News Release

January/February 2021 Annals of Family Medicine tip sheet

Peer-Reviewed Publication

American Academy of Family Physicians

Crowdsourced Responses from Dermatologists on Twitter Found to be as Effective as Formal Telemedicine

At the start of the pandemic, many doctors on the front lines turned to Twitter and other social media platforms to find guidance and solace directly from their peers. In early 2020, information on COVID-19 had yet to be studied and published in peer-reviewed journals or printed in medical textbooks. Since then, social media has been characterized as both a boon to medical communities seeking real time information and a major driver of misinformation on the virus and its spread. A new study from researchers at the University of Paris provides support for social media as a potentially useful tool in the doctor's diagnostic toolkit and a way for general practitioners with questions to connect to specialists who may have the answers.

In France, some general practitioners have turned to social media for help diagnosing common dermatological conditions. They post a deidentified photo of a skin condition to Twitter or MedPics, a private social networking site for doctors, and other clinicians can respond with their diagnosis. In a retrospective observational study, researchers compared the accuracy of using social media to crowdsource a dermatological diagnosis to the accuracy of asking a dermatologist using more traditional telemedicine methods. Researchers found that diagnoses suggested by doctors on social media generally agreed with teledermatology results, and diagnoses were even more strongly aligned when dermatologists were active in the crowdsourced response. When the images posted to social media were reviewed by an expert committee of dermatologists, the researcher found that primary diagnoses from social media were accurate about 60% of the time, whereas teledermatology consultations were correct about 55% of the time, with no significant difference between the two studied methods.

These results suggest that social media can be as useful as teledermatology services for doctors when diagnosing common and minor dermatological conditions, but consultation with an expert dermatologist may still be necessary. The authors acknowledge that social media is less secure than standard medical communications technologies and that Twitter and other public platforms do not take the same measures to protect patients' privacy.

Diagnostic Agreement Between Telemedicine on Social Networks and Teledermatology Centers

Alexandre Malmartel, MD and Sophia Serhrouchni, MD
University of Paris, Department of General Medicine, Paris, France

Black and Hispanic Californians Face Health Care Discrimination at Higher Rates and Are Less Trusting of Health Care Providers

A recent statewide survey of Californians uncovered that 30% of Black adults and 13% of Hispanic adults felt that they have been judged or treated differently by a health care provider because of their race/ethnicity or language. One out of six Black and Latino Californians were more likely to report strong mistrust of their health care providers. Researchers at the Charles R. Drew University in Los Angeles analyzed data from more than 2,300 White, Hispanic, and non-Hispanic Black adults who asked to report on perceived discrimination due to race, ethnicity, language, income, and insurance status or type. Black and Hispanic adults reported higher rates of discrimination across the board, including income and insurance-based discrimination. Black and Hispanic adults reported higher rates of discrimination, including income and insurance-based discrimination. In addition, 20% and 10% of Black and Latino adults stated that they could not get health care services they needed because of racial/ethnic or language discrimination, respectively.

The analysis also found a link between having a consistent primary care physician and overall medical trust. Adults who did not have a usual source of primary care were much more likely to report mistrust of healthcare providers. The research team discusses the link between medical mistrust, racial and ethnic discrimination in health care, and roots in institutionalized racism, declaring that "resolving mistrust requires addressing systemic bias and prejudice in the medical system," echoing recent sentiments expressed by the American Medical Association.

Discrimination and Medical Mistrust in a Racially and Ethnically Diverse Sample of California Adults

Mohsen Bazargan, PhD, et al
Charles R. Drew University of Medicine and Science, Los Angeles, California

Editors of 10 Medical Journals Commit to Equity and Justice in Primary Care Research

Today there is a renewed call to action for all medical researchers to confront systemic racism, write the editors of 10 North American primary care and family medicine journals. Racism is a pervasive and systemic issue that has profound adverse effects on health. The editors have issued a joint statement that amplifies calls to action from antiracist and Black Lives Matter movements in the pursuit of health equity. The statement also outlines immediate steps the journals will take to address equity, justice and systemic racism in primary care research.

The statement, published by the major North American medical journals for family medicine, including peer-reviewed publications from the American Academy of Family Physicians and the College of Family Physicians of Canada, places deliberate attention on the role of systemic racism in creating inequalities in health and the need to make immediate changes within the academic medical community to further equity and racial justice.

