Purpose The authors conducted a systematic review of the medical literature to determine the factors most strongly associated with localizing primary care physicians (PCPs) in underserved urban and rural areas of the United States. Method In November 2015, the authors searched databases (MEDLINE, ERIC, SCOPUS) and Google Scholar to identify published peer-reviewed studies that focused on PCPs and reported practice location outcomes that included U.S. underserved urban or rural areas. Studies focusing on practice intentions, non-physicians, patient panel composition, or retention/turnover were excluded. They screened 4,130 titles and reviewed 284 full-text articles. Results Seventy-two observational or case-control studies met inclusion criteria. These were categorized into four broad themes aligned with prior literature: 19 studies focused on physician characteristics, 13 on financial factors, 20 on medical school curricula/programs, and 20 on graduate medical education (GME) programs. Studies found significant relationships between physician race/ethnicity and language and practice in underserved areas. Multiple studies demonstrated significant associations between financial factors (e.g., debt or incentives) and underserved or rural practice, independent of preexisting trainee characteristics. There was also evidence that medical school and GME programs were effective in training PCPs who locate in underserved areas. Conclusions Both financial incentives and special training programs could be used to support trainees with the personal characteristics associated with practicing in underserved or rural areas. Expanding and replicating medical school curricula and programs proven to produce clinicians who practice in underserved urban and rural areas should be a strategic investment for medical education and future research.

Background Minority physicians are more likely than their counterparts to work in underserved communities and care for minority, poor, and uninsured patients, but much of this research has examined primary care physicians alone. Few have investigated whether non–primary care specialists of minority backgrounds are more likely to serve the underserved than nonminority specialists. Objective We examined whether underrepresented minority (URM) physicians from a wide variety of specialties are more likely than non-URM physicians to practice in underserved communities. Methods Using California Medical Board Physician Licensure Survey (2007) data for 48 388 physicians, we geocoded practice zip codes to medically underserved areas (MUAs) and primary care health professional shortage areas (HPSAs). Logistic regression models adjusting for age, gender, specialty, and other characteristics were used to explore associations with race, ethnicity, specialty, and designated underserved areas. Results We found that African American, Latino, and Pacific Islanders were more likely to work in MUAs and HPSAs than were white physicians (adjusted odds ratio, 1.22–2.25; p < .05). Similar patterns of practice in MUAs and HPSAs by physician race and ethnicity were found when performing the analyses separately among primary care physicians and physicians in non–primary care specialties. Conclusion In summary, our study underscores the importance of underrepresented minority physicians in all specialties for the physician workforce needs of disadvantaged communities. To improve health care for underserved communities, continued efforts to increase physician diversity are essential.

a b s t r a c tBackground: Improving medication management is an important component of comprehensive care coordination for health systems. The Managing Your Medication for Education and Daily Support (MyMeds) medication management program at the University of California Los Angeles addresses medication management issues by embedding trained clinical pharmacists in primary care practice teams. Objectives: The aim of this work was to examine and explore physician opinions about the clinical pharmacist program and identify common themes among physician experiences as well as barriers to integration of clinical pharmacists into primary care practice teams. Methods: We conducted a mixed quantitativeequalitative methods study consisting of a crosssectional physician survey (n ¼ 69) as well as semistructured one-on-one physician interviews (n ¼ 13). Descriptive statistics were used to summarize survey responses, and standard qualitative content-analysis methods were used to identify major themes from the interviews. Results: The survey response rate was 61%; 13 interviews were conducted. Ninety percent of survey respondents agreed or strongly agreed that having the pharmacist in the office makes management of the patient's medication more efficient, 93% agreed or strongly agreed that pharmacist recommendations are clinically helpful, 71% agreed or strongly agreed that having access to a pharmacist has increased their knowledge about medications they prescribe, and 75% agreed or strongly agreed that having a pharmacist as part of the primary care team has made their job easier. Qualitative interviews corroborated survey findings, and physicians highlighted the value of the clinical pharmacist's communication, team care and expanded roles, and medication management. Conclusion: Primary care physicians valued the integrated pharmacy program highly, particularly its features of strong communication, expanded roles, and medication management. Pharmacists were viewed as integral members of the health care team.

Acknowledging the growing disparities in health and health care that exist among immigrant families and minority populations in large urban communities, the UCLA Department of Family Medicine (DFM) sought a leadership role in the development of family medicine training and community-based participatory research (CBPR). Performing CBPR requires that academic medicine departments build sustainable and long-term community partnerships. The authors describe the eight-year (2000–2008) process of building sustainable community partnerships and trust between the UCLA DFM and the Sun Valley community, located in Los Angeles County. The authors used case studies of three research areas of concentration (asthma, diabetes prevention, and establishing access to primary care) to describe how they established community trust and sustained long-term community research partnerships. In preparing each case study, they used an iterative process to review qualitative data. Many lessons were common across their research concentration areas. They included the importance of (1) having clear and concrete community benefits, (2) supporting an academic–community champion, (3) political advocacy, (4) partnering with diverse organizations, (5) long-term academic commitment, and (6) medical student involvement. The authors found that establishing a long-term relationship and trust was a prerequisite to successfully initiate CBPR activities that included an asthma school-based screening program, community walking groups, and one of the largest school-based primary care clinics in the United States. Their eight-year experience in the Sun Valley community underscores how academic–community research partnerships can result in benefits of high value to communities and academic departments.

