Amidst a pandemic that has acutely highlighted longstanding failings of the US health care system and the graduate medical education (GME) enterprise that serves it, educators prepare to embark on another revision of the program requirements for family medicine GME. We propose in this article a conceptual framework to guide this endeavor, built on a foundation of the core functions that Barbara Starfield suggested might explain primary care’s salutary effects. We first revisit these “4C’s”—first Contact, Continuity, Comprehensiveness, and Coordination—and how they might inform design thinking in primary care GME guideline revision. We also propose the addition of Community engagement, patient-Centeredness, and Complexity. Training residents to deliver on these “7C’s,” functions critical to the delivery of high-performing primary care, is essential if family medicine residency graduates are to serve the clearly articulated, but unrealized, quadruple aim for US health care: improved patient experience and population health at lower costs while preserving clinician well-being. Finally, we highlight and illustrate examples of four critical enablers of these 7C core functions of primary care that must be accommodated in training guidelines and reform, suggesting a need for resident competencies in Team-based, Tool- and Technology-enabled, Tailored (“4T’s”) care of patients and populations.

Background: Laminin-α2-related congenital muscular dystrophy (LAMA2-CMD) is a devastating genetic disease caused by mutations in the LAMA2 gene. These mutations result in progressive muscle wasting and inflammation leading to delayed milestones, and reduced lifespan in affected patients. There is currently no cure or treatment for LAMA2-CMD. Preclinical studies have demonstrated that mouse laminin-111 can serve as an effective protein replacement therapy in a mouse model of LAMA2-CMD. Methods: In this study, we generated a novel immunocompromised dy W mouse model of LAMA2-CMD to study the role the immune system plays in muscle disease progression. We used this immune-deficient dy W mouse model to test the therapeutic benefits of recombinant human laminin-111 and laminin-211 protein therapy on laminin-α2-deficient muscle disease progression. Results: We show that immunodeficient laminin-α2 null mice demonstrate subtle differences in muscle regeneration compared to immunocompetent animals during early disease stages but overall exhibit a comparable muscle disease progression. We found human laminin-111 and laminin-211 could serve as effective protein replacement strategies with mice showing improvements in muscle pathology and function. We observed that human laminin-111 and laminin-211 exhibit differences on satellite and myoblast cell populations and differentially affect muscle repair. Conclusions: This study describes the generation of a novel immunodeficient mouse model that allows investigation of the role the immune system plays in LAMA2-CMD. This model can be used to assess the therapeutic potential of heterologous therapies that would elicit an immune response. Using this model, we show that recombinant human laminin-111 can serve as effective protein replacement therapy for the treatment of LAMA2-CMD.

Background Laminin-α2 related Congenital Muscular dystrophy (LAMA2-CMD) is a devastating genetic disease caused by mutations in the LAMA2 gene. These mutations result in progressive muscle wasting and inflammation leading to delayed milestones, and reduced lifespan in affected patients. There is currently no cure or treatment for LAMA2-CMD. Preclinical studies have demonstrated that mouse Laminin-111 can serve as an effective protein replacement therapy in a mouse model of LAMA2-CMD. Methods In this study, we generated a novel immunocompromised dy W mouse model of LAMA2-CMD to study the role the immune system plays in muscle disease progression. We used this immune deficient dy W mouse model to test the therapeutic benefits of recombinant human laminin-111 and laminin-211 protein therapy on Laminin-α2 deficient muscle disease progression. Results We show that immune deficient Laminin-α2 null mice demonstrate subtle differences in muscle regeneration compared to immune competent animals during early disease stages, but overall exhibit a comparable muscle disease progression. We found human laminin-111 and laminin-211 could serve as effective protein replacement strategies with mice showing improvements in muscle pathology and function. We observed that human laminin-111 and laminin-211 exhibit differences on satellite and myoblast cell populations and differentially affect muscle repair. Conclusions This study describes the generation of a novel immune deficient mouse model that allows investigation of the role the immune system plays in LAMA2-CMD. This model can be used to assess the therapeutic potential of heterologous therapies that would illicit an immune response. Using this model, we show that recombinant human Laminin-111 can serve as effective protein replacement therapy for the treatment of LAMA2-CMD.

Critical Access Hospitals (CAHs) were developed as a model to improve the access and availability of hospital services in rural counties. There has been limited research on clinical outcomes to evaluate the impact of CAHs since they were authorized through the Balanced Budget Act. This study evaluates CAH's performance on clinical outcomes, and compares health outcomes between rural counties with CAHs and rural counties without established federally supported hospitals. The American Hospital Association's (AHA) Annual Survey Database was used to identify CAHs within rural counties and their characteristics. The County Health Rankings (CHR) data were used to quantify health outcomes by county. US rural counties with CAHs versus remaining US rural counties without CAHs were correlated with measures of Clinical Care (p < 0.001). US rural counties with CAHs presented greater health status with regard to All Health Outcomes, p < 0.0001; Length of Life, p < 0.0001; Quality of Life, p < 0.0001; All Health Factors, p < 0.0001; Health Behaviors, p < 0.0001; Social and Economic Environment, p < 0.0001 and Physical Environment, p < 0.0001, than compared to US rural counties without CAHs. Rural counties serviced by CAHs demonstrate better overall health status scores, on several CHR metrics, as compared to rural counties without CAHs. The only exception to this conclusion being that rural counties without CAHs performed superiorly in the CHR metrics related to primary care and mental health services, demonstrating capacities in which CAHs could improve the impact on health in the counties they serve.