Systemic Racism and Health Disparities: A Statement From Editors of Family Medicine Journals

Sumi Sexton, MD, et al
Georgetown University, Washington, DC

Healing the Pain of Systemic Racism: How One Community Clinic in Minneapolis Will Rebuild

The uprisings for racial justice in Minneapolis resulted in damage to a neighborhood family medicine clinic. In this essay, physicians from that practice witness the pain of their community manifested in damage to their clinic and reflect on how medicine can begin to heal the pain of systemic racism. COVID-19 health disparities and the murder of George Floyd are cultural milestones with the same root causes: lack of access to quality health care, discrimination, and sustained inequities perpetuated by multiple systems, including health care. They argue that family medicine, and medicine in general must begin to heal at the community level through direct and organized action to address social, structural and political factors that influence health. The authors recognize that "you can't heal what you don't reveal" and issue a call to family medicine, a specialty that began as a countercultural movement within medicine, to train future family physicians in community engagement and policy advocacy to heal communities.

Family Medicine, Community, and Race: A Minneapolis Practice Reflects

Shailendra Prasad, MBBS, MPH, et al
University of Minnesota, Department of Family Medicine & Community Health, Minneapolis, Minnesota

Pregnant Women in North Carolina Gain Access to More Comprehensive Coverage Through Simplified Full Medicaid Enrollment

North Carolina did not expand Medicaid eligibility under the Affordable Care Act, which continued to put many low income women at risk for losing health care coverage post partum. The state did comply with ACA standards for simplifying Medicaid enrollment, automating the process and removing a stringent and often cumbersome financial assessment process. Analysis from researchers at Duke University found that these reforms enabled more low-income women to qualify for full Medicaid and reduced the number of women who instead qualified for more limited benefits under the state's Medicaid for Pregnant Women program. Researchers examined Medicaid claims and vital statistics in North Carolina from 2011 to 2017 and determined that, after changing the full Medicaid enrollment process in 2013 to adhere to the ACA standards, enrollment in full Medicaid during pregnancy doubled and Medicaid for Pregnant Women fell. Full Medicaid does not expire after 60 days and allows women access to crucial preventative health services that include primary care and contraception.

Pregnancy Medicaid Improvements in a Nonexpansion State After the Affordable Care Act

Jonas J. Swartz, MD, MPH, et al
Duke University, Department of Obstetrics and Gynecology, Durham, North Carolina

Dear White People: Do Your Part to Actively Engage in Anti-Racist Education and Policy Change

Members of the Society of Teachers of Family Medicine Minority and Multicultural Health Collaborative write an open letter to their white colleagues, as reflected in this essay. They discuss their experiences of being educated in unbalanced and biased academic systems, including medical schools. They also share how they have had to carry disproportionately higher financial debt due to student loans. And while physicians of color produce essential research highlighting gaps in care for underserved communities--and tools to address those gaps--they are undervalued, underpaid, denied career advancement, and experience daily micro- and macro-aggressions. As medical doctors who are also people of color, they write that they have had to bear the exhaustive burden of a minority tax, including assuming the responsibility of explaining and then fixing racism and associated inequities of racism in medicine while also balancing the complexities of "white fragility." The authors provide a list of specific actions that their white counterparts can follow to support and elevate the voices of all people of color to break down structural and systemic policies and practices that enforce a culture of racism, inequity, and bias.

Dear White People

Krys E. Foster, MD, MPH, FAAFP, et al
Thomas Jefferson University, Department of Family and Community Medicine, Philadelphia, Pennsylvania

One Biracial Psychiatrist Describes Her Experiences of Nuanced Racism

Emma Lo, MD, Assistant Professor of Psychiatry at Yale University School of Medicine, writes a first-person narrative of how she, as a biracial, female resident and early-career psychiatrist, has experienced marginalizing incidents in her practice. She also draws attention to the oversimplified categories that fail to consider racial nuances and the resulting culture that excludes and devalues biracial or multiracial health care clinicians. Lo writes about the emotions she feels in interacting with her colleagues who do nothing to stop the perpetuation of patients' racist views; her frustration about her inability to speak out against and confront the microaggressions she experiences for fear of awkwardness; and shame for her own perceived propagation of racist viewpoints. Lo hopes that her essay illuminates the ambiguity necessary in dialogues about race and enriches literature about racism in medicine. "Until the medical community appreciates a nuanced view of race, biracial and multiracial people should not be forced to choose a checkbox or a side; nor are we a sum of our parts," she writes.

