Clinician reflections on promotion of healthy behaviors in primary care practice

OBJECTIVE: Recommendations to use integrated models for health behavior change abound, however, the translation to practice has been poor. We used stimulated reflections of primary care physicians and nurse practitioners to generate insights about current practices and opportunities for changing how health behavior advice is addressed. METHOD: Twenty-one community practicing primary care clinicians invited to a nationally sponsored practice-based research network conference on promotion of healthy behaviors were asked to record aspects of health behaviors they addressed during a day of outpatient visits. In response to eight questions, clinicians reflected insights which were then analyzed by a multidisciplinary team to identify over-arching themes. RESULTS: Health behavior discussions are initiated and carried out predominantly by the clinician. These discussions occur primarily during health care maintenance visits or visits in which presenting complaints or chronic illnesses can be linked to health behaviors. Clinicians' reflections on viable opportunities for change include different modes of patient education materials such as web-based materials. Suprisingly infrequent were solutions outside of the clinical encounter or strategies that engage other staff or other community partners. CONCLUSION: Implementation of the integrated care model as an opportunity to enhance health promotion seems far from the current realities and future vision of even motivated network-based clinicians. (AU)

Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription.

OBJECTIVE: We identified those aspects of physician-patient communication that influence physicians to prescribe antibiotics for respiratory infections. STUDY DESIGN: A multimethod comparative case study was performed including descriptive field notes of outpatient visits. POPULATION: We included patients (children and adults) and clinicians in 18 purposefully selected family practices in a midwestern state. A total of 298 outpatient visits for acute respiratory tract (ART) infections were selected for analysis from more than 1600 encounters observed. OUTCOMES MEASURED: Unnecessary antibiotic use and patterns of physician-patient communication were measured. RESULTS: Antibiotics were prescribed in 68% of the ART infection visits, and of those, 79% were determined to be unnecessary according to Centers for Disease Control and Prevention guidelines. Patients were observed to pressure physicians for medication. The types of patterns identified were direct request, candidate diagnosis (a diagnosis suggested by the patient), implied candidate diagnosis (a set of symptoms specifically indexing a particular diagnosis), portraying severity of illness, appealing to life-world circumstances, and previous use of antibiotics. Also, clinicians were observed to rationalize their antibiotic prescriptions by reporting medically acceptable reasons and diagnoses to patients. CONCLUSIONS: Patients strongly influence the antibiotic prescribing of physicians by using a number of different behaviors. To decrease antibiotic use for ART infections, patients should be educated about the dangers and limited benefits of such use, and clinicians should consider appropriate responses to these different patient pressures to prescribe antibiotics.

Tailoring tobacco counseling to the competing demands in the clinical encounter.

OBJECTIVES: We identified patterns of tobacco cessation counseling in primary care practices, including contextual factors that influence its provision. STUDY DESIGN: A cross-sectional study was performed using direct observation of outpatient visits. POPULATION: We included 91 outpatient visits by cigarette smokers visiting 20 family physicians in 7 Nebraska community family practices. OUTCOMES MEASURED: We measured patterns and quality of tobacco counseling assessed by direct observation. RESULTS: A hierarchy of 5 patterns was discernable, ranging from appropriate to inappropriate provision or nonprovision of tobacco cessation counseling. CONCLUSIONS: Since tobacco-specific discussions are appropriate only in approximately three fourths of primary care visits by smokers, clinical practice guidelines that recommend intervention at every visit are unrealistic. However, the finding that only one third of eligible visits addressed tobacco makes it imperative that tobacco cessation counseling be reliably integrated into visits for well care and tobacco-related illnesses that represent teachable moments.

A framework for understanding visits by frequent attenders in family practice.

