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We describe an approach to defining and measuring a clinical process and its components. The approach was developed subsequent to an attempt to measure the value of an Electronic Patient Medical Record System (EPMRS). To build our model, we assume the medical record is a communications channel and extend Shannon's model to include the clinicians' concepts, tasks, and tactics. We assumed the patient care process is a series of actions and explore the appropriate dimensions for describing patient care events. The extended model of communication and patient care events enumerates the dimensions for gathering data to measure physicians' use of patient medical information systems while caring for patients. The clinical process model may be constructed using dynamical systems theory, also known as chaos theory. Traditional statistical modeling is compared to dynamical system modeling to suggest which method may result in a better model of the patient care process.

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep—ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.

The purpose of this study was to examine self-regulation as a mediator of the relation between family functioning and externalizing behaviour in 731 low-income children (M age = 41 months) across three time points. Specifically, this study focused on whether chaos in the home and positive behaviour support were indirectly related to externalizing problems through their influence on inhibitory control. The primary findings were as follows: (a) chaos in the home at age 3 years was indirectly related to externalizing behaviour at age 5.5 years through children’s inhibitory control at age 4 years, and (b) positive behaviour support at age 3 years was indirectly related to externalizing behaviour at age 5.5 years through inhibitory control at age 4 years. Implications of these findings and directions for future research are discussed.

Chaos in the home is a key environment in cognitive and behavioral development. However, we show that children’s experience of home chaos is partly genetically mediated. We assessed children’s perceptions of household chaos at ages 9 and 12 in 2337 pairs of twins. Using child-specific reports allowed us to use structural equation modeling to explore the genetic and environmental etiology of children’s perceptions of chaos. We found that these perceptions are significantly heritable (22%), with the remainder explained by environmental influences. Finding that genes influence children’s experience of chaotic environments has far-reaching implications for how we conceptualize the family home and its impact on cognitive and behavioral development.

Physiological systems such as the cardiovascular system are capable of five kinds of behavior: equilibrium, periodicity, quasi-periodicity, deterministic chaos and random behavior. Systems adopt one or more these behaviors depending on the function they have evolved to perform. The emerging mathematical concepts of fractal mathematics and chaos theory are extending our ability to study physiological behavior. Fractal geometry is observed in the physical structure of pathways, networks and macroscopic structures such the vasculature and the His-Purkinje network of the heart. Fractal structure is also observed in processes in time, such as heart rate variability. Chaos theory describes the underlying dynamics of the system, and chaotic behavior is also observed at many levels, from effector molecules in the cell to heart function and blood pressure. This review discusses the role of fractal structure and chaos in the cardiovascular system at the level of the heart and blood vessels, and at the cellular level. Key functional consequences of these phenomena are highlighted, and a perspective provided on the possible evolutionary origins of chaotic behavior and fractal structure. The discussion is non-mathematical with an emphasis on the key underlying concepts.

Physicians’ use of the Internet to gather medical information has increased in recent years. Several studies have been conducted to explore the implications of this use on patient education, the physician-patient relationship, and diagnosis/decision making. In order to better understand the current and future implications of Internet use on patient care activities, it is important to know the Internet sources physicians prefer to consult. The objective of this study was to determine the Internet sources of information physicians most often use to gather medical information. This study demonstrated that the vast majority of physicians indicate they access a targeted site rather than utilize a search engine (such as Google©) to gather medical information. Of the targeted site types, most physicians indicate they use 1) edited/secondary data sources as their primary medical information data retrieving, 2) about one quarter of the physicians surveyed indicated research databases which provide access to medical journal publications 3) a minority of physicians use sites dedicated to their specialized area and 4) a small percentage use medical web site portals.

Objectives

To explore general practitioners’ attitudes towards and use of a computer program for assessing genetic risk of cancer in primary care.

Design

Qualitative analysis of semistructured interviews and video recordings of simulated consultations.

Participants

Purposive sample of 15 general practitioners covering a range of computer literacy, interest in genetics, age, and sex.

Interventions

Each doctor used the program in two consultations in which an actor played a woman concerned about her family history of cancer. Consultations were videotaped and followed by interviews with the video as a prompt to questioning.

Main outcome measures

Use of computer program in the consultation.

