Change is coming to the UMKC School of Medicine Department of Community and Family Medicine where Michael O’Dell, M.D., chair of the department, has announced his retirement after nearly 40 years in academic medicine.
The School of Medicine announced that R. Stephen Griffith, M.D, has been appointed interim department and academic chair while a search for a permanent chair is completed. The appointment is effective April 12. Griffith previously served nine years as chairman of the department.
“I am pleased to be asked to serve as interim chair during the time of transition from Dr. O’Dell’s leadership until a new permanent chair is named,” Griffith said. “As a previous chair, I know the challenges of the position and look forward to working with the outstanding faculty of the department to prepare for the next chapter in the department’s journey.”
Griffith is a graduate of the University of Missouri-Columbia School of Medicine and completed his Family Medicine residency at the University of Arizona. A faculty member in the UMKC Department of Community and Family Medicine and Truman Medical Centers medical staff member since 1984, he was chair of Community and Family Medicine from 2001 until 2010. He has also served as residency program director and as the school’s rural health director.
O’Dell announced his retirement effective July 1. He will take a 10-week personal and educational enrichment break beginning April 12.
During his appointment as chair of Community and Family Medicine starting in 2010, O’Dell furthered the department’s clinical, educational, and scholarly missions. He also significantly expanded the faculty.
Before coming to UMKC, he served on faculty and held leadership positions at the University of Kansas, the University of Texas Medical Branch, the University of Alabama Birmingham’s Huntsville Campus, and the North Mississippi Medical Center.
O’Dell is a graduate of the University of Kansas School of Medicine and the University of Kansas Family Medicine residency program. He served on active duty as an officer in the U.S. Naval Reserves and retired holding the rank of captain. He was awarded the Meritorious Service Medal and other awards during his Naval career and was deployed in the first Gulf War.
The many forms of media from movies to photographs and even YouTube videos serve as an opening for analysis and discussion of individual experiences with illness and disability, said Therese Jones, Ph.D., associate director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus.
Jones served as the keynote speaker for the UMKC School of Medicine’s 2021 Sirridge Lecture in an on-line format on March 30.
Jones, who also is the director of the Colorado school’s Arts and Humanities in Healthcare Program, said these images offer an evocative illustration of health care issues ranging from access to care to life and even racism.
“These works can foster empathic responses, sharpen critical thinking and develop communication skills, especially in our work with health profession students,” Jones said. “Visual materials can serve as openings for our students to critique the culture of health care itself.”
She shared that 56 percent of children between the ages of 8 and 12 and 69 percent of teens from 13 to 18 years old use YouTube for educational reasons, including science topics. She also noted how images shared from cell phone photos and videos often play a crucial role in rallying social and political responses to confront issues and act as a catalyst for reform.
Jones also spoke about how many humanities programs in health professions schools share a common method of developing observational skills, critical thinking and empathy through student interaction with the visual arts from paintings and photography to visiting art galleries and museums. The School of Medicine provides similar opportunities in its humanities curriculum.
Jones explained a new thinking in academic medicine that focuses on art as an opportunity to unveil what is hidden in the images and recognizing what is unique or strange in what otherwise seems ordinary.
“The arts-based curriculum is designed to be a process, rather than an event in which learners move from the neutral position of looking to an implicated position of the witnessing,” Jones said. “They realize that seeing is more than description. That scene is filtered through their personal values and our cultural norms. And these inhibit nuanced, even contradictory observations.”
The goal, she explained, is to take participants from a sense of self-awareness to self-criticism, and teaching observation as a pathway to a more humane approach to health care.
A native Kansan who received both her bachelor’s and master’s degrees in theater arts and English at Pittsburg State University in Kansas, Jones received a Ph.D. in English in Colorado before taking a postdoctoral fellowship in medical humanities in Ohio. She currently teaches health, humanities and disability studies at the University of Colorado schools of medicine and pharmacy, and in physical therapy and physician assistance programs among others.
The Sirridge Lecture is named for William T. Sirridge, M.D., and his wife, Marjorie S. Sirridge, M.D., two of the UMKC School of Medicine’s original docents who viewed the humanities as an essential part of students’ medical training.