OBJECTIVE: Our purpose was to develop a typology of outpatient visits between family physicians and adult "frequent attender" patients. STUDY DESIGN: This was a cross-sectional observational study using qualitative analysis of family physician visits. Three family physician researchers reviewed detailed field notes for each patient based on direct observation of a single office visit to determine major themes and characteristics of physician-patient encounters. POPULATION: Non-pregnant adults in the top 5% for visit frequency, and age-and sex-mated non-frequent attenders were identified from among 1194 adult patients in 18 Midwestern family practice offices as part of The Prevention and Competing Demands in Primary Care Study. RESULTS: Visits by 62 patients who had made at least 25 visits in the previous 2 years were selected (frequent attender visits). Three major dimensions emerged to distinguish different encounter types: (1) biomedical complexity, (2) psychosocial complexity, and (3) the degree of dissonance between the patient and the physician. These 3 dimensions were used in a descriptive framework to characterize visit types as: simple medical, ritual visit, complicated medical, the tango, simple frustration, psychosocial disconnect, medical disharmony, and the heartsink visit. CONCLUSIONS: The discovery of a wide variation of encounter types among adult frequent attenders and the resulting descriptive framework laid a foundation for defining the appropriateness of outpatient health care utilization, for designing interventions to reduce inappropriate utilization, and for educating physicians regarding effective management of frequent attender patients.

Technician, friend, detective, and healer: family physicians' responses to emotional distress.

OBJECTIVE: We sought to develop a typology of physicians' responses to patients' expressed mental health needs to better understand the gap between idealized practice and actual care for emotional distress and mental health problems. STUDY DESIGN: We used a multimethod comparative case study design of 18 family practices that included detailed descriptive field notes from direct observation of 1637 outpatient visits. An immersion/crystallization approach was used to explore physicians' responses to emotional distress and apparent mental health issues. POPULATION: A total of 379 outpatient encounters were reviewed from a purposeful sample of 13 family physicians from the 57 clinicians observed. OUTCOMES MEASURED: Descriptive field notes of outpatient visits were examined for emotional content and physicians' responses to emotional distress. RESULTS: Analyses revealed a 3-phase process by which physicians responded to emotional distress: recognition, triage, and management. The analyses also uncovered a 4-quadrant typology of management based on the physician's philosophy (biomedical vs holistic) and skill level (basic vs more advanced). CONCLUSIONS: Physicians appear to manage mental health issues by using 1 of 4 approaches based on their philosophy and core set of skills. Physician education and practice improvement should be tailored to build on physicians' natural philosophical proclivity and psychosocial skills.

Understanding practice from the ground up.

BACKGROUND: Our objective was to understand family practices from the ground up through intensive direct observation of the practice environment and patient care. METHODS: Eighteen practices were purposefully drawn from a random sample of Nebraska family practices that had earlier participated in a study of preventive service delivery. Each practice was studied intensely over a 4- to 12-week period using a comparative case study design that included extended direct observation of the practice environment and clinical encounters, formal and informal interviews of clinicians and staff, and medical record review. DESIGN: This multimethod assessment process (MAP) provided insights into a wide range of practice activities ranging from descriptions of the organization and patient care activities to quantitative documentation of physician- and practice-level delivery of a wide range of evidence-based preventive services. Initial insights guided subsequent data collection and analysis and led to the integration of complexity science concepts into the design. In response to the needs and wishes of the participants, practice meetings were initiated to provide feedback, resulting in a more collaborative model of practice-based research. CONCLUSIONS: Our multimethod assessment process provided rich data for describing multiple aspects of primary care practice, testing a priori hypotheses, discovering new insights grounded in the actual experience of practice participants, and fostering collaborative practice change.

Patient care staffing patterns and roles in community-based family practices.

