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Storylines of family medicine VII: family medicine across the lifespan
  1. William B Ventres1,
  2. Leslie A Stone1,
  3. Katharine C Barnard2,
  4. Sara G Shields2,
  5. Mark J Nelson3,
  6. Maria Verónica Svetaz4,
  7. Clara M Keegan5,
  8. Joel J Heidelbaugh6,
  9. Paige B Beck1 and
  10. Lucille Marchand7
  1. 1Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
  2. 2Family Medicine and Community Health, UMass Chan Medical School, Worcester, Massachusetts, USA
  3. 3John Peter Smith Hospital Family Medicine Residency, Fort Worth, Texas, USA
  4. 4Family and Community Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
  5. 5Family Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
  6. 6Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
  7. 7Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
  1. Correspondence to Dr William B Ventres; wventres{at}uams.edu

Abstract

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In ‘VII: family medicine across the lifespan’, authors address the following themes: ‘Family medicine maternity care’, ‘Seeing children as patients brings joy to work’, ‘Family medicine and the care of adolescents’, ‘Reproductive healthcare across the lifespan’, ‘Men’s health’, ‘Care of older adults’, and ‘Being with dying’. May readers appreciate the range of family medicine in these essays.

  • Adolescent Health
  • Child Health
  • Geriatrics
  • Women's Health
  • Men's Health

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

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Introduction

Family medicine has consistently considered itself a ‘womb-to-tomb’ discipline. Although not all family physicians currently attend to patients across all age ranges, it is wise to consider the advantages of such a scope of practice. These advantages include an enhanced appreciation of the context of care, a deeper understanding of the meanings of the word family (and how these meanings apply to the practice of family medicine), a keen knowledge of the specific clinical priorities across the lifespan and an awareness of the enduring value of relationships regardless of the age of patients or the circumstances in which they live. Such inclusive practices also promote work satisfaction and a profound sense of professional worth.

Family medicine maternity care

Katharine Barnard and Sara Shields

Family physicians who provide maternity care bring a patient-centred focus, using principles of relationship, intersectionality and transformation in every interaction with pregnant people and their families.

The concepts of relationship, intersectionality and transformation are essential to family medicine and the care family physicians provide to multigenerational families.1 Perinatal care brings these concepts into sharp focus, as family physicians spend two intensive years promoting empowerment and growth, navigating family involvement and engaging in shared decision-making, all in the context of longitudinal, person-centred relationships.2 Family physicians support their patients as they confront adversities and stress; they learn what gives their patients strength through the challenges of pregnancy and early parenthood.3 Over time, family physicians come to understand who their pregnant patients trust, how they make decisions and what advice they choose to follow.

Juli’s first pregnancy is a story of such a journey. I (KCB) met Juli when she was nine years old, the youngest child of a single mom. Though Juli was favoured, she wanted to break free. At 14 she started dating and had one visit for birth control. Her next visit was for a pregnancy test, which turned out positive. The pregnancy was filled with physical discomfort, angst and eye-rolling from Juli and her mom. I tried to encourage Juli to think about readiness for childbirth and parenting, but she seemed stubbornly stuck in middle adolescence. Her mom worried, and so did I.

The labour seemed predictable at first, filled with intolerance to pain, ambivalence as to her readiness, and fear of what was to come. During the delivery, however, something magical happened. Juli reached down and took her baby in her arms; her entire affect changed. She was at once softer and fiercer. As she put the baby to breast, she became a mother.

Fourteen years later, as I care for her in her fourth pregnancy, I remember this moment with joy and wonder. Juli and I reflect on how far she has come, and I think of my role: shepherding, empowering, trusting, steadying and bearing witness to her transformation.

Family doctors involved in maternity care get to know their patients and families over time, building trust through shared relationships across generations. They show respect for their patients by asking questions about and appreciating the context of their patients’ lives. They seek to know the stories that brought their patients to their pregnancies and elicit dreams for the future of their families. In the many moments of anxiety that arise during normal perinatal care, family physicians serve as trusted guides through periods of doubt and fear.

