Voices from Left of the Dial: Reflections of Practice-Based Researchers

doi:10.3122/jabfm.2010.04.090189

J Am Board Fam Med. Author manuscript; available in PMC 2010 October 25.

Published in final edited form as:

J Am Board Fam Med. 2010 Jul–Aug; 23(4): 442–451.

doi: 10.3122/jabfm.2010.04.090189

PMCID: PMC2963189

NIHMSID: NIHMS233971

Voices from Left of the Dial:^* Reflections of Practice-Based Researchers

Lyle J. Fagnan, MD

Oregon Rural Practice-based Research Network (ORPRN) Department of Family Medicine Oregon Health & Science University 3181 SW Sam Jackson Park Road, L-222, Portland, OR 97239 503-494-1582 ; Email: fagnanl/at/ohsu.edu

Margaret A. Handley, PhD, MPH

UCSF Assistant Professor in Epidemiology and Biostatistics and UCSF Center for Vulnerable Populations Department of Medicine Bldg 10, 3rd floor San Francisco General Hospital 1001 Potrero Avenue, San Francisco CA 94110 415-206-5333 phone ; Email: handleym/at/medsfgh.ucsf.edu

Nancy Rollins

Oregon Rural Practice-based Research Network (ORPRN) Oregon Health & Science University 3181 SW Sam Jackson Park Road, L-222, Portland, OR 97239 503-494-1584 ; Email: rollinsn/at/ohsu.edu

James Mold, MD, MPH

University of Oklahoma Health Sciences Center (OUHSC) Family Medicine 900 NE 10^th Street, Oklahoma City, OK 73104 405-271-2370 ; Email: james-mold/at/ouhsc.edu

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Abstract

Background

Purpose

Practice-Based Research Networks (PBRNs) provide an important approach to implementing primary care research at the community level, thus increasing the relevance and utility of research findings for routine primary care practices. PBRNs expend considerable time and energy in the recruitment, engagement, and retention of network clinicians and practices to establish this community-based primary care research laboratory. This study assessed factors motivating PBRN clinicians to participate and stay involved in practice-based research in their primary care office setting.

Methods

We invited practicing clinicians across the United States who are affiliated with a PBRN to share their stories regarding motivations to participate in practice-based research. Using qualitative methods, we categorized the stories into the main motivation for participation and the perceived impact of participation.

Results

We collected 37 stories from clinicians affiliated with 12 PBRNS located in 14 states. Motivations for participation in practice-based research included themes associated with personal satisfaction, improving local clinic-based care, and contributing to community and system level improvements. Sources of personal satisfaction corresponded to the three psychological needs postulated by Deci's and Ryan's Self-Determination Theory: competence, autonomy, and relatedness.

Conclusions

These PBRN clinician stories describe the values, motivations and unique paths that clinicians took as they chose to participate and stay active in a practice-based research network. Their voices have the potential to influence others to participate in practice-based research.

INTRODUCTION

Proponents of translational research have identified practice-based research (PBR) and practice-based research networks (PBRNs) as essential for answering questions relevant to primary care and for overcoming barriers to the implementation of existing evidence into community-based primary care practice.(1, 2) A practice-based research network is defined as a group of separate practices that collaborate with each other and often with outside experts to conduct multiple research projects over an extended period of time while continuing to deliver care to patients.(3) Family physicians in PBRNs have been contributing new knowledge to the discipline of family medicine for the past three decades. The Ambulatory Sentinel Practice Network (ASPN) began collecting data in 1982 and published research on important primary care subjects such as headaches, spontaneous abortion, cough in children and carpal tunnel syndrome.(4–7) In an attempt to understanding the motivation of family physicians to participate in ASPN, researchers interviewed network family physicians about reasons for participation and found that the network studies created a bridge between practice and academia, made research possible while continuing to practice full time, and improved the quality of their patient care.(8)

Family physician involvement in practice-based research has continued to grow since the early days of ASPN and by 2004, the Agency for Healthcare Research and Quality (AHRQ) supported PBRN Resource Center identified 111 active primary care networks in the United States. (9) With the recent development of the National Institute of Health (NIH) Roadmap initiative and creation of the Clinical Translational Science Awards (CTSAs), opportunities for community-based family physicians to become involved in practice-based research has increased further.(10)