OBJECTIVES: Our study describes patient care staff patterns and roles in community-based family practices. STUDY DESIGN: We used a multimethod comparative case study design that included detailed descriptive field notes of the office environment of 18 family practices and of 1637 clinical encounters, as well as in-depth interviews of practice staff and physicians. Systematic analysis of these data provided detailed descriptions of patient care staff patterns and functions. POPULATION: We included physicians and staff in 18 community-based Nebraska family practices. RESULTS: Practices are staffed with a range of clinical personnel, including registered nurses, licensed practical nurses, certified medical assistants, radiology technicians, and trained and untrained medical assistants. Each of these has specific educational preparation that potentially qualifies them for different patient care roles; however, staff roles were determined primarily by local needs and physician expectations rather than by education, training, or licensure. Staffing patterns varied greatly; the majority of practices employed at least one registered nurse (10 of 18), one licensed practical nurse (5), or both (4). Still, the overall majority of practices used non-nursing personnel as the predominate patient care staff. Patient care staff-to-clinician ratios ranged from a low of 0.5 to a high of 3.3. CONCLUSIONS: Many recent recommendations about collaborative models of clinical care seem problematic when put into a context of the findings of current staffing patterns and use of personnel in family practices. Staff members often fulfill roles independent of training. Staff leadership is also potentially important for designing effective collaborative care models; however, we found leadership only occurred with the approval of clinic authorities. These practical issues are rarely addressed in normative recommendations about system change and intervention. Our findings indicate that there are considerable opportunities for better use of the nursing and other patient care staff in the delivery of clinical services. Developing a collaborative practice model should include formalizing expectations of staff to reflect training and experience, and explicitly configuring staff to meet the needs, values, and goals of a practice.

The effect of families on the process of outpatient visits in family practice.

OBJECTIVES: Our goal was to describe how physician knowledge of patients' families affects the processes of patient care in family practices. STUDY DESIGN: Using a multimethod comparative case study design, detailed dictated field notes were recorded after direct observation of patient encounters and the office environment as part of the Prevention and Competing Demands in Primary Care Study. We identified domains of outpatient visits in which patients were accompanied by a family member or in which family-oriented content was discussed. POPULATION: Outpatient encounters with 1637 patients presenting in 18 family practices in the Midwest were analyzed using an editing style. OUTCOMES: We developed a typology for ways in which family context affects outpatient visits. RESULTS: Patients were accompanied during 35% of all outpatient visits, the vast majority of these visits involving children. Family history or a family member's problems were discussed during 35% of visits during which no family member was present. An analysis of these "family-oriented" visits resulted in a typology of 6 ways that family context informs and affects the outpatient visit: (1) using family social context to illuminate patient disease, illness, and health; (2) using family to discover the source of an illness; (3) discussing and managing the health and illness of family members; (4) family concern for patient's health; (5) using the family as a care resource and care collaborator; and, (6) giving family members unscheduled care. CONCLUSION: Family context is an important feature of family practice that influences the processes of patient care. Since family-oriented care is an essential feature of family practice, outcomes of this largely hidden part of care deserve further study.

Use of office-based smoking cessation activities in family practices.

BACKGROUND: Smoking is the leading cause of morbidity and mortality in the United States. Recommendations for increasing physician effectiveness in smoking cessation through the use of office-based activities have been disseminated, but the extent of implementation is unknown. We describe the degree to which selected family practices in Nebraska have implemented 15 specific office-based activities. METHODS: We employed a cross-sectional integrated multimethod design. A research nurse observed a target physician and his or her staff during a 1-day visit in a random sample of 89 family practices. Data collection consisted of focused observation of the practice environment, key informant interviews, medical record reviews, and in-depth interviews with the physicians. RESULTS: The majority of the practices sampled had an office environment that restricted smoking, but few used visual cessation messages or information in the waiting room offering help and encouraging patients to quit. Most had educational materials that were supplied by pharmaceutical companies for promoting nicotine replacement systems. These materials were easily accessible in more than half of the practices. Smoking cessation activities were initiated and carried out by physicians with minimal use of their staff. Smoking status was documented in 51% of the medical records reviewed but seldom in a place readily accessible to the physician. All physicians were very aware of the importance of smoking cessation counseling, and most felt confident in their skills. CONCLUSIONS: Despite identification of patient smoking as a problem, most practices were not using office-based activities to enhance and support physician counseling. New perspectives for helping practices with this task need to be explored.