Thus, the locus of control in family medicine maternity care is pregnant persons in the context of the family, social and cultural environments that support them, not the clinician or the healthcare system. Although family physicians who provide maternity care address the pathologies that occasionally occur during pregnancy and childbirth, they also care for their pregnant patients in a holistic, person-centred way and avoid becoming preoccupied with the disease-focused approach common to modern maternity care. This holistic approach leads to excellent outcomes as well as deep satisfaction among patients and family physicians alike (figure 1).4 5,6

Figure 1

Maternity care: relationships, intersectionality and transformation. Adapted with permission.6

Readings

  • Barr WB. Women deserve comprehensive primary care: the case for maternity care training in family medicine. Fam Med 2021;53:524–7. doi: 10.22454/FamMed.2021.451637

  • Lemay G. A midwife’s guide to an intact perineum. Midwifery Today Int Midwife 2001;59:39–40.

  • Midmer DK. Does family-centered maternity care empower women? The development of the woman-centered childbirth model. Fam Med 1992;24:216–21.

Seeing children as patients brings joy to work

Mark Nelson

As family physicians, we have a front row seat to watch children grow, change, develop, mature, and reach their own unique potentials. We work together with parents, family members and community representatives to help kids reach their life goals.

I am fortunate to work in a refugee clinic and care for children who have suffered the harsh realities of war and life in refugee camps. These children present with multiple unaddressed physical, emotional and developmental needs that impede their abilities to thrive in the USA.

An integrated approach to healthcare that seeks to understand each child’s context (collaborating with extended family members, other health professionals, school personnel and community advocates) is essential for seeing these children flourish. I have learnt many lessons from this work.

  • The care of children is strategic—The interventions we make at an early age can have a lifelong impact. Some children grow and develop almost effortlessly, whereas others struggle to reach their potentials, hindered by multiple physical, social and environmental challenges. One obvious goal is to help children who are not thriving begin to thrive, and we first must identify the barriers that keep them from reaching their potentials. These barriers can be developmental, genetic, acute or chronic illness-related, cultural, linguistic, social or economic.

  • Children need to know they are valued—‘The greatest disease today is not leprosy or tuberculosis, but rather the feeling of being unwanted.’7 We need to combine the innovations of modern healthcare ‘with an older idea of medicine where the body is a garden to be tended rather than a machine to be fixed.’8

  • Be an excellent listener—‘These difficult problems need unhurried, thoughtful, caring study and analysis,’9 especially when the medical issues are complex and the children we care for come from cultures different from our own. It takes time to listen to children and their parents (or caretakers), and time to listen is often unavailable in our modern, data-driven healthcare system. The poet-physician William Carlos Williams, in describing house calls said, ‘I want to be a visitor first, then an advisor, and I hope a helper.’10

  • Listening has its own rewards—Our lives are enriched by the perspectives, cultures and experiences of others. Just as the children we see grow and change, we grow and change through our interaction with them.11 My own life has been enriched by the children and families I care for and their unique cultural perspectives.

  • Embrace the values of humility, collaboration and service—These are hard values to live by12; however, they are essential if we wish to see our paediatric patients flourish and reach their potential.

Family physicians have a unique role in the care of children as they often also attend to their parents and extended family members. Caring for multiple generations of families helps us better understand what challenges children face and how to best address them.

Our calling is to serve the needs of our patients, especially those who are most vulnerable. Caring for children, collaborating with families and community, and seeing those children thrive brings immense joy to a clinic day (figure 2).13

Figure 2

The joy of caring for children. Adapted with permission.13

Readings

  • Backer LA. Caring for children: re-examining the family physician’s role. Fam Pract Manag 2005;12:45–52.

  • Phillips RL Jr, Bazemore AW, Dodoo MS, Shipman SA, Green LA. Family physicians in the child health care workforce: opportunities for collaboration in improving the health of children. Pediatrics 2006;118:1200–6. doi: 10.1542/peds.2006–0051

  • Smilkstein G. The pediatric lap examination. J Fam Pract 1974;1:66–9.

Family medicine and the care of adolescents

Vero Svetaz

The key element of adolescent care is building relationship.