Results

The program was viewed as an appropriate application of information technology because of the complexity of cancer genetics and a sense of “guideline chaos” in primary care. Doctors found the program easy to use, but it often affected their control of the consultation. They needed to balance their desire to share the computer screen with the patient, driven by their concerns about the effect of the computer on doctor-patient communication, against the risk of premature disclosure of bad news.

Conclusions

This computer program could provide the necessary support to assist assessment of genetic risk of cancer in primary care. The potential impact of computer software on the consultation should not be underestimated. This study highlights the need for careful evaluation when developing medical information systems.

Key messagesGeneral practitioners are under increasing pressure to advise their patients about genetic predisposition to various diseasesComputers could help doctors to give genetic advice by simplifying the construction and assessment of family trees and implementing referral guidelinesThis qualitative evaluation explored the context in which a computer program for assessing genetic risk of cancer would be used in general practice and issues surrounding its integration into a consultationMost of the doctors found the program easy to use, but it affected their control of the consultation—because of their desire to share the computer screen with the patient and their inability to anticipate the information that would be displayedThe study identified important issues relating to the use of computers in consultations which may be of use in testing software for primary care in the future

OBJECTIVE

To assess whether providing customized clinical information to patients and physicians improves safety or quality of diabetes care.

RESEARCH DESIGN AND METHODS

Study subjects included 123 primary care physicians and 3,703 eligible adult diabetic patients with elevated A1C or LDL cholesterol, who were randomly assigned to receive customized feedback of clinical information as follows: 1) patient only, 2) physician only, 3) both the patient and physician, or 4) neither patient nor physician. In the intervention groups, patients received customized mailed information or physicians received printed, prioritized lists of patients with recommended clinical actions and performance feedback. Hierarchical models were used to accommodate group random assignment.

RESULTS

Study interventions did not improve A1C test ordering (P = 0.35) and negatively affected LDL cholesterol test ordering (P < 0.001) in the 12 months postintervention. Interventions had no effect on LDL cholesterol values (P = 0.64), which improved in all groups over time. Interventions had a borderline unfavorable effect on A1C values among those with baseline A1C ≥7% (P = 0.10) and an unfavorable effect on A1C values among those with baseline A1C ≥8% (P < 0.01). Interventions did not reduce risky prescribing events or increase treatment intensification. Time to next visit was longer in all intervention groups compared with that for the control group (P < 0.05).

CONCLUSIONS

Providing customized decision support to physicians and/or patients did not improve quality or safety of diabetes care and worsened A1C control in patients with baseline A1C ≥8%. Future researchers should consider providing point-of-care decision support with redesign of office systems and/or incentives to increase appropriate actions in response to decision-support information.

Purpose: The author reports key findings from a doctoral dissertation investigating what the curbside consultation is, how and why physicians use it, and what the implications for health sciences library services might be.

Settings/Informants: Primary informants included sixteen primary care physicians at six sites in one Midwestern state. Additional informants included twenty-eight specialists and subspecialists identified by the primary informants as colleagues who provided curbside consultations.

Methods: Qualitative research methods were used, including field observations, formal and informal interviews, and conversations with peer review physicians.

Results: Despite a lack of consensus about what constitutes a “good” curbside consultation, physician informants reported that curbside consultations were part of their medical education and that they continued to take part in them for a number of reasons. Tacit rules govern curbside consultation interactions, and negative consequences result when the rules are misunderstood or not observed.

Discussion/Conclusion: Acknowledging and understanding physicians' use of the curbside consultation to obtain and construct knowledge may suggest new ways for health sciences librarians to work with physicians in locating, diffusing, and disseminating clinical information.