Critical to the success of PBRNs in meeting the challenges presented by the NIH Roadmap Initiative is a cadre of engaged family physicians doing research studies. To assist in recruitment of community-based family physicians researchers, the Practice-Based Research Working Group of the North American Primary Care Research Group's Committee for the Advancement of the Science of Family Medicine directed the authors to conduct the PBRN Clinicians Stories Project. The intent of the project is to tell the stories of family physicians currently involved in practice-based research, sharing their motivation to do research with other family physicians and the larger community of academic researchers and research funding agencies. Since PBRNs may devote considerable time and effort to the recruitment, engagement, and retention of their clinicians, we felt it was important to examine motivation for initial interest in PBR as well as factors more specific to ongoing participation. In this qualitative study, we assess factors that motivate a diverse sample of PBRN clinicians to participate and stay involved in practice-based research in their primary care office setting. We have summarized the principal themes evaluated from these clinicians' stories collected between January 2007 and March 2008 from PBRN clinician-researchers practicing across a wide geographic range of the U.S. For the discussion, we have used the Self-Determination Theory (SDT) model as a framework for summarizing our motivational themes. SDT is a general theory of human motivation based on the need to feel competent, autonomous and related to others.(11, 12) SDT has recently been applied to understanding the psychology of how clinicians make decisions regarding the delivery of preventive health services.(13, 14)

METHODS

We sent an initial invitation by electronic mail in 2007 to 27 of the 43 primary care PBRNs affiliated with the Federation of Practice-Based Research Networks (FPBRN), which keeps an active inventory of Family Medicine PBRNs and maintains on-going communication in the form of a listserv with many PBRN directors.(15) Criteria for selecting the 27 networks included that they be comprised primarily of family physicians, had completed several studies and showed demonstration of recent activity. A second recruitment effort went to 51 PBRNs in 2008. In addition to the FPBRN inventory list, we identified PBRNs from the AHRQ PBRN Resource Center registry [http://pbrn.ahrq.gov/portal/server.pt]. PBRN directors distributed the invitation to primary care clinicians in their networks -- defined as family physicians, internists, or pediatricians who had been involved with at least one PBRN study and who might be interested in relaying their experiences to a broader primary care clinician community. We asked PBRN directors to solicit stories and to help obtain a diverse sample of stories from among their clinician members.

Interested clinicians completed a short series of demographic questions about themselves and their clinical training, and followed a suggested story template that included these questions:

How did you get interested or recruited to practice-based research?
What are your research interests?
Not many family physicians/primary care clinicians engage in research or quality improvement projects. What motivates you?
How has participation in research influenced you as an individual clinician?
How has participation in research influenced your practice?
How has participation in research influenced your community or health system?
How is participating in a network different from other organizations or activities looking to influence practice?

An informed consent form was included with the request for stories and completed by each clinician. Clinicians agreed to allow their names and PBRN affiliations to be included in project reports and publications. The study received approval from the Institutional Review Board at Oregon Health & Science University.

Data Analysis

Stories from clinicians who had signed the consent form and completed the demographic survey were included in this report. Using grounded theory approach, (16) two independent reviewers (LJF and MH) read each story and categorized the main response themes qualitatively. A third reviewer (JM) reviewed the stories and analyses. He agreed with the primary themes, suggesting that the first theme corresponded to the tenets of SDT, and made suggestions about the presentation of the information. We used an iterative method until consensus was reached.

Coders summarized responses within three domains:

(1)
The main motivation for participation and remaining involved,
(2)
A primary impact area resulting from the participation; and
(3)
A secondary benefit or impact area also achieved through the participation.

Following the coding of stories into these domains, the reviewers compared their results for each story classification. We selected only one theme for each story. In the few cases where there was disagreement on the classifications (fewer than 3 stories), the reviewers discussed the differences and came to an agreement.

RESULTS

We collected 37 stories from 38 clinicians in 12 primary care networks using the above convenience sample approach. Two clinicians shared a story from a common experience. Represented PBRNs are located in 14 states and one large PBRN is national (American Academy of Family Physicians National Research Network) (Figure 1).

Figure 1

Location and number (n) of participating clinicians

Clinician Characteristics

Participating clinicians in the PBRN Clinician Stories Project were predominantly male (76%) and family physicians (90%). Their mean age was close to 50 (mean 48.8 years, range 33–66 years). Most had participated in several PBRN studies, with over 52% having participated in at least six or more studies. The majority of clinicians had been in practice for over five years (92%) and had been in a PBRN for at least five years (68%). The size of the practice varied from nine participants in solo practice to 14 in practice groups with more than five clinicians. Participants practiced in both private clinics (60%) and public clinics (40%).

Thematic Areas for Motivation

Through stories of PBRN clinicians, we identified a number of themes that motivated clinicians to choose a practice path that included practice-based research. These themes related to satisfaction with certain aspects of the PBRN experience. Three tables detail the themes within each of these domains: (1) themes associated with personal satisfaction from participation (Table 1); (2) themes associated with satisfaction with improving local (practice-level) clinical care (Table 2); and (3) themes associated with satisfaction in achieving community-oriented primary care-related activities and making health system level changes (Table 3). Each table contains a summary of the clinician responses within the identified principal themes, the types of satisfaction related to the PBRN experience reflected upon in the story, and exemplar quotes.