Family medicine is the counterculture of our healthcare system.14 As such, we as family physicians focus our care on comprehensiveness and generalism—whole person and whole family care—working with patients where they are and in whatever circumstances they find themselves. We care for patients through their lifespan. More importantly, we care for families through their intergenerational developmental growth (figure 3).15 16

Figure 3

Health needs and actions in adolescents and young adults. Adapted with permission.16

Families go through different transitions during which the care we offer must be intergenerational. Adolescence is one of those developmental stages. It involves renegotiating rules and expectations between two or more generations. One family member—the adolescent— wants (and needs) more independence; those with authority need help guiding and watching over that transition. The process is like a mobile hanging from a ceiling—move one part of the structure and the whole thing moves.17

Connecting with adolescents requires the use of many skills. As family physicians, we must do the following:

  • Overcome the bias that societies have placed in youth and remove all notions that ‘they are okay and do not need us.’

  • Use all the relationship-based skills we can muster. Positive youth development18—evidence-based interventions used in adolescent care for prevention and promotion—is about our ability to be present and mindful, connecting with the emotions of our patients and resonating with their worlds. This is the heart of what we do as physicians caring for adolescents.

  • Build our structural competency to appreciate how adolescent development is influenced by contextual forces.19 Appreciate, as well, how the developing brains of adolescents—full of flexibility and often driven by passion—can make adolescents more vulnerable to stress and trauma.20

  • Understand the varied developmental stages of adolescence and thoughtfully communicate to create trusting bonds with teens and their parents over time.21

  • Invite shared presence: listen, affirm and reflect strengths. Repeat. One of the most important tasks of adolescence is to figure out one’s identity—racial/ethnic, religious, gender, sexual and political, among others. Our job is not to tell but affirm.

  • Support teens ‘becoming’ by honouring their budding efforts to grow into who they are.

  • Create life-saving safe spaces for intimate conversations to emerge, allowing adolescents to learn how to be unique, elevate their rights and develop critical consciousness around confronting bias-based bullying.22

The most fantastic reality is that when you as a physician are present with adolescents like this—observing expressions, making sense of pauses, gently pushing for more information (or, conversely, letting go of it), prioritising patients’ comfort and building trust—what results is attunement: a strong connection based on respect, presence, empathy and a strength-based attitude to life’s challenges. There is an added benefit, too—when you use this type of relationship-based approach with your adolescent patients, you gain vicarious resilience. And that, these days, is priceless.16

Readings

  • Christie D, Viner R. Adolescent development. BMJ 2005;330:301–4. doi: 10.1136/bmj.330.7486.301

  • Goodman M. How should doctors talk to teen patients? West J Med 2000;172:207. doi: 10.1136/ewjm.172.3.207

  • Reif C, Warford A. Office practice of adolescent medicine. Prim Care 2006;33:269–84. doi: 10.1016/j.pop.2006.01.008

  • Svetaz MV, Miller K, Gewirtz O'Brien J, McPherson L. Adolescent health: communication with adolescent patients. FP Essent 2021;507:11–8.

Reproductive healthcare across the lifespan

Clara Keegan

Managing reproductive health concerns improves our patients’ access to comprehensive care and makes us better family physicians.

Reproductive healthcare is vital to providing comprehensive family care as it deepens the relationship between patient and doctor by offering support for vulnerable and sensitive issues.

I entered healthcare to provide a patient-centred experience during gynecologic examinations. I chose medical school so I could deliver babies, and I pursued family medicine because I wanted to care for those babies after birth. While I maintain a ‘birth-to-death’ practice, I have gravitated towards what has traditionally been called ‘women’s healthcare’.

There are clear benefits to this work. I am able to address breast concerns, abnormal results on cervical cytology, pelvic floor dysfunction, abnormal uterine bleeding and vulvar skin changes. I offer the full spectrum of reversible contraceptive options. I can diagnose vaginitis at the point of care based on physical examination and microscopy. As a family physician, I manage symptoms related to pregnancy from a generalist perspective with a broad approach. I provide medication and procedural management of abortion and early pregnancy loss in my office.