The value of pharmaceutical representative visits and medication samples in community-based family practices.

BACKGROUND: Interactions between the pharmaceutical industry and physicians have been discussed in numerous publications; however, most articles are limited to surveys and self-report data and often focus on academic or training contexts. We describe the role of pharmaceutical representatives and the use of samples in community-based family practices, using data obtained by directly observing clinical encounters. METHODS: We collected detailed descriptive field notes of the direct observations of 53 primary care clinicians and 1588 patient encounters in 18 purposefully selected Nebraska family practices. We used a comparative case study design, that used depth interviews of clinicians and office staff, and included details of the interactions with pharmaceutical representatives and the use of samples in clinical encounters. RESULTS: Individual providers and practices displayed noticeable variation in their approaches to drug representatives and samples. We found formal strategies and policies in a minority of practices. Generally there was little structure in the organization and distribution of sample medications at the office level, and detailed patient education regarding these drugs was rarely observed in patient encounters. Nevertheless, samples were used in almost 20% of observed encounters, at times as starter dosages, but often as complete courses of treatment. The benefits derived from contact with the pharmaceutical industry varied substantially, but most often included free medication samples, meals, and patient education materials. CONCLUSIONS: Clinicians have a complex symbiosis with the pharmaceutical industry and need to critically evaluate their handling of samples and their contact with pharmaceutical representatives to optimize this relationship and ensure quality patient care. Clinics with specific policies for interactions with drug companies appear to derive more satisfaction from their encounters.

The organization and distribution of patient education materials in family medicine practices.

BACKGROUND: Millions of dollars are spent annually on the production and distribution of patient education materials; however, there are no studies describing their actual use by physicians. Using qualitative data from a large comparative case study, our analysis evaluates how patient education materials are organized and used in family practices. METHODS: Eighteen purposefully selected family medicine practices were directly observed for 4 to 12 weeks each. A total of 57 providers were shadowed by a research nurse, and detailed field notes on 1600 patient encounters were recorded. A 3-member analysis team reviewed the qualitative data and identified emergent patterns. RESULTS: Clinics' use of patient education materials fell mostly into 2 distinct patterns. "Stockpilers" were providers who relied on the clinic staff to develop and organize a common library of patient education handouts. Providers with a "personal stash" collected much smaller numbers of materials that they personally maintained. Providers in the latter group had a known repertoire of a limited amount of educational material and used it more often than providers with access to a greater variety and number of handouts. In all practices, providers distributed most handouts; staff and self-selection by patients played a minor role. CONCLUSIONS: It appears that provider involvement and familiarity with patient education materials are key to their use in clinical practice. Clinicians use written patient education materials most efficiently by personally selecting and maintaining a small number of handouts that address topics most relevant to their practice.

The prevalence, composition, and function of ethics committees in nursing facilities: results of a random, national survey of American Health Care Association members.