After adapting to COVID restrictions and holding a virtual race last year, Kansas City’s Hospital Hill Run (HHR) is back as a live, in-person event on June 5. Whether you walk or run, and whether you prefer a 5K, 10K or half-marathon distance, make plans to join the city’s oldest foot race and the first live half-marathon event in the Kansas City Metro this spring. Here’s the official HHR statement:
The Hospital Hill Run has been given the green light to move forward with a live event, as scheduled for 6/5/21, pending any unforeseen circumstances. Health and wellness of our participants is our top priority and all city and state protocols will be followed.
The UMKC Health Sciences District is sponsoring the event, and all UMKC faculty, staff, students, alumni and friends receive a 20 percent discount when you REGISTER using this code: WPFCUMKC21. For younger participants, K-12 registration is offered as well.
The Hospital Hill Run website provides resources, videos and training materials to help participants prepare for the race. Runners/walkers will receive race medals and t-shirts.
Not a runner? The race is also recruiting volunteers. Learn more.
The Hospital Hill Run, founded in 1974 by UMKC School of Medicine founder Dr. E. Grey Dimond, is the oldest foot race in Kansas City. What started as a single 6.8-mile race with 99 runners has evolved into a well-known, world-class event hosting thousands of runners from nearly all 50 states. It was recently voted the Best Organized Footrace/Run in Kansas City by The Pitch magazine readers, and the 2021 event will mark its 48th year of success.
There’s nothing quite like the excitement of Match Day, even when all the action is online. The roughly 100 graduates and graduates-to-be of the UMKC School of Medicine found out by email, just after 11 a.m. Friday, where they will spend the next stage of their medical careers.
Dean Mary Anne Jackson, M.D., addressed students, their families, faculty and friends with a video message. She congratulated the UMKC Class of 2021 for its hard work the past six years and especially during the past challenging year of COVID-19 shutdowns and other disruptions.
“This ceremony, which you know is a rite of passage for medical students across the country, is even more significant this year,” Jackson said. “I know the uncertainty of the pandemic has created disruptions for you on your medical school journey, from a pause in clinical rotations at the beginning, the elimination of away electives, the shortages of PPE that created changes in how we cared patients, and a move to virtual formats for didactic lectures, and everything from residency interviews to our most special ceremonies including this one.”
Jackson said the docents, faculty and staff were proud of the Class of 2021 and appreciated its members’ focus, flexibility and resilience.
“As you scatter across the country, I know you will continue to make us proud by demonstrating the knowledge, kindness, empathy, compassion and professionalism you’ve learned here,” Jackson said.
As they did a year ago, students had to celebrate individually, but many did so at home with friends and family.
Half of the UMKC class will be headed to a primary care residency in internal medicine, family medicine, obstetrics/gynecology, or pediatrics. That exceeds the national average and is in line with the school’s mission to provide primary care for the Kansas City area, Missouri and the rest of the Midwest.
The students won assignments in 22 states, from California to New York and Washington state to Florida. Missouri had 26 of the placements, followed by 10 in Texas, eight in Florida, six each in Kansas and Illinois, five in California and four each in Arizona, Indiana, Louisiana, Minnesota, New York and Ohio.
And, as usual, some are headed to the top names in medicine, including three to Mayo and two to the Cleveland Clinic. Twenty-four will stay in the Kansas City area, most of them at UMKC and its affiliate hospitals.
Internal medicine was the top category with 32 placements, followed by 10 in family medicine, nine in various types of surgery, eight in pediatrics or medicine-pediatrics, seven in emergency medicine and six in psychiatry.
One year after COVID-19 was declared a pandemic, UMKC School of Medicine Dean Mary Anne Jackson, M.D., says we are getting closer to returning to normal.
The first reported cases of a novel coronavirus called SARS CoV-2 were in December of 2019, and on March 11, 2020 – one year ago today – the Director-General of the World Health Organization declared the COVID-19 outbreak a pandemic. Based on the spread of COVID-19 to 114 countries and alarmingly high case-fatality rates, the declaration came with a caveat: with detection, testing, treating, isolating, tracing and mobilizing a response, we could change the course of this pandemic. At that time in the United States, there were 1,762 cases. Today we stand at more than 29 million cases and 528,829 people have lost their lives. We have seen the disproportionate impact of COVID-19 on our Black, Hispanic, and Native American populations, and many Americans have lost their jobs, income and housing. People have suffered disruptions in family bonding and lost family members to this disease. The human toll and downstream consequences – related to many who have avoided routine medical care, routine immunizations and cancer screenings – will have a cumulative impact on both physical and mental health. This impact will likely be seen for many years to come.
