend. Indeed, the gradual loss of idealism may well be why primary care including family medicine has been neglected as a field of choice for many aspiring applicants.

These changes are most disturbing considering that the ideals of medicine have been what has distinguished medicine as a “calling” honored by nearly all cultures and places throughout time. Indeed, these ideals well form the basis of the hippocratic oath. To the extent that medical trainees lose their idealism is a worrying indictment on the state of medicine today relative to its time-honored traditions and duties.

Setting/Populations: We (medical students & family medicine residents) interviewed individuals who have demonstrated a deep understanding of these phenomena, including attending physicians, medical historians, patient advocates and spiritual leaders.

Intervention/Study Design: The key questions we addressed in these interviews is their own personal journeys in pursuing medicine as a profession; the ideals, teachers and experiences that shaped them through this journey; the personal and system-wide practices they have enacted to protect their ideals both in their own individual work and in the broader workplace; and the role of advocacy by physicians and allied health professionals for greater healthcare reform.

Outcomes/Results: Through the course of these interviews, we learned of the pivotal role of deep personal experience and encouraging mentors to inspire our interviewees to pursue medicine. As professionals, they recounted how the ideals that led them to medicine often faced workplace and system-level challenges. Unanimously and unequivocally, all interviewees spoke on the need for greater physician voice for healthcare reform.

Conclusions: Only in its beginning stages, this interview project hopes to spark conversations and action at all levels of our healthcare workplaces and systems so that we can best live up to the ideals of medicine.

Disparity analysis at Laurel Family Practice
Chen, J*; Raczek, N; Gonzalez, J; Finney, J; Barron Vargas, G; Kennedy, C; Gupta, S.*

Context & Objective: To reduce healthcare disparities at Laurel Family Practice (LFP), we sought to determine whether certain clinical outcome measures differ based on markers of social identity.

Setting/Populations: We reviewed data for all Medi-Cal patients who had at least one appointment in 2021 at LFP, a Monterey County Health Department primary care clinic staffed by Natividad residents and faculty.

Intervention/Study Design: We defined dimensions of social identity for stratification: gender identity, primary language, age group, race/ethnicity, religion, sexual orientation, and zip code as a proxy for socioeconomic status. Data were available for a total of 4,610 patients, estimated to be 51.1% of all 2021 LFP patients.

We applied stratifications based on social identity to all 49 Quality Incentive Program (QIP) indicators.  QIP is coordinated through the California Association of Public Hospitals and Health Systems (CAPH) to provide an opportunity for value-based reimbursement in response to the 2016 federal Medicaid Managed Care Rule.

We identified the clinical indicators and social identities that were eligible for comparison based on the QIP specification of at least 30 patients. For each eligible social identity, we then tabulated the number of indicators with a clinical outcome at least 3% worse than the aggregate, again based on QIP specifications.

Outcomes/Results: Of eligible comparisons, we found a higher proportion of indicators with worse clinical outcomes compared to other groups among patients who were identified as cis-male (8 of 14 indicators; 57%), 18-39 years old (7/19; 37%), white (12/18; 67%), black (5/8; 63%); Christian (11/23; 48%), non-religious (9/23; 39%), or having a primary language of English (12/29; 41%).

Conclusions: Applying a simple stratification method to an available dataset is a practical approach to identify healthcare disparities. Equity-related limitations include an inadequate sample size for some indicators and social groups, and unavailability of data for non-Medi-Cal patients as well as populations who are unable to access the safety net system. Further work at LFP should focus on generating and testing hypotheses, designing related interventions, and continuing to monitor clinical outcomes for those populations identified as having worse outcomes.

---

Shelter in place global health: continuing education during a pandemic
Reouk, D*; Martinez, L*; Lyashevksy, C.*

Context & Objective: As part of the Kaiser Permanente Global Health Program, residents can participate in a global health rotation in an underserved population internationally. Due to the COVID19 pandemic, this program was paused for 2020-2021 and our residents were unable to travel to our chosen site, Ecuador. In order to maintain this important experience, the Kaiser Permanente San Jose Family Medicine Residency created an in-home global health curriculum.

Setting/Populations: Third-year residents participated in this two-week global health rotation in person and virtually.

Intervention/Study Design: Residents received lectures on the health care system of four different countries.  In addition, residents chose a country to do an in-depth analysis of their health care system and each chose one of 6 countries with the best and worst COVID19 responses to study and present their findings. This rotation would have included attending an in-person intensive Medical Spanish class. We were able to collaborate with the organization hosting the class, Cacha Medical Spanish Institute (CachaMSI) to accommodate to a virtual version of this instruction. The rotation also included a focus on career development with a panel of speakers with various levels of work experience in global health. Residents held a Flipped class session on various tropical infectious diseases. We also connected with a local organization, Asian Americans for Community Involvement (AACI), who presented on their various work with immigrant, refugee and low-income populations

Outcomes/Results: Overall, the rotation was well received. Residents reported that the health care system and pandemic study were good learning experiences. The infectious disease flipped class session was a good review. The global health experiences panel was inspiring with applicable career information. Medical Spanish sessions were intense and recommended providing more time in the future.

Conclusions: Because COVID19 continues to be a concern, Kaiser has paused the program for the 2021-2022 year and we will hold this rotation for the second year. In future sessions, we hope to do analyses of countries’ COVID19 vaccine development, response and distribution. We will also be provided more time for Medical Spanish instruction. We are very excited to adapt to a changing world and continue to provide education on such an important topic!

---

Global is local - an equity based approach to global health exchanges
Shumba, T.*

Context & Objective: There has recently been increased focus on health equity, and an emphasis on JEDi initiatives has been in line with developing interest in "decolonizing global health.” There is growing understanding that global health equity should encompass resource-denied populations both within and outside the US.

This project aimed to develop an equity focused global health exchange using lessons learned from developing and implementing curricula focusing on JEDI at the undergraduate, medical school and resident levels. Stanford joined the AMPATH (Academic Model Providing Access to Healthcare) consortium in 2019. This curriculum development project seeks to create an ideal immersive experience for rotating Kenyan students, and serve as a blueprint for future Stanford resident reciprocal exchanges.

Setting/Populations: Stanford undergraduates, medical students and residents who have participated in various JEDI informed curricula, previous Kenyan exchange program participants, and global health faculty at Stanford.

Interventions/study design: Curriculum development was informed by anonymized feedback from various student experiences including classes and seminar sessions on JEDI topics and social determinants of health, as well as undergraduate and medical school student feedback on “Decolonzing global health” seminar. Informal feedback was also obtained from faculty who will be involved in the rotating student experience, and from Kenyan students who previously participated in 6-week rotation at different university sites in the US. Strategic partnerships were created with the Stanford Visiting Scholars program, and resources from the clinical community mobilized to design an optimal exchange experience for rotating students

Outcomes/Results: Learner evaluations have shown that delving into JEDI topics improves their experience in a college setting, and medical students and residents have shown increased sense of belonging and empowerment to provide better patient care. Feedback from the Decolonizing Global Health seminars showed that discussion of these topics can lead to more mindful pursuit of global health projects focused on equitable exchange. These lessons informed design of a new 6 week exchange program at Stanford beginning 8/2022.