OBJECTIVES: To determine the prevalence, composition, and function of ethics committees in extended care facilities in the United States. DESIGN: Descriptive survey by mail. SETTING: A 5% random sample (n = 851) of nursing facility members of the American Health Care Association (n = 17,020). Most of these facilities (75%) are intermediate care facilities; the remainder include a varying number of skilled beds. METHODS: An eight-item questionnaire was sent to the randomly selected 851 extended care facilities. The questionnaire inquired about the existence of an ethics committee, plans for formation when applicable, composition of the ethics committee, and its function. Survey data was coded and merged with information on facility characteristics that are part of the American Health Care Association's database. RESULTS: Of the responding facilities (n = 394), 34% reported the presence of a functioning ethics committee, with an additional 19% indicating definite plans for ethic committee formation. Forty-three percent expressed no interest in establishing an ethics committee, and 4% reported having had an ethics committee sometime in the past. The greatest proportion of committee time was spent in case review (39%) with lesser amounts of time expended in areas of policy formation (27%) and education (27%). Forty percent of the ethics committees performed two or fewer case reviews per year. Nearly all committees included the following disciplines in the membership: nurses (96%), physicians (95%), and social workers (89%). Facility administrators (77%) and clergy (70%) were frequently represented. Very few facilities reported representation by residents (8%) and Certified Nursing Assistants (2%). The Medical Director served as a committee member on 75% of the ethics committees, and in more than one-half of those instances, he/she was the sole physician on the committee. CONCLUSION: Ethics committees are currently active in or there are plans for their development in more than 50% of extended care facilities in the U.S. this represents a very significant increase in prevalence during the last decade. This tendency to form ethics committee's may slow considerably in the future. Ethics committees exhibit considerable variability in structure and function.

Assessing quality. As pressure mounts for clinics to deliver quality, medical practice blueprints and genograms serve as useful tools.

Increasingly, medical practices feel pressure to provide and communicate high quality patient care. Offering their insight on how a medical practice can improve quality, the authors describe the process of delivering medical care during patient encounters. Specifically, they present two methods that can be used to understand, evaluate, and improve interactions between patients and providers: medical practice blue prints and medical practice genograms.

Practical tools for qualitative community-oriented primary care community assessment.

BACKGROUND AND OBJECTIVES: The evolution of managed care is creating a need for feasible methods for clinical practices to perform community assessments. Since some types of clinically useful data are best obtained through a qualitative community assessment, practical methods of carrying out this type of assessment are needed. Such practical methods are also important for community-oriented primary care, an attractive model for the marriage of population perspectives and clinical primary care. METHODS: Using methods suitable for busy clinical practices, qualitative data useful for clinical purposes were collected either by mail surveys, telephone surveys, or during focus group discussions in a low-income community. Characteristics of data obtained through each method, together with the costs, advantages, and disadvantages of each approach, were examined. RESULTS: All three methods revealed similar themes in their responses, though the range and emotional content of the responses varied by approach. Clinically useful data were obtained, although the potential for sampling and response biases must be considered. Costs, primarily related to professional time, varied by as much as 50% among the methods examined; telephone surveys were the least expensive per enrolled subject. CONCLUSIONS: The methods tested are potentially feasible in busy practices. However, practices should clarify their objectives and resources prior to using these methods.

Primary care physicians' perceptions of diabetes management. A balancing act.

BACKGROUND: Studies demonstrate significant shortfalls in the quality of care for diabetes. Primary care physicians' views of the management of diabetes have been inadequately explored. The objective of our study was to describe primary care physicians' attitudes toward diabetes, patients with diabetes, and diabetes care. METHODS: In-depth interviews were conducted by a trained research interviewer with a sample of 10 family physicians and 9 internists in Connecticut. Interviews lasted an average of 60 minutes and were audiotaped and transcribed. Data were interpreted by a multidisciplinary team using a standard qualitative text analysis methodology. Themes from each interview were used to identify and develop overall themes related to the areas of inquiry. RESULTS: Physicians' goals were congruent with current guidelines emphasizing the importance of good glycemic control and prevention of complications. However, physicians noted the challenge of balancing the multiple goals of ideal diabetes care and the realities of patient adherence, expectations, and circumstances. The majority of physicians described a patient-centered management style, but a substantial minority described a more paternalistic approach. Physicians did not identify or describe office systems for facilitating diabetes management. Differences between family physicians and internists did not emerge. CONCLUSIONS: The complexity of diabetes care recommendations coupled with the need to tailor recommendations to individual patients produces wide variation in diabetes care. Improvement in care may depend on (1) prioritizing diabetes care recommendations for patients as individuals, (2) improving physicians' motivational counseling skills and enhancing their ability to deal with challenging patients, and (3) developing office systems and performance enhancement efforts that support cost-effective practice and patient adherence.

