Fifty-four surveys were distributed and 14 Internal Medicine and 10 Family Medicine ACN physicians completed the survey. Response rate was 44%. The average age of the participants was 43 and 76% were female. Self-reported race was 48% White, 16% Asian, 12% Black; 24% selected other or declined to state. Twenty-four percent were of Hispanic ethnicity. Three-fourths were married or partnered and half had children. Twenty-five percent of the ACN physicians were foreign medical graduates. Practice activity is summarized in .
Practice Activity of the Ambulatory Care Network Physicians (n = 24)
Twenty-five percent of the ACN physicians had formal research training and 75% had some research experience (). Only 21% had clinical research training certification. Most (81%) of the clinicians with previous research experience found it a positive experience. Thirty-eight percent were currently involved in a clinical research project, primarily sponsored by NIH or health services agencies.
Research Training and Experience of the Ambulatory Care Network Physicians (n = 24)
Focus group and interview participants included 13 ACN physicians (8 Internal Medicine and 5 Family Medicine), five community-based Hispanic physicians (4 male and 1 female, all board-certified in one or more specialties), and all DNPs (n=4) in the faculty practice (all female; all board-certified in specialty).
Clinician Interest in Research
Survey, focus group, and interview data strongly support clinician interest in research, an essential predisposing factor for research participation. A key motivation was the relevance of the research topic to quality of care in their setting. Top-ranked types of clinical research in terms of ACN physician interest were: health services/outcomes research (88%), behavioral intervention (73%), observational (71%), retrospective (58%), dissemination (48%), and clinical trials (26%). All focus group and interview participants expressed some level of interest in research ranging from research facilitation to serving as a site investigator for multi-site clinical trials. Eighty percent of the ACN survey respondents indicated a willingness to deliver an intervention per research protocol. All DNPs had completed research course requirements as part of their clinical doctorate program.[14
Barriers and Facilitators (Enabling and Reinforcing Factors)
and display ACN study results related to barriers and facilitators (enabling and reinforcing factors) in three parts: items found in both the survey and focus groups, survey responses only, and additional thematic categories from the focus group data. In terms of perceived barriers (), clinician time and training appeared in both survey and focus group data whereas support staff-related barriers (e.g., time, compensation, training) were identified only in the survey. Lack of time/competing demands for time was the top-ranked barrier (92%) in the survey and 80% of ACN clinicians agreed that their lack of appropriate training was a barrier. Four thematic categories emerged only in the focus group data: difficulty filling clinical sessions to enable release for compensated research time, lack of collaborators to sustain research, difficulties overcoming IRB hurdles, and community distrust of research.
Barriers to ACN Physician Participation in Research
Facilitators for ACN Physician Participation in Research
Potential researchers from community sites described several barriers that did not surface in the ACN focus groups. The comments of Hispanic physician respondents reflected the financial responsibility associated with their independent practices and highlighted the need to have the research studies fit into clinical workflow and not negatively affect the bottom line. For instance, one physician said:
“Anything that makes me move in one direction, more than one iota….can decrease the efficiency to the point that actually patient care starts to suffer…there's no fat in private practice – we basically deal with bare bones.”
Hispanic physicians in independent community practices also described additional sociocultural issues including language, literacy, complexity of patients' lives, and the research protocol challenges related to community members who travel between New York and the Dominican Republic.
ACN clinicians described the importance of enabling factors such as collaborators, mentors, and research support staff to overcome the barriers to conducting research in busy clinical settings (). The data from the Hispanic physicians was consistent with the ACN in the need for funded research support staff, but also mentioned the importance of a respectful relationship between research partners from academia and those in the community. For example,
“I guess one of the most important things when you want to do this – especially with people who never had any experience –a good rapport… treat others with respect, it's something very important.”
The ACN physicians, Hispanic physicians and DNPs all described the important role of the patient-provider relationship in overcoming patients' reluctance for research participation. For example, one Hispanic physician commented “…the Hispanic patient will do most of the time whatever you ask them to do because they still they have the physician in very high regard – this guy is not going to do anything to harm me…” A DNP noted that “…if there is interest in the practitioners … patients might follow through.” During focus group discussions, ACN physicians also identified several specific strategies for engaging patients/community in research ().
Clinicians from potential research sites including the DNP practice described the important role of information systems, particularly electronic health records in facilitating research primarily to search for potential research, subjects and to retrieve data related to research variables.
Although respondents from all three groups (ACN, independent Hispanic physician practices, and DNPs) addressed the importance of compensation for time spent for research-related tasks, a unique category that emerged from the Hispanic physician data was the need for a stable revenue stream from research: “Neither do we want our funding to be episodic.”
In terms of reinforcing factors, all ACN clinicians identified the possibility of improving the quality of care in their practice site and contributing to knowledge development as incentives for research participation (). Other important incentives were professional development, continuing medical education, collaboration with academic researchers, and recognition as a PBRN member or research collaborator. Both ACN survey respondents (60%) and Hispanic physicians in community sites identified authorship as an incentive with one Hispanic physician stating “…sooner or later everybody (physicians) wants to see their name [in print].”