Conclusion: Global is truly local. It is important to apply lessons in justice and equity in the US setting to global health exchanges.

---

Care without criminalization: exploring transformative justice for personal and systemic abolition in healthcare
Khoeur, L.*

Context & Objective: While there has been increasing research on the impact of punitive justice frameworks on health outcomes, there has been little to no research exploring the role of transformative justice in healthcare.

Setting/Populations: The Bay Area Transformative Justice Collective, The DPH must Divest coalition, The UCSF Reparations and Anti-Institutional Racism Project, and Code CARE Parnassus and Mission Bay.

Intervention/Study Design: Care Without Criminalization is an ethnographic study in partnership with the Bay Area Transformative Justice Collective (BATJC) to examine the deeply personal, emotional, and communal engagement required to practice generative transformative justice in the healthcare system. This study analyzes the praxis and experiences of the members of the BATJC, DPH must Divest, UCSF REPAIR, and Code CARE to define the personal struggles of unlearning internalized notions of punitive justice in the context of conflict resolution at the interpersonal, community, and systemic levels. Through interviews, archival work, and ethnographic participation, this study explores critical frameworks for engaging with and apply models of transformative justice.

Outcomes/Results: Transformative justice requires the development of both intellectual and somatic skills to disentangle feelings of comfort from safety. From this somatic work, participants could foster a sense of agency and accountability in conflicts with their relationships, which led to sustainable capacity for the entire community to think creatively when responding to harm. Current healthcare systems are deeply entangled in punitive justice systems through issues like surveillance, gatekeeping, and criminalization. While providers often have a sense of these entanglements, systems-level policies of isolation, efficiency, and urgency prevent them from engaging in genuine change. Moving towards transformative justice frameworks requires personal reflection as well as community accountability to unlearn internalized notions of punitive justice and build healthcare systems based in care, non-disposability, and sustainability.

Conclusions: Applying transformative justice to healthcare systems requires a complex and interconnected development of somatic work, creativity, agency, and community relationship that dismantles systems of care that are rooted in disposability and paternalism. While is difficult work in a world that operates on punitive justice, moving through that discomfort creates the possibility for healthcare models that are accessible and sustainable for everyone.

Combating the stigma of addiction amongst healthcare workers
Matzat, S*; Gupta, S; Zaro, C.

Context & Objective: People who use drugs face stigma from all corners of society, including from healthcare systems. Mistreatment of people suffering from addiction is born out of the widely held but false belief that addiction is a personal failing rather than a chronic disease like any other. Research suggests that stigma towards people using drugs creates a reduced willingness of patients to seek treatment and a reduced willingness of providers to screen for and treat substance use disorders. Even well-planned efforts to expand access to treatment for substance use will not reach their full potential if interpersonal, institutional, and societal stigma is not curbed.

Setting/Populations: This project was completed at Natividad Medical Center, a semi-rural safety net hospital in Salinas, CA. Faculty and residents at the Family Medicine Residency serve as local champions for substance use treatment by offering an Opioid Use Disorder (OUD) consult service in the hospital.

Intervention/Study Design: This intervention was a campaign to combat the stigma of addiction amongst hospital providers and staff in order to make the clinical environment more welcoming for patients with substance use disorders.

The campaign consists of two main components - an educational video and a flier - aimed mostly to address the issue of language choice as it relates to substance use. The flier is adapted from the “Words Matter” campaign put forth by the Grayken Center for Addiction at Boston Medical Center.

Outcomes/Results: Hospital leadership incorporated the educational video into the larger effort at the hospital to address issues of inclusion, diversity, and equity. Several but not all hospital services agreed to hear a live presentation regarding stigma towards substance use. Fliers are actively being distributed throughout the hospital.

Conclusions: This initiative highlighted the importance of allying with hospital leadership in efforts to shift institutional culture. Having “buy-in” from service directors who made time for a live presentation on the topic elicited more awareness and engagement. While this work is expected to have a substantial impact, it may not fully eliminate substance use disorder stigma in the hospital. It will be important to continue advocacy to further monitor and eliminate stigmatizing language and behaviors.

---

Food insecurity among older adults predicts elevated dementia risk
Qian, H*; Khadka, A; Martinez, SM; Vable, A.

Context & Objective: Food insecurity is common among older adults, and a potential predictor of dementia risk, however, there are no published studies of this relationship. This study fills this critical gap in the literature using data from the U.S. Health and Retirement Study (HRS) cohort.

Setting/Populations: Data come from a subsample of HRS respondents aged 51 years and older who participated in the 2013 Health Care and Nutrition Study (N=8071) where food security status in the last 12 months.

Intervention/Study Design: Food insecurity was assessed using the validated 6-item U.S.D.A. Food Security Module. Per USDA coding, food security was categorized into three levels: high or marginal food security (reference group), low food security and very low food security. The outcome was a previously validated algorithmically defined dementia probability score (ranging from 0 to 1), estimated biennially from 2014 - 2018. To evaluate the relationship between food insecurity and dementia risk, we fit Generalized Estimation Equations with a logit link, and age as the time scale. All models assumed an autoregressive 1 correlations structure, and were adjusted for the following potential confounders: age at interview, baseline age, gender, race/ethnicity, marital status, birthplace, and  several measures of socioeconomic status: years of education, income and wealth, poverty status, mother and father’s years of education, labor force status, home ownership, veteran status, amount social security income, welfare benefits, veteran benefits, food stamps, and total government transfers received. Models were weighted so results are nationally representative.

Outcomes/Results: Those who experienced low (OR=1.52,95%CI:1.11,2.08) or very low food security (OR=1.42,95% CI:0.98,2.03) had higher dementia risk compared to those who experienced high or marginal food security.  There was no evidence of a dose-response relationship.

Conclusions: Food insecurity among older adults predicted elevated dementia risk. Future work should determine whether this relationship is causal.

---

COVID-19 vaccination perceptions among young adults of color in the San Francisco Bay Area
Carson, M*; Rios-Fetchko, F*; Ramirez, MG; Butler, JZ; Vargas, R; Cabrera, A; Gallegos-Castillo, A; LeSarre, M; Liao, M; Woo, K; Ellis, R; Liu, K; Doyle, B; Leung, L; Grumbach, K; Fernandez, A.

Context & Objective: COVID-19 vaccination rates among US young adults, particularly in communities of color, remain lower than other age groups. We conducted a qualitative, community-based participatory study to explore beliefs and attitudes about COVID-19 vaccines among young adults in Black/African American, Latinx, and Asian American/Pacific Islander (AAPI) communities in the San Francisco Bay Area.

Setting/Populations: Participants were recruited by partnering with community-based organizations in the San Francisco Bay Area. Focus groups included Black/African American (N = 13), Latinx (N = 20) and AAPI (N = 12) participants between 18 and 30 years of age.