The value of a family physician.

BACKGROUND: Most efforts to improve health care have been made without a full understanding of the value of a primary care approach. METHODS: This article synthesizes the observations from the Direct Observation of Primary Care (DOPC) study. This multimethod study of 138 family physicians in 84 practices included direct observation of 4454 patients visits were used to describe aspects of family practice that may provide value for patients. RESULTS: Family physicians provide and coordinate care for a wide variety of patients problems, prioritizing these competing demands on the basis of relationships developed during multiple patient visits over time. They use acute and chronic illness visits as opportunities to integrate care for specific diseases, mental health, and preventive care in ways that are tailored to the specific needs of patients and families. Higher rates of delivery of core attributes of family practice are associated with patient satisfaction and preventive services delivery, and are diminished by forced discontinuity of care. CONCLUSIONS: Family physicians prioritize and deliver care according to a broad agenda based on patient needs. These needs are understood within ongoing relationships with the patient, family, larger health care system, and community. This integrative approach includes numerous avenues for affecting important patient outcomes that are unlikely to be optimally met by less integrated models of medical care. Expanding the value of family practice will require the development and application of new knowledge of the core structures, processes, and contexts of family practice, and their effects on patient outcomes.

Understanding change in primary care practice using complexity theory.

BACKGROUND: Understanding the organization of primary care practices is essential for implementing changes related to delivery of preventive or other health care services. A theoretical model derived from complexity theory provides a framework for understanding practice change. METHODS: Data were reviewed from brief participant observation fieldnotes collected in the 84 practices of the Direct Observation of Primary Care (DOPC) study and in 27 practices from three similar studies investigating preventive services delivery. These data were synthesized with information from an extensive search of the social science, nursing, and health services literature concerning practice organization, and of the literature on complexity theory from the fields of mathematics, physics, biology, management, medicine, and family systems, to create a complexity model of primary care practice. RESULTS: Primary care practices are understood as complex adaptive systems consisting of agents, such as patients, office staff, and physicians, who enact internal models of income generation, patient care, and organizational operations. These internal models interact dynamically to create each unique practice. The particular shape of each practice is determined by its primary goals. The model suggests three strategies for promoting change in practice and practitioner behavior: joining, transforming, and learning. CONCLUSIONS: This model has important implications for understanding change in primary care practice. Practices are much more complex than present strategies for change assume. The complexity model identified why some strategies work in particular practices and others do not.

Illuminating the 'black box'. A description of 4454 patient visits to 138 family physicians.

BACKGROUND: The content and context of family practice outpatient visits have never been fully described, leaving many aspects of family practice in a "black box," unseen by policymakers and understood only in isolation. This article describes community family practices, physicians, patients, and outpatient visits. METHODS: Practicing family physicians in northeast Ohio were invited to participate in a multimethod study of the content of primary care practice. Research nurses directly observed consecutive patient visits, and collected additional data using medical record reviews, patient and physician questionnaires, billing data, practice environment checklists, and ethnographic fieldnotes. RESULTS: Visits by 4454 patients seeing 138 physicians in 84 practices were observed. Outpatient visits to family physicians encompassed a wide variety of patients, problems, and levels of complexity. The average patient paid 4.3 visits to the practice within the past year. The mean visit duration was 10 minutes. Fifty-eight percent of visits were for acute illness, 24% for chronic illness, and 12% for well care. The most common uses of time were history-taking, planning treatment, physical examination, health education, feedback, family information, chatting, structuring the interaction, and patient questions. CONCLUSIONS: Family practice and patient visits are complex, with competing demands and opportunities to address a wide range of problems of individuals and families over time and at various stages of health and illness. Multimethod research in practice settings can identify ways to enhance the competing opportunities of family practice to improve the health of their patients.