Table 1

Thematic Summary of PBRN Clinician Motivation Emphasizing PERSONAL SATISFACTION

Table 2

Thematic Summary of PBRN Clinician Motivation Emphasizing IMPROVING LOCAL CLINIC-BASED CARE

Table 3

Thematic Summary of PBRN Clinician Motivation Emphasizing COMMUNITY AND SYSTEM LEVEL IMPROVEMENTS

The motivations associated with personal satisfaction described in Table 1 reflect the basic psychological needs for competence, autonomy, and relatedness identified with SDT.(11, 12) Respondents mentioned improving their clinical skills (competence) because of PBRN participation. Others indicated a desire to improve the quality and relevance of academic research without having to work in an academic environment (autonomy). Many said the PBRNs created relationships between community clinicians and academicians that helped them withstand the challenges of day-to-day practice (relatedness).

The themes from the stories related to improving local clinic-based care place high value on improving the quality of care for patients and improving systems of care, including enhanced IT and patient/disease registries. The stories describe research as a tool to improve quality of care, often having benefits beyond those perceived as directly related to the study. The research studies provide access to tools, knowledge, practice change facilitators and mentors as a benefit of participation. Changes in local clinic care are possible because the PBRN studies take into account relevance to local care, practice staffing and workflow. Competence in chronic illness care and disease management was a common theme in this domain.

Clinicians report that the PBR studies are relevant to the health of their community and they are developing competence in the provision of population health care. Clinicians noted that PBRNs could address the gap between academia and community practice and influence the timely delivery of healthcare, as in an example of flu vaccination success facilitated by PBR, as well as the delivery of health care to unique populations served by the practice, such as migrants, the elderly and those living in more remote rural areas. PBRN studies cited in these stories reported opportunities for clinician and practice collaboration with major health plans and community health foundations. Being a part of a research community is a motivator for participation in a PBRN.

DISCUSSION

This qualitative study describes the motivation of family physicians to join, contribute and stay active within PBRNs. Although our study is limited by being comprised of self-identified participants in a convenience sample, we believe that these (and other) clinician stories provide an important medium to understand the intersection of research with professional practice and life and give voice to this unique method of participatory research.(17, 18) Greenhalgh and Wengraf note “The aim of narrative research is not necessarily to determine a `true' picture of events, but rather to explore such things as how the individual has made sense of these events, their attitude toward them, what meanings the events hold for them, and how these feelings came to be.”(19)

Narrative research such as our PBRN Clinician Stories Project provides useful information for academic researchers, including those linked with practice-based research networks and with community-based participatory research. PBRNs expend considerable time and effort in the recruitment, engagement, and retention of network clinicians and practices, so these narratives also provide useful information to the PBRN community, as well as a template for individual PBRNs to pursue their own stories projects.

These stories from 38 clinician members of practice-based research networks provide important insights regarding the motivations and values they associate with participation. These motivations and values relate to three levels of influence:

Meaning and belonging to the primary care profession and culture
The stories reflect the unique path taken by these clinicians and include issues of overcoming practice isolation, straddling academia while not losing the integrity of `outside' practice, developing and maintaining critical thinking skills, staying connected to colleagues and to the salient health topics that need addressed to improve primary care outcomes, and membership in a stimulating learning community. Frequently mentioned was the value of mentorship. It is important that PBRNs encourage clinician commitments, and additional commitments will be required from those who can provide mentorship outside of academia, where there are more established avenues. Recurrent themes that relate specifically to meaning and belonging within this group of clinicians include the family physician as a scientist; being validated, recognized, connected and belonging; and, being stimulated and energized. The family physicians sharing stories were not always able to find enough stimulation from like-minded colleagues in their local practice and community. Several physicians (Beasley, Friedler, Beaufait, and Bujold) with a long history of practice-based research noted that connecting with a PBRN provided a means to connect with other “unique” family physicians and some clinicians identified the link to academia through the PBRN as providing an important relationship that offered balance to the daily challenges of clinical practice.
Generating an evidence base for primary care
These clinicians placed a high value on improving the quality of care to their patients and improving systems of care, including enhanced IT.
Ensuring that the primary care evidence base is locally relevant and contributes to policy and population health
Clinicians valued community oriented outcomes that focus on public health, such as increase in flu vaccination rates for the entire community, and on developing research that was responsive to the needs and concerns of the clinician's entire community and communities within communities. Story clinicians noted value in collaboration, including establishing active partnerships with major health plans and a community health foundation. One clinician noted that Centers for Medicare & Medicaid Services (CMS) is interested in their disease management strategy.