Intervention/Study Design: We conducted focus groups between June and August 2021. Emerging themes were identified from transcripts using a modified Grounded Theory approach.

Outcomes/Results: Prominent themes among all three racial-ethnic groups included mistrust in medical and government institutions, strong conviction about self-agency in health decision-making, and exposure to a thicket of contradictory information and misinformation in social media. Social benefit and a sense of familial and societal responsibility were often mentioned as reasons to get vaccinated. Young adult mistrust had a generational flavor fueled by anger about increasing inequity, the profit-orientation of pharmaceutical companies and health institutions, society’s failure to rectify injustice, and pessimism about life prospects.

Conclusions: Factors influencing vaccine readiness among Black/African American, Latinx, and Asian American/Pacific Islander young adults have a distinct generational and life-course texture. Outreach efforts should appeal to young adults’ interest in family and social responsibility and the social benefits of vaccination, while being cognizant of the friction mandates pose for young adults’ sense of self-agency. Efforts will be most effective coming from trusted messengers with a proven commitment to communities of color and health equity.

---

Self-assessment: A powerful tool to assess resident learning in the community
Flores Tindall, K*; Feibusch, K; Hiserote, T.

Context & Objective: Self-assessment has been shown to promote achievement, improve engagement, enhance the learning experience, and reduce bias. Moreover, in community settings, self-assessment offers a particular advantage because only the residents know if they are achieving the rotation’s goals.

Setting/Populations: In our three-week Community Medicine rotation and four-week Community Integrative & Lifestyle Medicine rotation, residents work in diverse community settings and on a service-learning project. To assess changes in self-perceived understanding and confidence, we modified a validated self-assessment tool to administer pre and post-rotation for residents to reflect on their own growth and set goals for future learning.

Intervention/Study Design: We surveyed a total of nineteen residents from 2019 to 2022. We employed a validated residency self-reflection tool that included both qualitative and quantitative items which we administered pre- and post-rotation. We included our own Community Medicine rotation objectives and are now piloting integration of relevant ACGME milestones.

Outcomes/Results: In terms of quantitative results, all residents showed overall improvement in the amount of agreement with the statements on the self-assessment form. Residents improved their self-reported knowledge, skill and confidence in working with community partners. In qualitative analysis, representative quotes include: “Looking back it seems like I’ve actually made a lot of progress. It’s pretty satisfying…it seems like I’ve learned so much.” “Definitely met ALL of my goals!” The expanded tool which includes milestones is currently being piloted for the first time.

Conclusions: The self-assessment tool provides the powerful ability to gain insight into resident experience in the community where we may not be directly supervising them or entirely in control of the curriculum. In addition, self-assessment provides additional insight into their perceived achievement of ACGME milestones which have been traditionally difficult to measure and prone to bias. Moving forward, self-assessment may be adapted to other rotations as a formative tool to allow residents to reflect on their goals and their progress.

Implementing a code lavender policy as an intervention tool within a community-based family medicine residency program
Flores, G*; Arias, A.

Context & Objective: The AAFP proposes a holistic view of the factors affecting physician well-being from five points of entry. At its base the model addresses a physician culture of propagating self-sacrifice as a cultural norm and encouraging peer-to-peer support. “Code Lavender” policies have been adopted by various academic medical centers to support staff members and family members in times of acute stress. The Natividad Family Medicine Residency wellness committee aimed to create a code lavender policy to address the needs of medical residents. The policy aids in the recognition of acute stress and can help prevent it from impacting resident well-being. This will empower resident physicians to ask for help in a timely fashion.

Setting/Populations: A formal code lavender policy was developed collaboratively by faculty and resident members of the residency wellness committee.  This policy applies to resident physicians at Natividad, a community based single residency hospital in Salinas, CA. It can be used across residency settings including the continuity clinic, labor and delivery and inpatient services.

Intervention/Study Design:

Residents can activate code lavender for a variety of situations, such as an emotionally traumatic experience, or for an individual whose emotional stamina has been drained by that “one more difficult situation”. Calling a code lavender does not necessarily require the resident to be relieved from their duties. We divided our Code lavender into 2 levels based on severity and anticipated interventions: level 1: care for the caregiver is needed.  The resident communicates with a senior resident and together they determine the additional support required.  Level 2: a traumatic experience or circumstance requires the resident to step aside and be relieved from their duties.

Outcomes/Results: Code lavender has been informally in use in academic year 2021-22. The policy was approved in March 2022. Results of the resident survey will be presented and used to inform policy revisions if needed.

Conclusions: Well-being as defined by the CDC is “judging life positively and feeling good”. The COVID-19 viral pandemic has placed extra stress on resident physicians. The code lavender policy is a system-based change in the context of a residency program to promote resident well-being.

---

Implementing professional development curriculum in family medicine residency program
Reouk. D*; Patel, L; Uy, A.

Context & Objective: Family medicine physicians soon find themselves in the roles of physician leaders, teachers, and practice managers almost immediately after training.  Often, these new physicians don’t receive adequate training in these areas. With our professional development curriculum our residents gain the skillset to be more comfortable transitioning into this stage of their careers.

Setting/Populations: Family medicine residents in a community family medicine program.

Intervention/Study Design: We created a curriculum to cover leadership, teaching, and practice management in addition to patient safety, professionalism, and med-legal topics.   2-week rotations were designed and scheduled longitudinally over the 3- year residency.  Topics were selected based on feedback from new hires and covered in progressive manner based on level of training.  Focused group evaluations at end of rotation revealed that these sessions were very helpful in career planning and overall professional development.  We will be surveying our graduates, fellows and current 3rd year residents who all have completed the curriculum.  The survey will evaluate the effectiveness of this training in obtaining a job and assimilating into the workforce as an attending or fellow.

Outcomes/Results: The focused group feedback was done each year. PGY1 found feedback model, their own leadership and learning style exploration, panel management, coding and Electronic Medical Record tips and tricks most effective, PGY2 found the teaching and leadership training, team communication, fellowship, and practice style workshop most effective and PGY3 found interview, CV, finance, and contract workshops to be most effective.  Future step includes survey as above.

Conclusions: A dedicated professional development curriculum to help residents both plan their career and equip them to be future physician leaders and teachers has been effective in transitioning our residents to the next stage of their careers and should be widely applied in training programs.

---

Adaptation and validation of the quality of contraceptive counseling (QCC) scale for use in Ethiopia and India
Holt, K; Gebrehanna, E; Sarnaik, S*; Kanchan, L; Reed, R; Yesuf, A; Uttekar, BV.

Context & Objective: High-quality contraceptive counseling supports individuals’ reproductive autonomy and well-being. We sought to adapt and validate the QCC Scale, originally constructed in Mexico (QCC-Mexico), for use in Ethiopia and India to expand its utility for measurement of client experiences of contraceptive counseling. QCC-Mexico consisted of 22 four-point response scale item. We grounded item adaptations for India and Ethiopia in qualitative research on women’s preferences for counseling previously conducted in each setting. We then fielded the adapted item pools and examined psychometric properties to construct two adapted scales.