What Are You? A Biracial Physician on Nuanced Racism

Emma Lo, MD
Yale University, School of Medicine and Connecticut Mental Health Center, New Haven, Connecticut

How One Dutch City and Its Family Physicians Responded to the COVID-19 Pandemic

Family physicians play a central role in providing the first point of access for health care in the Dutch health system. Researchers studied the changes in presented health problems and the demand for primary care during the initial COVID-19 crisis in Nijmegen, a city in the Netherlands. They analyzed data from 25 family physicians and more than 26,000 patients in and around the city. Specifically, researchers examined the most prominent symptoms of COVID-19 including COVID-19 itself as a reason for the family practitioner visit, comparing February through May of 2019 with 2020. In March of 2020 more people presented with respiratory tract symptoms than in March of 2019. COVID-19 became the most common respiratory tract-related reason for contacting a family physician. However, from April to May 2020, presented symptoms dropped to levels lower than in 2019. Due to the pandemic, the demand for primary care changed rapidly. Acute and chronic health problems, and prevention visits, decreased, while mental health visits did not change. Study findings stress the importance of securing care for all health problems in a primary care's preparations for a major epidemic and to avoid the collateral damage of a health system's single-minded focus on an epidemic.

The Covid-19 Pandemic in Nijmegen, the Netherlands: Changes in Presented Health Problems and Demand for Primary Care

Henk Schers, PhD, et al
Radboud University Medical Center, Nijmegen, The Netherlands

Reviewing the Evidence for Cloth Mask Use Among Health Care Workers

A rapid, evidence-based review summarizes the effectiveness of cloth masks in protecting health care clinicians from respiratory viral infections, such as COVID-19. Nine studies were included in the review, and all but one were conducted prior to the COVID-19 pandemic. The only randomized trial of cloth face masks published at the time of this review compared the infection rates of influenza-like illness among groups of health care professionals who wore cloth masks, medical masks, or inconsistent mask use in the hospital setting. That study reported wide-ranging confidence intervals when comparing groups, but overall, they conclude that cloth mask use was associated with significantly higher viral infections than exclusive use of medical masks.

A majority of studies were conducted in laboratory settings and evaluated either cloth face mask fit and airflow when compared to other kinds of mask or the filtration abilities of cloth material and masks. All filtration studies tested aerosolized particles including noncoronavirus, bacteria, and simulated biologic particles, and results were highly variable but suggested some level of participle filtration. Notably, available filtration studies did not specifically test COVID-19 transmission or respiratory droplet transmission. The lab studies all conclude that cloth masks provided an inferior fit and were less effective at filtering viral particles compared to standard medical or N95 masks. Conclusions of this qualitative review align with current Center for Disease Control and Prevention guidelines that recommend use of an N95 respirator for care of patients with COVID-19. The authors also recommend that for health care professionals without access to medical masks, a cloth mask should be paired with the plastic face shield, with frequent cloth mask changes to reduce the risk of moisture retention.

The Potential for Cloth Masks to Protect Health Care Clinicians From SARS-CoV-2: A Rapid Review

Ariel Kiyomi Daoud et al
University of Colorado School of Medicine, Aurora, Colorado

Primary Care Plays Key Role in Managing COVID-19 in Three Asian Cities

Despite having some of the densest living spaces and the highest number of international visitors, Hong Kong, Singapore, and Beijing have utilized their respective primary health care systems to keep their COVID-19 cases and deaths relatively low. Researchers studied the primary health care systems in the three cities to identify features of each system that other cities can use as examples to prepare for and prevent deaths in future health crises. Wong et al write that all three cities have made use of primary care in performing public health surveillance and primary care functions, underscoring their assertion that primary care is an indispensable part of any health system and can play an important role in addressing future infectious disease outbreaks when it is supported, engaged, and integrated with other parts of a health system.

A Tale Of 3 Asian Cities: How is Primary Care Responding to COVID-19 in Hong Kong, Singapore, and Beijing?