These direct benefits are very important, but there are others that extend to the broader patient care that my practice offers. I have intentionally developed patient-centred counselling skills related to contraception and pregnancy options, which has improved my ability to provide nonjudgmental shared decision-making with my patients. Trusting, longitudinal relationships help me have frank discussions with my patients about sensitive topics related to sexual health.

My perspective allows me to have conversations with adolescents about puberty, gender, sexual activity and considerations related to pregnancy and infectious disease in an age-appropriate and approachable manner.

When I advise people of the risk of unexpected pregnancy with their chosen method, I let them know that if a pregnancy does occur, I can manage their pregnancy and deliver their baby. Alternatively, I can help them end their pregnancy. Once patients decide to continue their pregnancies, regular prenatal visits help us to deepen our therapeutic relationships. My patients also appreciate navigating a miscarriage or abortion with the support of the physician they have known for years.

These relationships help improve treatment. For example, the interpersonal and procedural techniques that make insertion of intrauterine devices more tolerable for teenage nulliparas are equally relevant when I see people who have experienced trauma. As understanding of the implications and limitations of hormone replacement therapy (HRT) improves, my relationships with people help me balance safety concerns with how HRT can improve quality of life during the menopausal transition.23 24

Benefits also extend to the rest of the family. If a sexually transmitted infection is identified, expedited partner therapy feels natural to me as I am accustomed to caring for multiple members of a family.25 During pregnancy, I often get to know my patient’s partner, and it is not uncommon for a second parent to join my practice along with the newborn.

Most outpatient reproductive health concerns are within the scope of family medicine. Managing contraception, pregnancy and pelvic health for patients adds depth to our longitudinal relationships. Without a doubt, reproductive healthcare is a rewarding way to support patients throughout the lifespan within family medicine (figure 4).26

Figure 4

The triple goddess symbol and the female life cycle. The triple goddess symbol depicts the three major phases of the moon. It also embodies the maiden, mother and crone archetypes that symbolise separate stages in the female life cycle.26

Readings

  • Coffman M, Wilkinson E, Jabbarpour Y. Despite adequate training, only half of family physicians provide women’s health care services. J Am Board Fam Med 2020;33:186–8. doi: 10.3122/jabfm.2020.02.190293

  • Manze M, Romero D, Sumberg A, et al. Women’s perspectives on reproductive health services in primary care. Fam Med 2020;52:112–9. doi: 10.22454/FamMed.2020.492002

  • Nothnagle M, Prine L, Goodman S. Benefits of comprehensive reproductive health education in family medicine residency. Fam Med 2008;40:204–7.

Men’s health

Joel Heidelbaugh

Family physicians have three key roles in men’s health. They must encourage men’s awareness of health issues, urge men to embrace the healthcare they need and deserve, and empower men during their health care visits.

What is men’s health?

‘Guy problems. You know, prostate and genital problems. Men die of heart attacks and strokes mostly, often working out at the gym. Oh yeah, and some cancers too. And stupid, risky behaviours. Guys like to take chances, and they don’t always think about what might happen to them. Guys should know better. Yeah, that should just about cover it.’27

When discussing the topic of men’s health, it is important to understand why men do and do not seek healthcare. In 2022, 14% of US adult men aged 18 years or older reported fair or poor health status.28 Compared with 88% of women, only 79% of men reported having a doctor visit for any reason in the past 12 months. In addition, compared with 82% of women, only 73% of adult men had a wellness visit within the preceding 12 months.28 Life expectancy for US men declined for the fifth year in a row to approximately 73 years compared with 79 years for women.29

How do we account for such discrepancies, and how can we improve the quality and length of life for our male patients?

Male gender is a major determinant of public health in the USA and worldwide. Although major health disparities exist between men and women, few health initiatives have adequately acknowledged or addressed this determinant to improve outcomes. Discrepancies in health issues between men and women cannot be explained solely by biological differences, thus a deeper understanding of the many factors that influence health decisions and behaviours of men must be investigated.30 As well, the global healthcare community must be willing to address the culture of men.

Men’s health experts have long studied how the challenges of masculinity, coupled with the frequent reluctance to seek help, have prevented men from securing the healthcare provisions they need and deserve. Commentaries about reluctance of men to access clinical medical services have fostered work in community-based promotion of men’s health, and there has been a rapid growth in community-based programmes that uniquely target men.