Children, while less likely to have severe disease, now account for more than 3.2 million – or 13.2% – of the COVID-19 cases across our country. The pandemic has taken an enormous toll on our youngest, most of whom have not been able to attend in-person school and have been isolated from family and friends. Children have lost multiple family members, many are food-insecure, and all have suffered at least some degree of toxic stress from the pandemic. This result is now being manifest as an increase in emergency room visits for mental health and behavioral complaints. In our community, we are just starting to return to at least partial in-person education for those who attend public schools in both Missouri and Kansas. In most cases, a hybrid of virtual and in-person learning remains the norm of today. The cumulative loss in learning for a child could average 5-9 months by the end of the school year. And for students of color, who lack internet, devices and appropriate places to study, the loss could be as much as 12 months. We must invest in bridging this gap and make sure every child has an opportunity for success.
As the pandemic unfolded, we were forced to make changes, to adapt and quickly evolve like we’d never done before in the 50-year history of our medical school. We are proud of the curricular innovation we brought to meet student needs and to ensure teaching, supervision and assessment. We kept student advancement our top focus. And we celebrated our students who graduated in 2020 – the first-ever to finish their medical school journey with virtual electives – with an entirely virtual Match Day and an entirely virtual graduation sending them off to residency programs to join the front lines of care. Even as we brought back students to clinical rotations last summer, we continued with a largely virtual biomedical science curriculum taught by talented faculty who, too, were learning to optimize virtual learning while navigating the pandemic personally. We saw flexibility and resilience from all of our students, staff and faculty to move forward all students – medical students, physician assistant and anesthesia assistant students – in their medical journey. Our senior students who will celebrate Match Day next Friday, with a virtual ceremony, will now join our medical community as they pursue residency training in a new era alongside their physician assistant and anesthesia assistant colleagues who are starting practice.
Now, we will join our current senior students to celebrate Match Day next Friday – again with a virtual ceremony – to mark their steps into the medical community to pursue residency training in a new era.
There are many reasons to be encouraged. The pace of disease has slowed, and we are seeing the lowest number of new cases, hospitalizations and deaths since last spring. Prediction models suggest that a third of the population has natural immunity – I taking the number of cases we know, combined with the estimate of the number who have had asymptomatic infection. And there are some experts who suggest SARS CoV-2 may have a seasonality where summer may produce a natural reprieve. Add to that we are welcoming the era of COVID-19 vaccines – the clear path that will lead to the herd immunity necessary to stop the spread of this deadly virus. Today, we stand at three vaccines that have received emergency-use authorization and have all demonstrated the ability to reduce serious disease and deaths. Nearly 19% of the U.S. population has received a first dose of vaccine and 2.17 million doses are being administered every day as of March 4, 2021. While vaccine supply is not yet ready to meet demand, we expect enough vaccine from Pfizer, Moderna and Johnson & Johnson by end of April to fully vaccinate more than 200 million adults. That would put us on pace to have 50% of the population vaccinated by May 25. There is still a huge logistical challenge to providing equitable access to vaccination, and approximately one-half of those 65 and older have not yet received the vaccine. We need to prioritize getting vaccines to our seniors, as we know that age is a predictor of hospitalization and mortality from COVID-19. When compared to someone 30 years of age, it’s a 100 times greater risk for death in those 65 and older, a 1,000 times greater risk of death in those 75 and older, and a 10,000 times greater risk of death for those who are 85 and older. Ensuring access and reducing logistical challenges for this population is critical even as we open up access to more eligible populations.
As we vaccinate more and more Americans, the CDC provided new guidance this week: Those who are fully vaccinated can safety gather with family and friends. At the same time, experts are still recommending restrictions on travel. This caution relates to the increase in spread of vaccine variant viruses across the U.S. and the plateau of cases seen in many states. This may portend another surge of disease, even as we seem to be on the cusp of recovery. Vaccine manufacturers are already progressing on the work needed to provide a booster or multi-virus vaccine to address the variant spread.
So, on this day, one year into the pandemic that has disrupted all of our lives in ways we could have never imagined, know that we will return to normal. And know that we are increasingly getting closer to the point that we put the pandemic in our rear-view mirror.