Samuel Y.S. Wong MD, MPH, et al
Chinese University of Hong Kong, Jockey Club School of Public Health and Primary Care, Hong Kong

Becoming a Virtual-First Doctor and the Promises of Telehealth

The COVID-19 pandemic offers a glimpse into a world where virtual medical visits and telehealth could become the norm. In this essay, Ben Kaplan, a fourth-year medical student at the University of North Carolina, shares his experience providing all-virtual care for two at-risk patient populations. Kaplan is among a generation of doctors-in-training who have stepped up to provide virtual front line care during the coronavirus pandemic, all through expanded telephone and video-call based care. The author's experience making check-in calls for high-risk community members and providing video-based gender-affirming care experiences have led Kaplan to see telehealth as a bridge between the health care system and individuals who lacked access to consistent, high-quality care long before the pandemic. Kaplan recognizes some of the major limitations of virtual care, but ultimately calls for expanded access to telehealth and mixed virtual and in-person "hybrid" clinical care.

He discusses the American Academy of Family Physicians and other medical associations' endorsement of health insurance reforms that would achieve "telehealth parity," providing standardized reimbursement for telephone and video-based care on par with in-person visits. In order to ensure that telehealth reaches those who might need it most, Kaplan also argues for expanded access to broadband internet and investing in digital literacy skills as a social determinant of health. He writes, "Telehealth is not a one-stop solution to our nation's vast structural inequities, and its limitations with respect to in-person care merit serious consideration. However, if my brief experience is any indication, telehealth may continue to be a crucial resource for some of our most marginalized patients long after this national state of emergency has resolved."

Access, Equity, and Neutral Space: Telehealth Beyond the Pandemic

Ben Kaplan, MPH
University of North Carolina, Chapel Hill, School of Medicine, Chapel Hill, North Carolina

Bonus: Visual Abstract at

US Pandemic Response Highlights Urgent Need for Health Care Reforms to Reduce Health Disparities

The US health care system has responded to the disruption caused by COVID-19 with short-term measures that do not fix the underlying problems with the current system. This approach underscores the ways in which that system fails low-income people, racial and ethnic minorities, and other vulnerable populations that have been hit particularly hard by the pandemic. Marshall H. Chin, MD, a physician at the University of Chicago, stresses the urgency of addressing the underlying structural problems that perpetuate health disparities now. He presents three keys to developing lasting equity-specific reforms to the health care system: greater implementation of already successful interventions (e.g., expanding health coverage, implementing interventions that attack drivers of disparities, addressing social factors); creating a business case to reduce disparities; and engaging in "hard conversations about whether we truly value the opportunity for everyone to have a healthy life."

Cherry Blossoms, COVID-19, and the Opportunity for a Healthy Life

Marshall H. Chin, MD, MPH
University of Chicago, Section of General Internal Medicine, Chicago, Illinois

Treatment for Chronic Pain Must Address Both Physical and Social Pain

Physical pain and social pain may be more closely related than previously thought. Social pain, which typically results from interpersonal rejection or abuse, has been viewed as a non-medical response to external factors. However, recent research suggests that some physical and social stress responses may arise because of shared processing in the brain. Long-term usage of opioid medications could perpetuate a cycle of experiencing both physical and social pain and may increase risk of addiction. The authors, both of whom prescribe opioid medications, caution, "We must recognize that when physical and social pain coexist, long-term opioid therapy is more likely to harm than help." They advocate a move "toward chronic pain care models that do not separate physical pain (as a medical issue) from social pain (as a non-medical issue)."

When Physical and Social Pain Coexist: Insights Into Opioid Therapy

Mark D. Sullivan, MD, PhD and Jane C. Ballantyne, MD
University of Washington, Seattle, Washington

Fewer Patient Encounters Drive Decline in Total Primary Care Office Visits

Despite seeing gains in insurance coverage for preventive health services under the Affordable Care Act, the US has seen a declining rate of primary care visits over the past fifteen years. Are fewer individuals seeing primary care physicians. The authors of this study compared two factors that contribute to that decline to determine whether it was the number of primary care patients or the frequency of their clinical visits that contributed most to the overall decline. Over a fifteen year period from 2002 to 2017, both the number of unique patients seeing PCPs and the number of visits per patient declined. At the start of their analysis in 2002, most Americans saw a primary care physician about 4.3 times in a two-year span. By the end of the study in 2016, frequency of contact dropped to about 3.7 visits. Additionally, the total number of unique patients who had contact with a primary care physician decreased by 2.5% over 15 years and declined across all age groups at varying rates. Applying the rates to adjusted population estimates, the authors conclude that less frequent visits by the average American makes up a larger proportion of the primary care decline compared to the number of primary care patients overall.