Such activity-based programmes work to shift unhealthy masculine norms and advance men’s health literacy.31 Expanding the delivery of men’s health to male-friendly spaces while developing favourable recruitment and retention strategies in primary care practices can augment medical and mental health services, decrease the incidence of fatal chronic diseases, decrease suicides and overdoses, and strengthen the role of healthy males in our communities.

Family physicians are well poised to support these programmes and engage with men of all ages and provide optimal care to address acute, chronic and preventative health issues. By building trusting relationships with their male patients over time, family doctors can provide men with in-depth care over their entire lifespan (figure 5).

Figure 5

Men’s health: look beyond the symbol.

Readings

  • Griffith DM. ‘I AM a man’: manhood, minority men’s health and health equity. Ethn Dis 2015;25:287–93. doi: 10.18865/ed.25.3.287

  • Heidelbaugh JJ. The adult well-male examination. Am Fam Physician 2018;98:729–37.

  • Baker P, Shand T. Men’s health: time for a new approach to policy and practice? J Glob Health 2017;7:010306. doi: 10.7189/jogh.07.010306

Care of older adults

Paige Beck

Caring for older adults requires a perfect balance of applying five core primary care values in light of patients’ and families’ needs and wishes, with a nod to the realities of ageing.

The five core values shared by geriatric medicine and family medicine include (1) preventive care, (2) comprehensive care, (3) coordination of care, (4) communication and interpersonal skills and (5) patient-centred/family-oriented care.32

An 83-year-old male presented with his daughter for sudden decline in health. The daughter noted that two months prior, her father started having difficulty walking and caring for himself. At a doctor’s visit about a week later, she stated that he was diagnosed with dementia, although without imaging studies or cognitive evaluation. Subsequently unable to provide adequate care due to her father’s intermittent angry outbursts and severe agitation, patient and daughter came to me for a second opinion.

After a comprehensive history and physical exam (including neurocognitive evaluation), I explained that I suspected the patient’s symptoms were likely the result of a stroke. I believed he probably had vascular dementia.

I referred him to physical therapy and counselled on ways to decrease risk of falls. I commended the daughter for the care she was providing and validated her feelings of frustration. I counselled her on caregiver stress; I gave her resources for community-based programmes aimed at providing care in the home. I encouraged her to seek help from other family members and to consider respite care to reduce the risk of caregiver burnout. I also started the patient on a selective serotonin reuptake inhibitor for the anger and agitation he was experiencing and scheduled a CT (computerized tomography) for diagnostic confirmation.

At follow-up, I reviewed the CT results—they showed chronic infarct of the cerebellum and internal capsule. In addition to starting medications for secondary prevention, I counselled him on lifestyle modifications to prevent or delay further strokes.

The daughter later reported a significant improvement in her father’s agitation. She expressed gratitude for the resources and advice provided during our previous visit. She thanked me for listening to her and taking the time to address her concerns and find a definitive diagnosis for her father.

Caring for older adults is not about just knowing the core values, but how to apply them. In family medicine, preventive care is often composed of screening tests and interventions to prevent disease or disease progression. As patients age, the goal of preventive care tends to refocus towards maintaining patients’ function and preventing disability. Comprehensive care entails addressing the social issues and mental health issues, not just medical ones. Coordination of care means working across a spectrum of settings, including subspecialist offices, hospitals and nursing facilities, especially during times of transition. Simply listening to patients can have a huge impact on outcomes, as does understanding the importance of family members. Patient-centred care is largely based on shared decision-making and respecting patient and family preferences in light of cultural beliefs and social determinants.

The beauty of caring for older patients lies in balancing such practical concerns as physical ailments, family issues and cultural norms with such existential concerns as expectations, fear and acceptance—knowing the core values of geriatrics and applying them with wisdom and compassion (figure 6).33

Figure 6

Caring for older adults. Adapted with permission.33

Readings

  • Bott N, Lindsay A. Diagnosing dementia and clarifying goals of care. Am Fam Physician 2019;100:369–71.