OBJECTIVE: To describe the rationale, development, content, and results of the AHSR-sponsored conference on developing a research agenda focused on improving the quality of care for children. DATA SOURCES AND METHODS: Planning documents, background papers, and conference proceedings. PRINCIPAL FINDINGS: The conference developed the research agenda focused on (1) monitoring the health of children; (2) evaluating the efficacy and effectiveness of health services for children; (3) assessing the quality of healthcare provided to children; (4) improving the quality of healthcare within health systems; (5) assessing the performance of community systems for children; (6) exploring the impact of different financial incentives on the provision of pediatric healthcare; and (7) developing and disseminating clinical practice guidelines and other information to physicians, families, and consumers. Specific issues and research questions in each area are also presented. Strategies for implementing the research agenda are presented and include: (1) expanding the child health services research workforce; (2) developing child healthcare quality improvement research centers; (3) conducting research in specific high-priority areas; (4) focusing research on improving the health of vulnerable populations; (5) improving child health data and collection systems at the national level; (6) developing better community health monitoring for children; (7) building and supporting research networks and a consortium of research users; and (8) developing a coordinated interagency federal effort to advance this agenda and to provide accountability for its completion. CONCLUSION: The proposed research agenda should be a national priority so that all Americans can be assured that children are receiving the best quality of care that the United States can provide.

Background

Alongside advances in medical information technology (IT), there is mounting physician and patient dissatisfaction with present-day clinical practice. The effect of introducing increasingly complex medical IT on the ethical dimension of the clinical physician’s primary task (identified as direct patient care) can be scrutinized through analysis of the EMR software platform.

Questions/purposes

We therefore (1) identify IT changes burdensome to the clinician in performing patient care and which therefore lower quality of care; and (2) suggest methods for clinicians to maintain high quality patient care as IT demands increase.

Methods

Elemental relationships from information theory and physical chemistry are applied to the profit-generating creation and flow of medical information between patients, physicians, administrators, suppliers, and insurers. Ethical implications for patient care and the doctor-patient relationship are drawn in the light of these relationships.

Where are we now?

Little has been accomplished, or even discussed, regarding limiting healthcare IT growth. Quality of patient care is expected to suffer unless physicians carefully scrutinize, refine and occasionally reject portions of the increasing healthcare IT burden being placed upon them.

Where do we need to go?

Better medicine, simply understood as more effective prevention and treatment of musculoskeletal disease, is our professional goal. We need to establish mechanisms whereby we can limit, control or even reverse IT changes that hinder this goal. Clinicians must confront the negative impact many healthcare IT changes have on patient care.

How do we get there?

Suggestions for maintaining high standards of practice in the face of the new IT burden include: (1) Increasing IT time-awareness. Clinicians should examine actual time spent in clinical versus computer-based activity and implement changes if that ratio is too high. (2) Increasing IT goal awareness. (3) Examine the software creating a medical record to see how much of what it records is there for financial, as opposed to medical reasons. Is the software helping my patient or someone else’s bottom line? Is it for talking to colleagues about sick people or to insurance companies?

Background

Chaotic homes predict poor school performance. Given that it is known that genes affect both children's experience of household chaos and their school achievement, to what extent is the relationship between high levels of noise and environmental confusion in the home, and children's school performance, mediated by heritable child effects? This is the first study to explore the genetic and environmental pathways between household chaos and academic performance.

Method

Children's perceptions of family chaos at ages 9 and 12 and their school performance at age 12 were assessed in more than 2,300 twin pairs. The use of child-specific measures in a multivariate genetic analysis made it possible to investigate the genetic and environmental origins of the covariation between children's experience of chaos in the home and their school achievement.

Results

Children's experience of family chaos and their school achievement were significantly correlated in the expected negative direction (r = −.26). As expected, shared environmental factors explained a large proportion (63%) of the association. However, genetic factors accounted for a significant proportion (37%) of the association between children's experience of household chaos and their school performance.

Conclusions

The association between chaotic homes and poor performance in school, previously assumed to be entirely environmental in origin, is in fact partly genetic. How children's home environment affects their academic achievement is not simply in the direction environment → child → outcome. Instead, genetic factors that influence children's experience of the disordered home environment also affect how well they do at school. The relationship between the child, their environment and their performance at school is complex: both genetic and environmental factors play a role.

Background

Chaotic homes predict poor school performance. Given that it is known that genes affect both children's experience of household chaos and their school achievement, to what extent is the relationship between high levels of noise and environmental confusion in the home, and children's school performance, mediated by heritable child effects? This is the first study to explore the genetic and environmental pathways between household chaos and academic performance.