The UMKC School of Medicine has announced that Jeanne M. James, M.D., FAAP, MBA, has been named the school’s new chair of the Department of Pediatrics. James will also serve as pediatrician-in-chief at Children’s Mercy and pediatrics department chair at the University of Kansas School of Medicine.
“Dr. James has incredible expertise and experience that will further enhance the academic excellence of Children’s Mercy and I look forward to working with her on behalf of our students” said Mary Anne Jackson, M.D., dean of UMKC School of Medicine.
Most recently, James served as chief of cardiology at the Medical College of Wisconsin (MCW) and held the Leigh Gabrielle Herma Endowed chair for cardiology and served as the medical director of cardiology for the hospital.
Before joining MCW in 2017, James spent more than two decades at Cincinnati Children’s Hospital and the University of Cincinnati advancing through the academic ranks, ultimately achieving the rank of professor and earning progressive leadership roles. She began at the academic rank of instructor in the Department of Pediatrics, a faculty position accompanying her appointment as a Proctor Scholar in the department and a post-doctoral fellow in the laboratory of Jeffrey Robbins, Ph.D..
Throughout her career in Cincinnati, James continued working with the lab and developed many productive research collaborations. In addition, she served the Heart Institute as Pediatric Cardiology Fellowship program director, medical director of Cardiovascular Genetics and director of the Mouse Echocardiography Core. Among other roles, James served the University of Cincinnati as chair of the Department of Pediatrics Reappointment, Promotion and Tenure Committee and was a member of the Cincinnati Children’s Hospital Institutional Review Board.
James earned her bachelor’s degree in chemistry at West Virginia University and went on to the West Virginia School of Medicine. At 20 years of age, she was the youngest member of her class, but was widely recognized not for her age, but for her early achievements and leadership. She completed her pediatrics residency at Vanderbilt University Medical Center, followed by her fellowship in Pediatric Cardiology, also at Vanderbilt. During this time, she was a research fellow in the Molecular Physiology and Biophysics lab of Michael M. Tamkun, Ph.D.
A year-long, national search to fill this position was co-led by Drs. Shawn St. Peter and Tamorah Lewis and included many representatives from UMKC School of Medicine, Children’s Mercy and KU Hospital.
“I thank all who played a role in helping us fill this important position – expectations were high and the committee delivered,” said Jackson. “No doubt Dr. James will be a leader and a great addition to our faculty.”
From its beginning, the School of Medicine has emphasized compassionate patient care, professionalism and humanism. The school’s chapter of the Gold Humanism Honor Society welcomed a class of 30 students, faculty and medical residents who embody those traits during a virtual induction ceremony.
This year’s class included 20 fifth-year students, four faculty physicians and six residents nominated by their colleagues. The inductees were selected based on demonstrated excellence in clinical care, leadership, compassion, and dedication to service.
The GHHS is a national honor society established in 2002 with sponsorship from the Robert Wood Johnson Foundation. Today, GHHS has more than 160 chapters in medical schools and residency programs throughout the country and more than 35,000 members who serve as role models in health care.
The School of Medicine chapter also welcomed two new faculty sponsors this year in Renee Cation, M.D., assistant professor of pediatrics, and Beth Rosemergey, D.O., associate professor and director of the Community and Family Medicine Residency program, who have taken on the role previously held by long-time faculty sponsor Carol Stanford, M.D.
Because of the ongoing COVID-19 pandemic, the Jan. 24th induction ceremony took place as a brief Zoom event led by chapter co-presidents Margaret Urschler and Charles Burke.
2021 GHHS Inductees
5th Year Medical Students: Jessica Anyaso
Dr. Rebecca Aguayo
Dr. Apurva Bhatt
Dr. Jasmine Haller
Dr. Gayathri Kumar
Dr. Rebecca Malstev
Dr. Johana Mejias-Beck
Dr. Douglas Burgess
Dr. Kavita Jadhav
Dr. Jennifer McBride
Dr. Judith Ovalle
The UMKC Health Equity Institute has chosen eight collaborative research projects to benefit from “mini-grants” of $1,700 to $2,200.