Setting/Populations: We conducted cognitive interviews (n=20 clients/country) and client exit surveys in Addis Ababa, Ethiopia (n=599) and in rural and urban Vadodara, India (n=313).

Intervention/Study Design: QCC-Mexico items were adapted for the Ethiopian and Indian contexts. After assessing that items were consistently and clearly understood via cognitive interviews, country-specific item pools were tested through client exit surveys at clinic sites in each city. We used Classical Test Theory and structured equation modelling to test whether original scale properties from Mexico held in Ethiopia and India and to examine properties of individual items. Convergent validity was also examined using a concurrent measure of global client experience.

Outcomes/Results: Psychometric analyses revealed the adapted scales were valid and reliable for use, and the final scales retained content validity according to the original published QCC construct definition. Specifically, confirmatory factor analysis revealed high factor loadings for almost all items on the original dimensions: Information Exchange, Interpersonal Relationship, Disrespect and Abuse. Internal consistency reliability was high in both settings (Alpha=0.92 in Ethiopia and 0.74 in India). Final item pools contained 26 items in Ethiopia and 23 in India. Correlation analyses established convergent validity.

Conclusions: Our adaptation and validation processes resulted in three, context-specific versions of the QCC Scale, which remained highly consistent between settings. This suggests that the QCC Scale is robust to contextual differences and may easily transfer to other settings without extensive modifications. Ultimately, the QCC Scale and subscales fill a critical gap in measurement tools for ensuring high quality of care and fulfillment of human rights in contraceptive services, and consistent findings across continents suggest versatility in use across different contexts.

---

Adapting and validating the G-NORM (Gender Norms Scale), in Nepal: An examination of how gender norms are associated with agency and reproductive health outcomes
Sedlander, E*; Dahal, M; Bingenheimer, J; Puri, M; Granovsky, R; Rimal, R; Diamond-Smith, N.

Context & Objective: There are calls for the sexual and reproductive rights field to prioritize changing gender norms to ensure that women can act on their reproductive rights. Studies have found female empowerment and agency are associated with health care use and equitable beliefs about gender can serve as drivers of family planning use. However, there are gaps in how we measure gender norms. We sought to resolve this issue by addressing important missing theoretical components of gender norms measures, including differentiating between descriptive norms (perceptions about what others do) and injunctive norms (perceptions about what others should do), and adding a referent group (the community).

Setting/Populations: The data used to adapt and validate the G-NORM, a gender norms scale, come from newly married women of reproductive age (18-25) who live in the Nawalparasi district in Nepal (n=187). This region is more socially disadvantaged compared to other rural areas in Nepal, and the status of women, including household decision making, is lower.

Intervention/Study Design: Our team originally developed and validated the G-NORM in India. In this paper, we describe how we subsequently adapted and validated it in Nepal. After analyzing qualitative data to identify context specific gender norms items, we conducted cognitive interviews to ensure that women understood the questions. We subsequently administered all items in a survey. We conducted psychometric testing including exploratory factor analysis, confirmatory factor analysis, and construct validity - associations with theoretically relevant scales.

Outcomes/Results: Like the original G-NORM, exploratory factor analysis showed a two-factor structure, descriptive norms and injunctive norms, with high alphas for both subscales (0.92, 0.89). Fit statistics showed that our model fit the data well and as hypothesized, more equitable gender norms were associated with having higher scores on the decision-making scale, increased odds of intending to use family planning, and older ideal age at marriage.

Conclusions: Overall, our findings can contribute to greater theoretical consistency in the gender and social norms literature, provide an improved measure of gender norms in Nepal for implementors and researchers, and add to the body of evidence that gender norms are critical to consider for both agency and reproductive health outcomes.

Increasing successful referrals from Clinica Martin Baro to primary care and insurance
Bazyani, D; Bhullar, S; Gomez, A; Vydro, S*; Tapia, M.

Context & Objective: Clinica Martin Baro (CMB) is a student-run clinic in the Mission neighborhood of San Francisco. CMB patients are typically referred to the Family​ Health Center (FHC) at Zuckerberg San Francisco General Hospital to establish longitudinal primary care with a successful referral rate of 18.8%. “Successful referrals” are when CMB patients attend their primary care appointments. There is limited literature describing successful referral rates from student-run clinics to primary care; however, a benchmark was extrapolated from a prior work studying underhoused individuals that described a successful referral rate of 31%. This quality improvement project’s objective was to investigate the referral pathway from CMB to the Family​ Health Center (FHC) at Zuckerberg San Francisco General Hospital and increase the successful referral rate from CMB to FHC from 18.8% to 30.0% after one year of intervention.

Setting/Populations: The pre-intervention study population included 64 CMB patients referred to primary care at FHC between 2017 and 2020. The post-intervention study population included 27 CMB patients referred to primary care at FHC from January to May 2021.

Intervention/Study Design: Interviews were conducted with CMB and FHC affiliates to identify reasons patients fail to​ attend their FHC appointments. This project’s intervention created a consistent primary care referral pathway from CMB to FHC. Firstly, the One-E-App verified patients’ insurance status in real-time. If their insurance was inactive, then patients were referred to Healthy SF. Secondly, CMB volunteers were directed to coordinate patients’ availability and call patients for appointment reminders. Finally, telephone follow-ups surveyed if patients attended their appointments and potential concerns.

Outcomes/Results: The post-intervention successful referral rate was 51.8%: an increase of 33.0% from the pre-intervention sample. A comparison of proportions found the difference between the pre- and post-intervention rates to be statistically significant with a p-value of 0.0015 and 95% confidence interval.

Conclusions: This project reaffirmed that public insurance in the United States is difficult to navigate. While programs like Healthy-SF exist to provide insurance access to vulnerable populations, these populations still experience barriers to accessing these programs. Future interventions through student-run clinics such as CMB may play a significant role in helping patients establish and maintain primary care.

---

Got to catch them all! - incorporating procedures training early and frequently in medical education
Chelvakumar, M*; Shumba, T*; Teng, V*; Montacute, T.*

Context & Objective: Due to the projected shortage of primary care providers, many studies have been performed to determine what factors influence medical students’ decisions to pursue Family Medicine. Learning basic outpatient procedures is exciting for medical students, and early exposure is a wonderful way to engage their interest in the broad scope of practice of family physicians. We propose that by incorporating procedural training workshops taught by family medicine residents/faculty throughout the medical school years and as part of the core family medicine clerkship, we will increase medical students’ awareness and interest in family medicine as a career choice. In addition, a procedures-focused primary care elective has been offered to pre-clinical medical students for hands-on learning but also to expose students to primary care culture.

Learning Objectives for session participants:

(1) Describe the value of using procedural teaching as a way to engage medical students’ interest in family medicine.

(2) Explain three strategies and approaches to incorporating procedural skills into curricular and non-curricular teaching to increase interest in family medicine.