Method

Children's perceptions of family chaos at ages 9 and 12 and their school performance at age 12 were assessed in more than 2300 twin pairs. The use of child-specific measures in a multivariate genetic analysis made it possible to investigate the genetic and environmental origins of the covariation between children's experience of chaos in the home and their school achievement.

Results

Children's experience of family chaos and their school achievement were significantly correlated in the expected negative direction (r = −0.26). As expected, shared environmental factors explained a large proportion (63%) of the association. However, genetic factors accounted for a significant proportion (37%) of the association between children's experience of household chaos and their school performance.

Conclusions

The association between chaotic homes and poor performance in school, previously assumed to be entirely environmental in origin, is in fact partly genetic. How children's home environment affects their academic achievement is not simply in the direction: environment → child → outcome. Instead, genetic factors that influence children's experience of the disordered home environment also affect how well they do at school. The relationship between the child, their environment, and their performance at school is complex: both genetic and environmental factors play a role.

Background

Public use of the Internet for health information is increasing but its effect on health care is unclear. We studied physicians' experience of patients looking for health information on the Internet and their perceptions of the impact of this information on the physician-patient relationship, health care, and workload.

Methods

Cross-sectional survey of a nationally-representative sample of United States physicians (1050 respondents; response rate 53%).

Results

Eighty-five percent of respondents had experienced a patient bringing Internet information to a visit. The quality of information was important: accurate, relevant information benefited, while inaccurate or irrelevant information harmed health care, health outcomes, and the physician-patient relationship. However, the physician's feeling that the patient was challenging his or her authority was the most consistent predictor of a perceived deterioration in the physician-patient relationship (OR = 14.9; 95% CI, 5.5-40.5), in the quality of health care (OR = 3.4; 95% CI, 1.1-10.9), or health outcomes (OR = 5.6; 95% CI, 1.7-18.7). Thirty-eight percent of physicians believed that the patient bringing in information made the visit less time efficient, particularly if the patient wanted something inappropriate (OR = 2.5; 95% CI, 1.5-4.4), or the physician felt challenged (OR = 3.6; 95% CI, 1.8-7.2).

Conclusions

The quality of information on the Internet is paramount: accurate relevant information is beneficial, while inaccurate information is harmful. Physicians appear to acquiesce to clinically-inappropriate requests generated by information from the Internet, either for fear of damaging the physician-patient relationship or because of the negative effect on time efficiency of not doing so. A minority of physicians feels challenged by patients bringing health information to the visit; reasons for this require further research.

Background

Coordination between care providers of different disciplines is essential to improve the quality of care, in particular for patients with chronic diseases. The way in which general practitioners (GP's) and medical specialists interact has important implications for any healthcare system in which the GP plays the role of gatekeeper to specialist care. Patient experiences and preferences have proven to be increasingly important in discussing healthcare policy. The Dutch government initiated the development of a special website with information for patients on performance indicators of hospitals as well as information on illness or treatment.

In the present study we focus on the transition of care at the primary – secondary interface with reference to the impact of patients' ability to make choices about their secondary care providers. The purpose of this study is to (a) explore experiences and preferences of patients regarding the transition between primary and secondary care, (b) study informational resources on illness/treatment desired by patients and (c) determine how information supplied could make it easier for the patient to choose between different options for care (hospital or specialist).

Methods

We conducted a qualitative study using semi-structured focus group interviews among 71 patients referred for various indications in the north and west of The Netherlands.

Results

Patients find it important that they do not have to wait, that they are taken seriously, and receive adequate and individually relevant information. A lack of continuity from secondary to primary care was experienced. The patient's desire for free choice of type of care did not arise in any of the focus groups.

Conclusion

Hospital discharge information needs to be improved. The interval between discharge from specialist care and the report of the specialist to the GP might be a suitable performance indicator in healthcare. Patients want to receive information, tailored to their own situation. The need for information, however, is quite variable. Patients do not feel strongly about self-chosen healthcare, contrary to what administrators presently believe.