Each project pairs a community organization and a UMKC researcher to explore ways to improve health care access for underserved communities. The research topics in this first round of grants include COVID-19 effects on family resilience and easing the trauma of shooting victims. The community partners range from a tenants’ organization and the Kansas City Housing Authority to Children’s Mercy and Truman Medical Centers.
“One goal with these mini-grants is to encourage the kind of research that results in sustainable initiatives, instead of efforts that can fade away after a big grant runs out,” said Jannette Berkley-Patton, Ph.D., a professor in the School of Medicine.
Berkley-Patton, the director of the Health Equity Institute, a UMKC initiative launched by Chancellor C. Mauli Agrawal, added: “We received some great proposals from teams that include strong community partners. We also assigned research mentors to any grant recipients who didn’t already have an expert researcher on board.”
Here are descriptions of the projects receiving the mini-grants, along with their UMKC affiliated partner and community partner.
Refugees Raising Black Boys in the U.S.
To explore parental strategies of Congolese, Sudanese and Somali refugee parents raising sons in a racially hostile climate. The UMKC partner is Johanna Nilsson, Ph.D., professor of psychology. The community partner is Sarah Payton with Jewish Vocational Services.
A Qualitative Analysis of Patient Feedback on Early Mental Health Intervention for Nonfatal Shooting Victims
To conduct interviews with victims and tailor treatment approaches to better serve the needs of predominantly Black patients, whose voices have been historically underrepresented in the development of treatment approaches and care decisionmaking. The UMKC partner is Joah Williams, Ph.D., assistant professor of psychology. The community partner is Rosemary Friend with Truman Medical Centers.
A Pediatric Health and Community Partnership to Improve Family Resilience During the Coronavirus Pandemic and Beyond
To measure the impact of the coronavirus pandemic on trauma exposure and the physical, mental and emotional well-being of children and families from underserved communities in the Kansas City metropolitan area. This study will help inform the development of interventions to increase resilience in families during the COVID pandemic and beyond. The UMKC partner is Andrea Bradley-Ewing, who holds master’s degrees in public administration and psychology and is director of community engaged research at Children’s Mercy. The community partner is Gerald Douglas, director of resident services at the Kansas City Housing Authority.
Pastors’ Spouses Study
To explore the impact of COVID-19 on churches and pastors’ spouses and develop strategies and tools to support them as they support their churches and communities. The UMKC partner is LaVerne Berkel, Ph.D., associate professor in the School of Education. The community partner is Nordia Ikner with the Linwood Boulevard SDA Temple.
Increase Health Equity by Improving Neighborhood Routes to Schools and Parks
To increase physical activity by Central Middle School students through built environment improvements to better connect the neighborhood to the school and Central Park. This project will allow students to have a voice in this collaborative process among schools, city services, non-profit organizations and researchers. The UMKC partner is Amanda Grimes, assistant professor of nursing and health studies. The community partner is Laura Steele, education director at BikeWalkKC.
Fruit and Veggie Connect
To explore the feasibility to connect fresh produce from a community garden to families with young children who are enrolled in a home visiting program. The UMKC partner is Laura Plencer, M.D., associate professor of pediatrics. The community partner is Sommer Rose, research program manager at Children’s Mercy Hospital.
What Do We Want? Housing! When Do We Want It? Now!
To analyze how Kansas City Tenants — a grassroots organization with the goal of organizing to ensure that everyone has a safe, healthy, accessible and affordable home in Kansas City, Missouri — was able to rapidly develop a robust membership base and gain traction among city, state and national government officials. To also identify where the organization has yet to make inroads and why, and how it is addressing new challenges brought about by the 2020 pandemic, which is aggravating the housing crisis. The UMKC partner is Michelle Smirnova, Ph.D., an assistant professor in the Department of Sociology and an associate faculty member in Women, Gender and Sexuality Studies. The community partner is Tara Raghuveer, founding director of KC Tenants.
Green Team Toolkit
The Green Team Toolkit brings local youth together with neighborhood residents to improve their parks, trails, and vacant lots. The project seeks to develop a process where neighborhood residents and youth can work together to create a plan to improve the natural and built environment in their community. The UMKC partner is Panayiotis Manolakos with the Department of Economics. The community partner is Brenda Brinkhous-Hatch with the Groundwork Northeast Revitalization Group (Groundwork NRG).