(3) List the resources and equipment that would be needed to teach several procedures (toenail removals, abscess I&D, skin biopsies, LARCs) at their home institutions.

Conclusions: Early introduction to family medicine faculty through procedural workshops can be a wonderful way for medical students to gain exposure and increase their interest in a career in family medicine. Participants will leave this presentation with a framework for developing procedural sessions at participants’ home institutions and practical ways to train medical students in procedures, while also expanding the primary care pipeline and increasing sense of community in medicine.

---

Health Equity: What it is and How do Residency Programs promote Excellence in Teaching Equity
Mills, W.*

Context & Objective: Natividad engaged in a long term strategy to improve teaching Health Care Equity in 2020. This included research, presentations, curriculum development, redesigning resident evaluations, resident and faculty selective, faculty development and other residency program systems redesign. 

Setting/Populations: The focus was on the continuum of learners and faculty at Natividad. The Residency leadership collaborated on many levels. 

Intervention/Study Design: Multiple process improvements affecting broad range of residency performance focused on Justice, Equity, Diversity, Inclusion, Anti-Racism, Anti-Oppression. 

Outcomes/Results: Improvements in broad range of emerging JEDI-AA program competency metrics 

Conclusions: Main take home is we are all life long life learners, and using the Master Adaptive Learner Model, we will share lessons learned through the lens of resident, faculty, GME leadership that can be used by others in similar roles 
 

Advancing justice, equity, diversity, inclusion, anti-racism and anti-oppression through a unified family medicine residency curriculum
Garcha, J*; Gonzalez, E; Musselman, M; Mills, W; Gupta, S. 
Mission Hall, Room 1400 (1st fl)

Context and Objective (why did you do your project?): The concepts of justice, equity, diversity, and inclusion (JEDI) have become increasingly recognized for their power to advance the core mission of the Natividad Family Medicine Residency. We recognize that longstanding systemic racism & oppression in medicine have led to disproportionate adverse outcomes among people of color and other marginalized populations in our community and beyond, which has been even more apparent in the setting of the COVID-19 pandemic. We also understand that as Family Medicine physicians, we are at the forefront of patient advocacy, a role which requires us to take concrete actions to demand better for our patients. For many in our residency, DEI work is not a new concept. However, conversations surrounding healthcare injustice can be difficult and uncomfortable across all levels of knowledge.
Through the creation of a formalized JEDI-Anti-racism, Anti-oppression (JEDI-AA) curriculum, we have established a sustainable, open, safe action learning environment for faculty, residents, and students to explore these sensitive topics, and to accelerate change within our spheres of influence and control.
Our overarching curriculum goals are to improve healthcare outcomes and disparities, and foster a healthier and safer work environment for greater staff performance, retention and leadership. The key strategies are to 1) strengthen JEDI-AA leadership and management, 2) maintain an internal Community of Practice, 3) build JEDI-AA capacity among staff, 4) increase diversity and inclusion among staff, and 5) improve quality, safety and equity in patient healthcare experiences. Initial tactics have been determined, and are more likely to differ across institutional contexts.

Relevance to Family Medicine: As Family Medicine physicians we aim to treat the person and not only the disease; in doing so we must use a holistic approach when providing care within our community. We believe that in order to accomplish this we must maintain a structural competency construct and be cognizant of the many intersections between race, socioeconomic background, spoken language, gender, sexual orientation, or ability/disability status, and the clinical encounter. These factors can and do affect the care we provide and our patients’ experience traversing the healthcare system at large. Training designed through a DEI lens will not only better prepare us to deliver equitable health care now and become more effective change agents, but will hopefully also inspire trainees to continue advancement of such efforts in their practice, teaching and every other aspect of their careers.

How you will make the session interactive with the audience: Family Medicine residency programs are in various stages of establishing or strengthening DEI curricula.  Our goal in this workshop is to strengthen a Community of Practice around these efforts and advance DEI efforts through sharing experiences and cross fertilizing ideas for leadership, broader engagement, change management, and ongoing monitoring.  For each of the overarching goals of the Natividad Family Medicine Residency JEDI-AA curriculum, we will describe our strategy and tactics and solicit reactions from the audience and sharing of other experiences, while summarizing the group’s conclusions and potential next steps.  This will be done using breakout groups, rapid audience surveys, and discussion actively facilitated by the speakers. Reactions and experiences with DEI work may also be collected and summarized through the use of tools such as WordClouds or other modalities.

Conclusions (What are the takeaways for the audience): Through a strategic initiative rooted in resident-faculty partnership and centered around the concepts of JEDI-AA, we have started a curriculum within our residency, obtained buy-in from key stakeholders, and implemented a collection of learning activities and advocacy efforts with longitudinal presence throughout the academic year.  Further progress will build on this foundation, and will require growing a broader Community of Practice within and among our various institutions.

Natividad Family Medicine Residency JEDI-AA Curriculum Approach
1. LEADERSHIP AND MANAGEMENT
Hospital DEI Committee
ACGME CLER Healthcare Disparity committee
Faculty JEDI-AA leads
Residency JEDI-AA Chiefs
Hospital DEI pledge
Residency anti-racism pledge
Review hospital and residency mission and vision statements
Tracking of pledge commitments
2. COMMUNITY OF PRACTICE
Speaker series
Literary circle
Electronic newsletter
Faculty and residency updates
3. CAPACITY BUILDING
Hospital Unconscious Bias training
DEI specific coaching
Residency didactic series
Expand didactics to other disciplines (e.g, nephrology)
Clinic attending DEI focused precepting guide
UCSF Teaching for Equity and Inclusion certificate
CME series
4. STAFF DIVERSITY AND INCLUSION
Equitable recruitment
Annual review of residency applicant assessment materials
Annual climate survey
Hospital Equitable Recruitment DDI training
Equitable curricula and assessment
Review curricular/assessment materials
CA/CAFP/UCSF equity and anti-racism guidance for clinical presentations
Establish Affinity Groups
5. PATIENT QUALITY, SAFETY, HEALTHCARE DISPARITIES
Eliminate race-based clinical paradigms
Measure and address healthcare disparities
Patient Centered Medical Home

---

Pipeline in a box
Armendariz, V*; Bamidele, S*; Hansen, M*; Sidhu, N.* 
Mission Hall, Room 1407 (1st fl)

Context and Objective (why did you do your project?): Underrepresented minorities (URMs) have disproportionately poorer health outcomes from preventable health conditions such as heart disease, diabetes, stroke, and some cancers (Bouye et al., 2016). In addition to structural barriers, language discordance and the inability to relate to medical providers further contributes to this gap (Bouye et al., 2016). However, studies have shown that URM patients have better health outcomes when cared for by providers from similar backgrounds (Jackson et al., 2014). Additionally, URM providers are more likely to go into primary care and to work in underserved communities (Cohen et al., 2002). Unfortunately, Black and Bipoc healthcare providers remain underrepresented in medicine due to educational disparities, lack of mentors and role models in higher education and medicine, and early discouragement by school counselors from pursuing higher education (Toretsky et al., 2018). Studies have shown that early pipeline programs with a focus on health professions and science, technology, engineering, and mathematics (STEM) can counteract the aforementioned barriers, ultimately helping to not only increase diversity in the healthcare workforce but also improve URM patient health outcomes (Smith et al., 2009).