  • Newman MC, Lawless JJ, Gelo F. Family-oriented patient care. Am Fam Physician 2007;75:1306, 1310.

  • O'Brien J. Caring for caregivers. Am Fam Physician 2000;62:2584, 2587.

Being with dying

Lu Marchand

Family physicians care for whole persons throughout their lifespans—they care for patients from beginning to end. Caring for dying patients is a normal and notable part of family medicine.

Providing primary palliative care—the care of persons with serious illness from the moment of diagnosis through the process of dying to the time of death—is an essential competency of all family physicians.

It involves being present, listening to patients’ stories, blending those stories with medical histories and establishing patient-centred goals of care that change over the trajectory of people’s lives, for however long they may be. It means treating symptoms that occur from terminal diseases as well as managing side effects of treatment using pharmaceuticals and non-pharmaceutical means, such as acupuncture, touch and energy therapies. It includes attending to advance care planning by establishing powers of attorney for healthcare and reviewing Physician Orders for Life-Sustaining Treatment forms.34–36

As trusted personal physicians, family doctors can fully attend to the needs of dying patients in their practices by implementing home visits, supervising hospice care and frequently communicating with patients and families. A biopsychosocial spiritual approach to care is extremely helpful when providing care for dying persons, as is the involvement of interprofessional teams of health professionals. Grief and bereavement care is also critical; hospice and family medicine team members and community-based support systems are especially helpful in this regard.37 38

Laura was a 70-year-old patient who presented for care in my rural family practice. She was frustrated because she had red eyelids, flushed skin, and severe diarrhoea. She had been to a famous clinic for a workup of her symptoms. An ophthalmologist treated her eye problem, a dermatologist her skin condition, and a gastroenterologist her diarrhoea. Nothing they recommended helped. ‘I’ve come to you to figure this out,’ she said when I first met her. I felt intimidated.

Driving home from work that day, Laura’s symptoms coalesced in my mind—carcinoid syndrome! She nearly died before starting a new treatment for the condition. Luckily, this treatment worked, and I gave her monthly injections for several years. She did well during that time, buoyed by a new partner, a very active social life and lots of dancing. After four years, the medicine no longer worked, and her dying time came. I did home visits and supervised her hospice care.

On my last visit with Laura, she expressed thanks for the years of life she might not have had had her carcinoid syndrome not been diagnosed and treated. She expressed her gratitude for my care as well. ‘Thank you, Dr. Marchand, for these beautiful years.’ We cried in mutual grief, love, and gratefulness. Eventually, I treated her symptoms to help make her comfortable, yet alert, prior to her death.

Laura taught me so much about living and dying well. I will never forget her.

This is what care for the dying can provide us as family physicians: deep meaning, purpose and the value of the simple yet profound relationships we have with our patients. Dying is a normal part of life—it can be a genuinely heartfelt experience for us, our patients, their families and the communities we serve (figure 7).39

Figure 7

Holding the preciousness of life and end of life. Reproduced with permission.39

Readings

  • De Benedetto MAC, de Castro AG, de Carvalho E, Sanogo R, Blasco PG. From suffering to transcendence: narratives in palliative care. Can Fam Physician 2007;53:1277–9.

  • Loxterkamp D. A good death is hard to find: preliminary reports of a hospice doctor. J Am Board Fam Pract 1993;6:415–7.

  • Marchand L, Kushner K. Death pronouncements: using the teachable moment in end-of-life residency training. J Palliat Med 2004;7:80–4.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors WBV and LAS conceived of the Storylines of Family Medicine series. WBV, KCB, MJN, MVS, CMK, JJH, PBB and LM wrote the first drafts of their respective essays or sections in the manuscript. All authors contributed to the conception and editing of their respective essays or sections in the manuscript. Essay first authors reviewed and approved the final version of their contributions. WBV is the guarantor of this work and, as such, had full access to all the components of the manuscript and takes responsibility for the integrity of and accuracy of the information contained within. Illustrations: except as noted, authors designed the initial illustrations associated with their essays, and WBV created the final published images. All graphical icons originated from the Noun Project (https://thenounproject.com/).

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Author note All patient names are pseudonyms. Identifying data have been changed to protect patient anonymity.