The immediate past-president of the American Medical Association, Patrice Harris, M.D., said leadership is vital to properly address the persistent gaps and inequities in health care that have been highlighted during the COVID-19 pandemic.
Harris delivered the UMKC School of Medicine’s Dr. Reaner and Mr. Henry Shannon Lecture in Minority Health on Feb. 12 in a virtual event. She served as president of the AMA in 2020 during the onslaught of the pandemic.
“I think we can all agree that we have a lot on our to-do list, going forward, post COVID, and it’s going to require leadership,” said Harris, the first African American woman to serve as AMA president.
Harris said that as the coronavirus evolved, one of the AMA’s primary roles under her guidance was to ensure that the organization provided the most up-to-date, evidence-based resources and information in the midst of a public health crisis.
“You want to make sure that you are leading and providing accurate information,” she said. “Clearly it was also our priority to make sure that physicians, practices and health care systems had the resources needed to navigate through the disruption. It certainly has been a tremendous disruption and still is. We wanted to make sure that we were fighting for physicians and practices and health care institutions so that we could better serve our patients.”
Harris shared what she said was a 25-year journey to becoming the 174th president of the AMA. She recalled that it wasn’t until after she had completed her undergraduate years of college at West Virginia that she met her first African American female physician.
After earning her medical degree in 1992 and becoming a psychiatrist, Harris served in leadership roles with several psychiatric organizations including the American Psychiatric Association.
Today, Harris is a psychiatrist and recognized expert in children’s mental health and childhood trauma. She serves as an adjunct assistant professor in psychiatry and behavioral sciences at Morehouse School of Medicine and the Emory Department of Psychiatry and Behavioral Sciences. In private practice, she consults public and private organizations on health service delivery and emerging trends in practice and health policy.
Along her journey to leading the AMA, Harris learned some lifelong lessons such as the importance of working together. The advocacy victories achieved in Washington, D.C., and at state levels don’t typically come through working in silos and without partnerships, Harris said.
Another vital learning moment in leadership came in realizing the need to embrace differing opinions.
“It is sometimes difficult if you are in the room and you’re the only one that has a disconfirming opinion,” she said. “But leadership requires us to make sure we voice appropriately, respectfully, strategically, disconfirming opinions.”
That, Harris added, includes having what can be tough discussions about issues including social and institutional inequities.
“We have to have the sometimes very difficult conversations about racism,” she said. “It is up to institutions, universities, the AMA, businesses, Fortune 100 companies, Fortune 500 companies to make sure they are having these conversations and make sure that the folks around the decision-making tables about to have these conversations are in contact with their stakeholders.”
The annual Dr. Reaner and Mr. Henry Shannon Lectureship in Minority Health creates an awareness about health disparities and provides medical professionals, students, residents and the local community information about timely issues that affect underserved and minority communities.
The U.S. Department of Housing and Urban Development has awarded $700,000 to the University of Missouri-Kansas City to explore and evaluate best practices for identifying and removing lead paint hazards from Kansas City homes.
The grant is in partnership with the Kansas City, Missouri Health Department’s Childhood Lead Poisoning Prevention Program and Lead Safe KC Project, which helps remove lead paint hazards in homes of families with young children; and Children’s Mercy Environmental Health Program, which has assessed more than 1,400 homes for environmental risks and supports allergen research.
Homes that were built before 1978 might contain lead paint, which could put residents, especially young children and pregnant women, at risk for lead poisoning. Lead poisoning can cause speech delays, brain damage and other health effects.
Using Kansas City and Children’s Mercy data, the UMKC Center for Economic Information will perform a comparative impact analysis of the specific lead hazard control treatments used in the intervention in terms of blood-lead levels and social costs.
“The goal will be to develop a data-driven quality improvement evaluation model that HUD-sponsored lead-hazard control programs will be able to use in the management and performance evaluation of their own programs,” said Doug Bowles, Ph.D., director of the UMKC Center for Economic Information, co-principal investigator on the grant.
“An additional goal will be to develop a data-driven, housing-based index that lead-hazard control programs can use to select the homes most in need of lead-based hazard remediation,” said Steve Simon, Ph.D., of the School of Medicine and co-principal investigator on the grant.
The study will examine data from the Kansas City Health Department, comparing lead poisoning information with home repair strategies to determine the most effective, sustainable and cost-efficient methods of protecting families.