The objective of our workshop is to teach family medicine residency programs a reproducible framework for starting a pipeline program. In this workshop, participants will explore the concepts and logistics of starting a pipeline program. Participants will define the rationale for pipeline programs, identify how to establish community partnerships, examine how to assess stakeholders’ requirements and goals for participation, design a basic lesson plan, and name the initial steps necessary for them to start a pipeline program at their home institution.

References:

Bouye KE, McCleary KJ, Williams KB. Increasing Diversity in the Health Professions: Reflections on Student Pipeline Programs. J Healthc Sci Humanit. 2016;6(1):67-79.

Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the Health Care Workforce. Health Affairs. 2002;21(5):90-102. doi:10.1377/hlthaff.21.5.90

Jackson CS, Gracia JN. Addressing health and health-care disparities: The role of a diverse workforce and the social determinants of health. Public Health Reports. 2014;129(1_suppl2):57-61. doi:10.1177/00333549141291s211

Smith SG, Nsiah-Kumi PA, Jones PR, Pamies RJ. Pipeline programs in the Health Professions, part 1: Preserving diversity and reducing health disparities. Journal of the National Medical Association. 2009;101(9):836-851. doi:10.1016/s0027-9684(15)31030-0

Toretsky C, Mutha S, Coffman J. Breaking Barriers for Underrepresented Minorities in the Health Professions. 2018;1-28.

Relevance to Family Medicine: The holistic approach in family medicine, where the whole patient rather than just their illness is factored into a treatment plan, naturally positions the family physician as an advocate. Additionally, URM healthcare providers are more likely to enter primary care and work in underserved communities. Consequently, family medicine residencies provide an opportune environment for pipeline programs.  In addition to community advocacy, pipeline programs also provide teaching and curriculum development opportunities and an increased sense of professional fulfillment for residents and faculty.

How you will make the session interactive with the audience: After presenting a brief didactic on the framework of a pipeline program, we will host an interactive workshop where participants will utilize the “toolbox” we have generated to further explore different aspects of implementing a program within their own community/residency. The toolbox includes templates and annotations that will allow a residency to establish a pipeline mentoring program in partnership with the community. Furthermore, participants will identify strategies to integrate pipeline programs into residency curricula and build resident skills specific to providing health education and mentorship. Participants will examine how to use templated resident evaluations specific to ACGME milestones as well as stakeholder pre/post surveys from the toolbox to inform resident development and program iteration.

Conclusions (What are the takeaways for the audience): By the end of this workshop, participants will possess a framework for starting a pipeline program that enriches resident, school, community, and ultimately URM patient experience and outcomes at large. Participants will gain instructions and templates for the creation of a pipeline program, including information on networking, curricular content creation, resident and program evaluation, and integrating pipeline participation into the core resident educational experience.

---

Challenging race-based medicine and moving toward race-conscious medicine
Tong, M.*; Kane, M; El-Sabrout, H; Hahn, M; Tran, L.
Mission Hall, Room 2103 (2nd fl)

Context and Objective (why did you do your project?): Despite race having no biologic basis, the medical community has used race to explain differences in disease prevalence and outcomes without explicitly naming racism as a cause for disparities. In clinical medicine, race comes into play in multiple ways that may contribute to disparities, such as through provider bias, clinical training, and clinical tools and algorithms that guide decision-making. While more recently known examples of race-based medicine in clinical calculators include eGFR estimators, other algorithms and guidelines include race in ways that may perpetuate disparities. At the same time, the lack of recognition of variation in health risks by race in other guidelines, including cancer screening guidelines, may also worsen disparities.

Our objectives are as follows:
(1) Examine how race-based clinical algorithms and guidelines come into play in decision-making and treatment and whether such practices are appropriate,(2) Identify remnants of structural racism in clinical medicine that are actionable, and
(3) Offer a framework to critically evaluate race-based medicine and move forward towards health equity and race-conscious medicine

Relevance to Family Medicine: The manifold goals of family medicine include that of enhancing population health and mitigating health disparities through person- and family-centered care, education, and discovery. The duty of family medicine training is to provide high-quality, comprehensive primary care education that recognizes the social, economic, and cultural dimensions of health and illness. Race-based medicine can perpetuate health disparities, while failure to acknowledge racial differences in health risks conversely may perpetuate health disparities and racism (e.g., in preventative health screening in diabetes and cancer).

How you will make the session interactive with the audience: [Didactics – 15 min]: We will provide a brief overview of race in clinical decision making and algorithms, touching on prior and ongoing work both at UCSF and nationally. We will cover at a high-level provider bias and health care disparities and the intersections between bias and medical training approaches (e.g., disease nomenclature, heuristics, and learning materials). We will then cover the state of race in clinical algorithms (much of which has been documented in the literature) with a focus on metrics relevant to a primary care setting. We will also include discussion of ways in which preventive health screening practices may perpetuate and address racial health disparities, and touch on other emerging areas in health care (including artificial intelligence, machine learning, and precision medicine) that may implicitly perpetuate racial bias.

[Workshop – 30 min]

Guided reflection activity (5 min) – BREAKOUT GROUPS

o How has race shaped your clinical care as a provider/patient?

o How have you seen racial bias play out in clinical practice and how do you as an individual/department address instances of bias?

o What actions do you think are most important for addressing provider and institutional bias?

Discussion of examples of race-based medicine (15 min) – BREAKOUT GROUPS

o Group 1: Race-specific cutoffs/guidelines

- Race ASCVD-risk scores and statin therapy

        - Race-specific BMI cutoffs for diabetes screening

        - COVID-19 specific management and outcomes:

                PFT race ranges (eg. UCSF uses race cutoffs)

                COVID-19 therapeutics (race-based considerations)

o Group 2: Cancer screening

        -  Discussion around age cutoffs and criteria for cancer screening (eg. Breast cancer, colorectal, lung, cervical, and prostate) as it pertains to race-based/race-conscious medicine

o Group 3: Race-based pharmaceutical prescribing practices

        -  How do/should we counsel patients race-based recommendations around drug administration/dosing (eg. HTN management)?

        -  What to do with race in EHR when precision medicine is not yet mainstream and available? Discussion around diversity in clinical trials

Group discussion piece (5 min) – Poll Everywhere or Word Cloud

o Where else in medical education have you seen racial stereotyping or bias come into play in medical teaching/pedagogy? Boards questions, lectures/didactics?

o Brainstorm: what are actionable, successful means of addressing structural racism in clinical medicine? What does race-conscious medicine look like for you? Anticipated challenges?

