Primary skeletal muscle fibers first form in the segmented portions of paraxial mesoderm called somites. Although the neural tube and notochord are recognized as crucial in patterning myogenic cell lineages during avian and mammalian somitic myogenesis, the source, identities, and actions of the signals governing this process remain controversial. It has been shown that signals emanating from the ventral neural tube and/or notochord alone or Shh alone serve to activate MyoD expression in somites. However, beyond a role in initiating MyoD expression, little is known about the effects of Shh on primary muscle fiber formation in somites of higher vertebrates. The studies reported here investigate how the ventral neural tube promotes myogenesis and compare the effects of the ventral neural tube with those of purified Shh protein on fiber formation in somites. We show that purified Shh protein mimics actions of the ventral neural tube on somites including initiation of muscle fiber formation, enhancement of numbers of primary muscle fibers, and particularly, the formation of primary fibers that express slow myosin. There is a marked increase in slow myosin expression in fibers in response to Shh as somites mature. The effects of ventral neural tube on fiber formation can be blocked by disrupting the Shh signaling pathway by increasing the activity of somitic cyclic AMP-dependent protein kinase A. Furthermore, it was demonstrated that apoptosis is a dominant fate of somite cells, but not somitic muscle fibers, when cultured in the absence of the neural tube, and that application of Shh protein to somites reduced apoptosis. The block to apoptosis by Shh is a manifestation of the maturity of the somite with a progressive increase in the block as somites are displaced rostrally from somite III forward. We conclude that purified Shh protein in mimicking the effects of the ventral neural tube on segmented mesoderm can exert pleiotropic effects during primary myogenesis, including: control of the proliferative expansion of myogenic progenitor cells, antagonism of cell death pathways within the precursors to muscle fibers, and during the crucial process of primary myogenesis, can exert an effect on diversification of muscle fiber types.

Background and Objectives: Family physicians are increasingly making or contemplating various methods of practice transformation, but most report significant barriers to making that transition. Given strong interest in practice transformation, and perceived barriers to doing so, it is important to examine how some practices are implementing changes and overcoming barriers. In this project, Family Medicine for America’s Health Practice Team learned from practices across the United States that are transforming and experiencing the benefits of working in a comprehensive, value-based practice. The objectives of the project were to identify drivers of transformation to value-based care and ways of working with drivers to mitigate potential barriers, and to determine relationships between practice transformation and joy of practice. Methods: Fifteen practices of varying size and type from 11 states participated in this project. Practices were sent a short-answer survey about their practice, transformation, and payment structure. Next, practices participated in a 45-60-minute deep-dive interview. All surveys and interviews were iteratively coded to identify themes using Thomas Bodenheimer, MD, et al’s building blocks of high performing primary care framework. Results: Engaged leadership, data-driven improvement, team-based care, and comprehensiveness and care coordination were primary drivers of transformation, with payment as a needed foundation. Practice transformation helped meet the triple aim and was correlated to joy of practice. Conclusions: Practices are transforming to comprehensive value-based care delivery and experiencing greater joy in practice; but payment reform is required to spread and sustain practice transformation.

Achieving health equity requires an evaluation of social, economic, environmental, and other factors that impede optimal health for all. Family medicine has long valued an ecological perspective of health, partnering with families and communities. However, both the quantity and degree of continued health disparities requires that family medicine intentionally work toward improvement in health equity. In recognition of this, Family Medicine for America’s Health (FMAHealth) formed a Health Equity Tactic Team (HETT). The team’s charge was to address primary care’s capacity to improve health equity by developing action-oriented approaches accessible to all family physicians. The HETT has produced a number of projects. These include the Starfield II Summit, the focus of which was “Primary Care’s Role in Achieving Health Equity.” Multidisciplinary thought leaders shared their work around health equity, and actionable interventions were developed. These formed the basis of subsequent work by the HETT. This includes the Health Equity Toolkit, designed for a broad interdisciplinary audience of learners to learn to improve care systems, reduce disparities, and improve patient outcomes. The HETT is also building a business case for health equity. This has focused efforts on demonstrating to the private sector an economic argument for health equity. The HETT has formed a close partnership with the American Academy of Family Physicians’ (AAFP’s) Center for Diversity and Health Equity (CDHE), collaborating on numerous efforts to increase awareness of health equity. The team has also focused on engaging leadership in all eight US national family medicine organizations to participate in its activities and to ensure that health equity remains a top priority in its leadership. Looking ahead, family medicine will be required to continuously engage with government and nongovernment agencies, academic centers, and the private sector to create partnerships to systematically tackle health inequities.

Family Medicine for America’s Health (FMAHealth) is a strategic planning organization effort that was created out of the reevaluation of the first Future of Family Medicine project from 2004. This article is a summary of the key findings of the FMAHealth Practice Core Team. At the highest level, we find that family medicine practices have compelling intrinsic and extrinsic reasons to evolve to new models of care delivery. We have demonstrated that payment transformation is imperative to successful practice transformation and that comprehensive payment models that include attention to physician work within the social determinants of health and require fewer administrative burdens will be key to achieving the quadruple aim. To bridge payment reform and practice transformation will require better and fewer measures of physician effectiveness in order to allow the physician-patient dyad to thrive in these new models. Achieving these goals will require a sustained national effort involving not only the many family medicine membership organizations, but their collaborative work with others in the health care transformation industry who may not have been our traditional partners. Educational initiatives must be robust, available to all family physicians regardless of professional organization membership, and focused on meeting physicians and physician practice managers where they are with the goal of moving them toward a state of more advanced care delivery. This article outlines the work done by the FMAHealth Practice Team that supports the above assertions.