Decreasing Use of Primary Care: A Repeated Cross-Sectional Study of MEPS 2007-2017

Michael E. Johansen, MD, MS and Joshua D. Niforatos, MD, MTS
OhioHealth, Grant Family Medicine, Columbus, Ohio and The Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland

Consent Forms Design Influences Patient Willingness to Share Personal Health Information

Patients are sometimes asked to share their personal health information for research purposes. Informed consent and trust are critical components in a patient's decision to participate in research. Researchers at the University of Florida conducted a three-arm randomized controlled trial to compare the effects on patient experiences of three electronic consent (e-consent) designs that asked them to share PHI for research purposes. Participants were randomized to a standard e-consent form (standard); an e-consent that contained standard information plus hyperlinks to additional interactive details (interactive); or an e-consent that contained standard information, interactive hyperlinks, and factual messages about data protections and researcher training (trust-enhanced). Researchers found no differences in preferences at one-week follow up. However, after six months, participants expressed the most satisfaction and subjective understanding with the trust-enhanced e-consent. The authors write that research institutions should consider developing and further validating e-consents that deliver information interactively, beyond that which is required by federal regulations, including facts that may enhance patient-informed consent and trust in research.

An Electronic Tool to Support Patient-Centered Broad Consent: A Multi-Arm Randomized Clinical Trial in Family Medicine

Elizabeth H. Golembiewski, PhD, MPH, et al
Mayo Clinic, Rochester, Minnesota

Medical Practice Patterns Vary Between Physicians More Than They Vary Within an Individual Physician's Practice Over Time

Harmful medical practices, like inappropriate prescribing of opioids and racial and income-based discrimination in clinical settings, can vary across medical practices and individuals. Patients may find that even common primary care health services, like getting a chest x-rays or a referral to a heart or lung specialist, can differ widely depending on your doctor or clinic location. These variations in medical practice can have serious consequences for the quality, equity and cost of one's health care; however, it's unclear whether these disparities can be attributed to individual differences, from one doctor to another or to changes in your doctor's individual practice over time, perhaps in response to shifts in clinical guidelines or advancements in diagnostic technologists. Is it person-to-person variation or variation over time? A group of Israeli researchers sought to answer this question in a retrospective cohort study using a decade of data from the largest health care provider in southern Israel. This study shows variations between physicians' practice patterns to be significantly more pronounced than variations within an individual physician's practice patterns over a decade. Researchers assessed the medical practice patterns of 251 primary care physicians, including their rates of imaging tests, cardiac tests, laboratory tests, and specialist visits. After adjusting for different patient and clinic characteristics, practice pattern variations remain high, while individual physicians' patterns over time appear stable. The authors propose that medical practitioners' personal behavioral characteristics might help explain variations across practice patterns.

Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, 3,238,498 Patient-Years

Victor Novack, MD, PhD, et al
Ben-Gurion University of the Negev, Soroka University Medical Center, Be'er-Sheva, Israel

Innovations in Primary Care

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care's front lines. In this issue:

  • House Calls Without Walls: Street Medicine Delivers Primary Care to Unsheltered Persons Experiencing Homelessness--A "street medicine" team brings full-spectrum primary care on location to unsheltered homeless individuals in Los Angeles, part of an emerging model of "reality-based medicine."
  • A Community Partnership to Improve Access to Buprenorphine in a Homeless Population--A new mobile health service formed through a community partnership in Chicago has improved access to medical treatment for opioid use disorder for individuals experiencing homelessness during the COVID-19 pandemic.
  • Targeted Inpatient Screening Mammogram Program to Reduce Disparities in Breast Cancer Screening Rates--A program targeting disparities in breast cancer screening demonstrates the feasibility of performing targeted inpatient screening mammograms to improve screening rates among Medicaid and dual-eligible patients.


Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and The College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website,

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