Learning Resources Sharing Time (1 min)

o Highlight resources for learning about race in medicine (Institute for Healing and Justice in Medicine, “Mind the Gap”, and other UCSF initiatives such as the REPAIR project)

Conclusions (What are the takeaways for the audience):
• As primary care providers and gatekeepers of the health care system, family medicine practitioners are well-positioned to address certain systemic barriers in health care.
• Medical pseudo-science and scientific racism fail to account for political/social factors such as poor housing, poverty, lack of health care, and racism that contribute to racial health disparities.
• Improving distinction between race and genetic ancestry and the impacts of racism on health in medical education is important for teaching about population health and eliminating teaching approaches of race as an unmodifiable/unactionable risk factor for health disparities.
• Race-conscious medicine requires tangible tools to undo the ways medicine perpetuates racist pedagogy while acknowledging meaningful and actionable clinical differences.

Get out of the way: centering patient voice and agency in healing through an integrative primary care model
Desai, A*; Eisenstein, T; Wolfe-Modupe, F.*
Mission Hall, Room 1400 (1st fl)

Context and Objective (why did you do your project?): We have embedded an integrative consult clinic within a primary care clinic to better meet needs of patients who are not responding well to conventional care alone. Our FQHC caters to a diverse population of medicare/medicaid patients who speak a variety of languages and face multiple chronic social stressors in their lives.  Our largest ethnic group is hispanic at just under 50% of patients, followed by asian, black and white populations in that order.  We started a pilot integrative consult clinic embedded within this primary care clinic and within the Family Medicine Residency program with the goal to center patient voice and patient models of illness and healing. We provide access to complementary modalities such as acupuncture, body work, mind-body counseling, and more, as patient desires expand our offerings. From September 2020-September 2021, we served 132 different patients with 362 visits total and 15 residents rotating through.  Our integrative consult clinic project works towards building a shared understanding between patient and clinician to inform the path towards wellness.

Relevance to Family Medicine: We believe integrative medicine is a natural extension, or even natural expression of Family Medicine.

How you will make the session interactive with the audience: In this interactive workshop we hope to share and regenerate a framework for patient driven-healing to meet the needs of diverse and marginalized patient populations. We have found the following structured tools most impactful, and believe both can be used in a faster-paced primary care clinic setting. 1) incorporating patient voice into HPI through the questions such as: what do you think is causing your illness?  What do you think you or your body needs to heal? 2) using a wellness wheel graphic tool to aid patient-centered health behavior change. Participants will engage with these tools themselves within the workshop to reflect on their approach to primary care and their individual pathways to centering patient healing.

Conclusions (What are the takeaways for the audience): Changing the framework to patient driven-healing goals is a form of abolitionist healthcare that could better meet the needs of diverse and marginalized patient populations who seek care in mainstream health systems.This practice asks providers to be in consistent and dynamic conversation with their patients and themselves about what healing will mean in any given moment.

---

We are not alone: Exploring Residency Faculty Wellness
Zaro, C*; Arias, A; Nolan, O 
Mission Hall, Room 1407 (1st fl)

Context and Objective (why did you do your project?): Over the past decade, rising numbers of family physicians experience burnout, defined as emotional exhaustion, depersonalization, and decreased sense of personal accomplishment.  This correlates with the introduction of the EHR, increased emphasis on the fee-for-service model, and decreasing time with patients.  In 2020, 47% of family physicians reported burnout, and professional isolation was cited as a major contributor.

A 2022 survey reported overall decreased faculty engagement in clinical, teaching and research domains during the pandemic, with younger and female faculty affected more.  Social distancing had a negative impact on department problem solving ability and on personal emotional well-being.  High quality proximal leadership providing good communication and a supportive culture was identified as helpful in mitigating these effects.

Much attention has been put to understanding and strategizing to improve resident wellness and mitigate burnout.  This session will focus on exploring the particular stressors and difficulties of faculty in the UCSF collaborative of family medicine residency programs, and how the pandemic has impacted us.  We acknowledge the complexity of faculty wellness, as many of us ride a roller coaster alternating between highs of immense gratification with our work and lows of deep frustration and exhaustion.

Relevance to Family Medicine: We will be exploring the inner workings of family medicine residency programs to understand contributors to faculty dissatisfaction.

How you will make the session interactive with the audience: We will briefly review known contributors to physician burnout and wellness, pre and post-pandemic, as reported in recent published surveys. Next, we will present real scenarios currently faced by faculty which contribute to dissatisfaction, frustration, or disengagement.  We will also present examples of factors or situations which bring us gratification.  This will be done by asking participants to either write down 1-2 of each or express them verbally, to be listed on easel pads for the group to see and discuss as a group.

The following are some of the scenarios/examples that will be presented to start the discussion:

Factors that cause the downs:

Not enough time given for admin tasks.  Having the feeling that other faculty are being given more time because they complained about it.

Never-ending EMR inbasket tasks, especially messages sent to me about things my MA or an RN could manage

Never-ending paper reports to review, especially when realizing that someone else already saw the same report earlier and dealt with it.

Working through lunch because mornings and afternoons are for patient care.

Scheduling meetings, preparing agendas, doing minutes, all for just a couple of people to attend

And the ups:

Positive feedback from residents about an educational presentation

Getting thanks from PD or other faculty for doing something well

Being able to get a workflow to work better

Watching a resident put into practice something I just taught them

Conclusions (What are the takeaways for the audience): The aim will be to acknowledge and validate the various difficulties in our daily lives, while connecting faculty with similar challenges in a spirit of camaraderie and ongoing collaboration.  The hope is that this discussion will improve awareness of our professional well-being as faculty.  In addition, we aim to lay the groundwork for exploring strategies and proposing solutions as a group.

Creating a climate change curriculum for family medicine residencies
Henley, E*; Kelm, J; Dragomanovich, H.
Mission Hall, Room 1400 (1st fl)

Context and Objective (why did you do your project?): The connection between climate change and health are clearly recognized by scientists and increasingly by the US public.  While most can appreciate the acute effects of extreme weather events on health - wildfires and smoke, heat waves, and drought, there is less appreciation of the effects of climate change on chronic disease such as cardiovascular, respiratory, and mental health.  Recently, more medical schools have started incorporating teaching about climate change into their curriculum, but anecdotal information suggests this is not happening much within residencies.  

The main objective of this session is to engage the audience in identifying key concepts and issues that should be part of a model curriculum on climate change and health that could be implemented within a family medicine residency.  The session will start by briefly describing the known effects of climate change on health, the concept of adaptation/resiliency and mitigation as responses, and the key areas that healthcare organizations could be working on to address climate change issues.  We will then move to a brainstorming session with participants to gather their ideas for content and implementation of a climate change curriculum.