Objective Patients with multiple medical conditions and complex social issues are at risk for high utilization and poor outcomes. The Connecting Provider to Home program deployed teams of a social worker and a community health worker (CHW) to support patients with social issues and access to primary care. Our objectives were to examine the impact of the program on utilization and satisfaction with care among older adults with complex social and medical issues. Design Retrospective quasi‐experimental observational study with matched comparator group. Setting Community‐based program in Southern California. Participants Four hundred twenty community dwelling adults. Intervention Community‐based healthcare program delivered by a social worker and CHW team for older adults with complex medical and social needs. Measurements Acute hospitalization and emergency department (ED) visits in the 12 months preceding and following enrollment in the pilot program. A “difference‐in‐difference” analysis using a matched comparator group was conducted. Comparator group data of patients receiving usual care were obtained. Surveys were conducted to assess patient satisfaction and experiences with the program. Results The mean age of patients was 74 years, and the program demonstrated statistically significant reductions in acute hospitalizations and ED use compared with 700 comparator patients. Pre/post‐acute hospitalizations and ED visits were reduced in the intervention group. The average per patient per year reduction in acute hospitalizations was −0.66, whereas the average per patient reduction in ED use was −0.57. Patients enrolled in the program reported high levels of satisfaction and rated the program favorably. Conclusions A care model with a social worker and CHW can be linked to primary care to address patient social needs and potentially reduce utilization of healthcare services and enhance patient experiences with care.

BACKGROUNDThe Hablamos Juntos—Together We Speak (HJ)—national demonstration project targeted the improvement of language access for Spanish-speaking Latinos in areas with rapidly growing Latino populations. The objective of HJ was to improve doctor-patient communication by increasing access to and quality of interpreter services for Spanish-speaking patients.OBJECTIVETo investigate how access to interpreters for adult Spanish-speaking Latinos is associated with ratings of doctor/office staff communication and satisfaction with care.DESIGNCross-sectional cohort study.PATIENTSA total of 1,590 Spanish-speaking Latino adults from eight sites across the United States who participated in the outpatient HJ evaluation.MEASUREMENTSWe analyzed two multi-item measures of doctor communication (4 items) and office staff helpfulness (2 items), and one global item of satisfaction with care by interpreter use. We performed regression analyses to control for patient sociodemographic characteristics, survey year, and clustering at the site of care.RESULTSNinety-five percent of participants were born outside the US, 81% were females, and survey response rates ranged from 45% to 85% across sites. In this cohort of Spanish-speaking patients, those who needed and always used interpreters reported better experiences with care than their counterparts who needed but had interpreters unavailable. Patients who always used an interpreter had better adjusted ratings of doctor communication [effect size (ES = 0.51)], office staff helpfulness (ES = 0.37), and satisfaction with care (ES = 0.37) than patients who needed but did not always use an interpreter. Patients who needed and always used interpreters also reported better experiences with care in all three domains measured [doctor communication (ES = 0.30), office staff helpfulness (ES = 0.21), and satisfaction with care (ES = 0.23)] than patients who did not need interpreters.CONCLUSIONSAmong adult Spanish-speaking Latinos, interpreter use is independently associated with higher satisfaction with doctor communication, office staff helpfulness, and ambulatory care. Increased attention to the need for effective interpreter services is warranted in areas with rapidly growing Spanish-speaking populations.

Diabetes Mellitus type 2 (DM) is one of the most common chronic conditions among older adults and is often present with co-morbidities and geriatric syndromes. The management of cardiovascular disease risk factors in older adults with DM is of important significance to clinicians. The literature was reviewed from 2002-2012 to provide an American Geriatrics Society (AGS) expert panel with an evidence base for updating and making new recommendations for improving the care of the older adult with DM. This review includes only the domains of the management of blood pressure, lipid control, glycemic control, and use of aspirin. Over the last ten years, new randomized clinical trial (RCT) evidence designed to study the impact of different blood pressure treatment targets did not find that intensive blood pressure control (<130 mmHg) reduced myocardial infarction and mortality. There are increased risks of side effects with achieving a blood pressure of < 120 mmHg. Statin class lipid lowering drugs are effective in reducing cardiovascular events among middle aged and older adults but data on niacin and fibrates is limited. Lipid lowering trials of statins and other lipid lowering agents do not evaluate the cardiovascular effects of treating lipids to different low density lipoprotein (LDL) cholesterol targets. There were no randomized clinical trials of lipid lowering drugs that enrolled significant numbers of adults age 80 years and above with or without DM. Three major RCTs that investigated intensive glycemic control did not find reductions in primary cardiovascular endpoints and one study reported increased mortality with a hemoglobin A1C < 6%. Two recent published RCTs were designed to study the cardiovascular benefits of aspirin use by patients with DM. Both trials failed to significantly reduce primary cardiovascular endpoints with aspirin compared to control groups. Overall, RCTs enrolled very few adults greater than 80 years of age or with significant co-morbidities. More research is needed for clinicians to effectively tailor care to older adults with DM because of heterogeneity in health status, co-morbidities, duration of disease, frailty and functional status, and differences in life expectancy.

The path to a surgical career as experienced by African American and Latino surgeons is heavily influenced by mentors mediating their integration into surgical culture and engendering a feeling of belonging. Future surgeons from groups underrepresented in medicine would benefit from identifying aspirational figures early, a structured introduction into the rigors of the profession, and a deconstruction of negative surgical norms.