Personal satisfaction motivations to participation in PBRNs, particularly those aligned with meaning and belonging to the primary care profession and culture, correspond with Deci's and Ryan's Self-Determination Theory (SDT) to explain how human beings become proactive and engaged.(11, 12) The three innate psychological needs of competence, autonomy, and relatedness describe the forces behind intrinsic motivation and mental health. Social contexts such as PBRNs facilitate satisfaction of these three needs and correlate with optimal motivation. The stories we describe include:

Competence — intellectual stimulation, “the physician as the critical scientist”, creating and applying a primary care evidence-base, and staying up to date
Autonomy — enjoyment of research without the hassle of academic work-life
Relatedness — the importance and influence of mentors, belonging to a group of like-minded individuals, and social gatherings (convocations). The PBRN provides an antidote to the intellectual isolation and loneliness associated with day-to-day primary care practice.

The clinicians represented in these stories participate in PBRNs because it is interesting and satisfying and they are in control of their choices. Although there is little published work regarding motivations to participate in practice-based research, the factors described are similar to earlier reports. In a study of ASPN practices, Green and Niebauer (1991), found a desire to be a part of a group doing relevant practice-based research and recruitment by an esteemed individual to be the most important reasons for joining a PBRN.(20) These interviews of 11 ASPN members emphasize the personal and professional rewards of participation.(8) They describe the value of being part of the bigger picture, enhanced academic credibility and critical thinking, and contributing answers to relevant research questions. Whereas the majority of studies done in ASPN were descriptive and disease and symptom oriented, PBRNs today are most often involved in dissemination and implementation of studies designed to enhance the delivery of preventive health services and chronic illness care. With too much work and too little time, the interest and relevance in changing systems of care is high among family physicians. Our stories describe PBRNs as facilitators of change and show the high value these family physicians place on their relationship with the PBRN. One PBRN study identified membership in a practice-based research network as a determinate of staying in rural practice longer. (21)

Study limitations

We were able to recruit family physicians from only 12 networks and these physicians likely reflect a high degree of engagement. There was considerable variation in the effort to recruit stories among the PBRN directors. There is considerable consistency among the stories we analyzed and the themes described reflect the broader community of family physicians participating in practice-based research.

It is likely that these stories reflect the values of a group of individuals who have found common ground in participating in practice-based research. Although these stories describe unique paths, clinicians participating in PBRNs share a number of motivational factors. It is our intention that the voices of these family physicians will influence others to participate in practice-based research.

Acknowledgements

The authors would like to thank the PBRN clinicians who provided us their stories: Mary E. Arenberg, Robert W. Bales, John W. Beasley, David Beaufait, Zachary T. Bechtol, Robert Blankenfield, Ed Bujold, Samuel Church, Steven A. Dosh, Chet Fox, Kurt Frantz, Edward Friedler, Kenneth Gjeltema, Enrique Gonzalez-Mendez, Scott Graham, Tamara Hartsell, Paul Hicks, David L. Hahn, Analia V. Keenan, Annette Kenney, Robbie Law, Katherine Merrill, Margaret Meyers, James W. Mold, Suben Naidu, J. Michael Pontius, Lance Reynoso, Bruin Rugge, Eric Sanford, Urmimala Sarkar, John Schott, George S. Schroeder, Linda Stewart, Scott Stewart, Lynn M. Strange, Christopher H. Tashjian, Daniel Triezenberg, W. Michael Woods. In addition, we thank the affiliated PBRNs: American Academy of Family Physicians National Research Network (AAFP NRN), Colorado Research Network (CareNet), Dartmouth COOP Project (Dartmouth COOP), Great Lakes Research Into Practice Network (GRIN), Metropolitan Detroit Practice-Based Research Network (MetroNet), Oklahoma Physicians Resource/Research Network (OKPRN), Oregon Rural Practice-Based Research Network (ORPRN), Practice Partner Research Network (PPRNet), Research Association of Practices (RAP), University of California San Francisco Collaborative Research Network (UCSF CRN), Upstate New York Practice-Based Research Network (UNYNET), and Wisconsin Research and Education Network (WREN). The authors also thank the members of Practice-Based Research Subcommittee of the North American Primary Care Research Group (NAPCRG) Committee on Advancing the Science of Family Medicine (CASFM) regarding assistance with manuscript development.

Funding Sources This research was supported in part by Clinical and Translational Science Awards to Oregon Health & Sciences University, NIH/NCRR 1U1 RR02414-01(LF and NR) and to the University of California, San Francisco, NIH/NCRR UL1 RR02413 (MH).

Footnotes

Conflict of Interest Statements The authors report no conflict of interest.

Note to NIH - Please include: The published version of this article can be accessed on the Journal of the American Board of Family Medicine website at: http://jabfm.org/cgi/reprint/23/4/442

^*”Left of the Dial” refers to the radio stations that are found on the lower end of the radio dial where local community programming can be heard, and to a song from The Replacements, which describes the resilience of local musicians who can best be heard left of the dial (fading in and out) when driving across country.

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