Relevance to Family Medicine: To date, the implications of climate change on health have been underappreciated.  The increased occurrence of extreme events such as fires and heat waves has started to change this.  Some larger healthcare systems and hospitals have started to build resiliency and adopt mitigation strategies, but less has been happening inside clinics both with patients and communities served.  Family medicine residencies which are known for their focus on building continuity relationships with patients, serving vulnerable populations (who are particularly susceptible to the health effects of climate change), and attentive to the communities they work in, should be particularly interested in initiating efforts to respond to climate change.  These efforts could involve educating patients and communities about the connection between climate change and health, building resiliency to extreme weather events such as implementing strategies to deal with extreme heat and smoke, steps to lower the carbon footprint of clinics, and advocacy, particularly at local and state levels.

National polling shows that climate change is of particular interest to younger people, a demographic that includes family medicine residents.  Furthermore, since medical schools are starting to teach about climate change, it seems a missed opportunity not to continue this during residency where individuals have more  capacity to apply their learning.  Finally, we need the help of residents and faculty to figure out how to best bring climate change issues into the clinic setting since the evidence for its effect on health is so clear and yet so little acted on.

How you will make the session interactive with the audience: The focus of the session will be to engage the audience in identifying key concepts of a family medicine residency climate change curriculum as well as teaching and implementation strategies to incorporate such a curriculum into a program.  To generate discussion, the presenters will use a recently published curriculum proposal (Philipsborn et al; Climate Change and Practice of Medical Education. Academic Medicine 2021;96:355-367) to identify potential content areas that can serve as a stimulus for dialogue and additional brainstorming with participants.   We will collate the ideas proposed during the session and invite all who attend (and others who might be interested) to participate in a post-Colloquium virtual follow-up effort to translate these ideas into an actual curriculum.

Conclusions (What are the takeaways for the audience): This will be a highly interactive session.  Climate change is an extremely important issue with significant and widespread effects on health.  The time is ripe to incorporate teaching about it into family medicine residency curriculum.  We need ideas from residents, faculty, and staff about what such a curriculum should include and how it should be taught.  If successful, the Alliance could make a significant contribution to medical education as there is just not much in this arena right now.  For residents and faculty looking for an ongoing scholarly project, working on this curriculum post-session might be of interest.

---

Addressing birth equity – a family medicine-led collaborative pilot
Nath, K*; Iten, E*; Pecci, C*; Dudley, B*; Daniels, R.* 
Mission Hall, Room 1407 (1st fl)

Context and Objective (why did you do your project?): Black individuals experience the highest rates of maternal morbidity and mortality of any racial/ethnic group, with four-to-six times higher likelihood of dying from birth/pregnancy-related causes. This increased rate remains even when educational and income level are adjusted. The data is stark and unfortunately consistent over locale and time. Transforming the perinatal experience to reduce these disparities requires novel, collaborative and disruptive efforts to approach equitable outcomes. Family physicians are uniquely positioned to address this issue, as leaders, collaborative workers, and community advocates. Our project is directed towards active learning by family medicine learners and practitioners to develop clinical and advocacy skills to uplift Black parent and infant outcomes across the UCSF Alliance.

During this workshop, we will introduce terminology of birth equity to learners and explore proposed solutions for experienced providers looking to make an impact.  We hope to instill understanding of concepts such as allostatic load and upstream medicine in terms of health care access to provoke ideas about how to engage in change on a large scale. We will review commonly used measures and reporting tools, current advocacy partners, and how family physicians can claim their space as population health advocates and push for best practice tools to be utilized to affect maternal outcomes. We will spur interactive conversation to review state and local resources which have upstream impacts on patient care and provide opportunity for experienced practitioners to share how they overcome barriers to care for their patients. Finally we will invite all participants to engage with our pilot program beyond the colloquium.

Relevance to Family Medicine: This pilot is being developed in conjunction with California Health Care Foundation and Purchaser Business Group on Health, which support the work of the California Maternal Quality Care Collaborative, and may be one of few family medicine led (non OB) approaches to birth equity on a state level. The pilot will include interdisciplinary strategies in the prenatal, intrapartum and postpartum stages. Family physicians are well versed on implicit bias and institutional racism and we are ready for an opportunity to lead care transformation initiatives

How you will make the session interactive with the audience: This session will be an active, participant-driven session with breakout groups to share best practices and discuss proposed strategies of the pilot project. Provider interaction and collaboration across health systems is core to the success of the pilot program, and we believe the best way to mitigate existing systems that perpetuate inequities. Inspired learners will have an opportunity to join the pilot program to develop into Subject Matter Experts or advocate for Best Practice tools at their home institutions.

Conclusions (What are the takeaways for the audience): Concepts of allostatic load, upstream medicine, health care access and birth equity are all recommended learning points in forthcoming proposed ACGME guideline revisions. Prenatal, Perinatal and post-partum care are integral to family medicine. Our identity as patient and community advocates can bring population and continuity lenses to social structures that create inequities. Birth Equity is one such issue which needs a family medicine perspective. Thanks to the UCSF Educational Alliance, we suspect the session may develop into a productive workshop with many collaborators to cultivate strong partners for this pilot program!

---

Tell me what to do: an interactive simulation of family systems educational pedagogy
Johnson, C*; Martinez, N. 
Mission Hall, Room 2103 (2nd fl)

Context and Objective (why did you do your project?): Background - Family medicine was created to be a unique specialty to integrate the behavioral sciences and biological sciences to provide comprehensive clinical care to both the individual and families. As a specialty of unity, it was intended to be a direct counter to the hyper-specialized and fragmented care that exists in medicine. There are many economic and clinical barriers to providing the high level behavioral science training initially intended at the birth of the specialty. Drawing from family therapy, which was created around the same time as a family medicine and with a similar ethos, this session will demonstrate a training model for integrating greater contextualization of an individual into clinical practice.

Objectives:

(1) Provide a foundational understanding of family systems approach to patient care

(2) Promote the necessity of group-based live supervision in addition to traditional observation sessions for trainees

(3) Demonstrate the power of collective wisdom and healing in both an educational setting and a clinical setting.

Relevance to Family Medicine: As noted above, there are many economic and clinical barriers to providing high level behavioral science training. Due to these pressures, it is easy to apply a reductionist model of behavioral science training that is actually antithetical to the ethos of family medicine. To obtain the illusion of greater efficiency or simplicity, there is a pattern of adopting algorithmic approaches to behavioral health in lieu of stepping into a person's humanity. In this session, we will provide a practical example of how using multiple levels of inquiry and interventions can be equally efficient and, more importantly, maintain a high level of humanity in our profession.

How you will make the session interactive with the audience: The session will be a simulation of the family systems training that exists at the UCSF-San Francisco General Hospital Residency Program. As in our training program, we will have a resident interview a patient and solicit the audience for advice and feedback in real time (as would happen a typical during a live supervision training session). The audience will be asked to tackle questions of identity, imbalances of power and privilege, and personal values in order to help the resident co-facilitator conclude the session with a patient.

Conclusions (What are the takeaways for the audience): The intention is to meet the objectives in hopes that the audience will:

(1) Have a greater understanding of family systems and the need to integrate this theory into daily family medicine practice

(2) Develop a greater appreciation for group live supervision as a means of crowdsourcing trainee growth