Physiological signals often are highly non-stationary (i.e., mean and variance change with time) and multiscaled (i.e., dependent on the spatial or temporal interval lengths). They may exhibit different behaviors, such as non-linearity, sensitive dependence on small disturbances, long memory, and extreme variations. Such data have been accumulating in all areas of health sciences and rapid analysis can serve quality testing, physician assessment, and patient diagnosis. To support patient care, it is very desirable to characterize the different signal behaviors on a wide range of scales simultaneously. The Scale-Dependent Lyapunov Exponent (SDLE) is capable of such a fundamental task. In particular, SDLE can readily characterize all known types of signal data, including deterministic chaos, noisy chaos, random 1/fα processes, stochastic limit cycles, among others. SDLE also has some unique capabilities that are not shared by other methods, such as detecting fractal structures from non-stationary data and detecting intermittent chaos. In this article, we describe SDLE in such a way that it can be readily understood and implemented by non-mathematically oriented researchers, develop a SDLE-based consistent, unifying theory for the multiscale analysis, and demonstrate the power of SDLE on analysis of heart-rate variability (HRV) data to detect congestive heart failure and analysis of electroencephalography (EEG) data to detect seizures.

Background

Primary health care in industrialized countries faces major challenges due to demographic changes, an increasing prevalence of chronic diseases and a shortage of primary care physicians. One approach to counteract these developments might be to reduce primary care physicians’ workload supported by the use of health information technology (HIT) and non-physician practice staff. In 2009, the U.S. Commonwealth Fund (CWF) conducted an international survey of primary care physicians which the present secondary descriptive analysis is based on. The aim of this analysis was twofold: First, to explore to what extend German primary care physicians already get support by HIT and non-physician practice staff, and second, to show possible future perspectives.

Methods

The CWF questionnaire was sent to a representative random sample of 1,500 primary care physicians all over Germany. The data was descriptively analyzed. Group comparisons regarding differences in gender and age groups were made by means of Chi Square Tests for categorical variables. An alpha-level of p < 0.05 was used for statistical significance.

Results

Altogether 715 primary care physicians answered the questionnaire (response rate 49%). Seventy percent of the physicians use electronic medical records. Technical features such as electronic ordering and access to laboratory parameters are mainly used. However, the majority does not routinely use technical functions for drug prescribing, reminder-systems for guideline-based interventions or recall of patients. Six percent of surveyed physicians are able to transfer prescriptions electronically to a pharmacy, 1% use email communication with patients regularly. Seventy-two percent of primary care physicians get support by non-physician practice staff in patient care, mostly in administrative tasks or routine preventive services. One fourth of physicians is supported in telephone calls to the patient or in patient education and counseling.

Conclusion

Within this sample the majority of primary care physicians get support by HIT and non-physician practice staff in their daily work. However, the potential has not yet been fully used. Supportive technical functions like electronic alarm functions for medication or electronic prescribing should be improved technically and more adapted to physicians’ needs. To warrant pro-active health care, recall and reminder systems should get refined to encourage their use. Adequately qualified non-physician practice staff could play a more active role in patient care. Reimbursement should not only be linked to doctors’, but also to non-physician practice staff services.

Over the past four years there have been 93 multiple-casualty terrorist attacks in Israel, 33 of them in Jerusalem. The Hadassah-Hebrew University Medical Center is the only Level I trauma center in Jerusalem and has therefore gained important experience in caring for critically injured patients. To do so we have developed a highly flexible operational system for managing the general intensive care unit (GICU). The focus of this review will be on the organizational steps needed to provide operational flexibility, emphasizing the importance of forward deployment of intensive care unit personnel to the trauma bay and emergency room and the existence of a chain of command to limit chaos. A retrospective review of the hospital's response to multiple-casualty terror incidents occurring between 1 October 2000 and 1 September 2004 was performed. Information was assembled from the medical center's trauma registry and from GICU patient admission and discharge records. Patients are described with regard to the severity and type of injury. The organizational work within intensive care is described. Finally, specific issues related to the diagnosis and management of lung, brain, orthopedic and abdominal injuries, caused by bomb blast events associated with shrapnel, are described. This review emphasizes the importance of a multidisciplinary team approach in caring for these patients.

Background

This study advances the use of a utility model to model physician-patient interactions from the perspectives of physicians and patients.

Presentation of the hypothesis

In cases involving acute care, patient counseling involves a relatively straightforward transfer of information from the physician to a patient. The patient has less information than the physician on the impact the condition and its treatment have on utility. In decisions involving lifestyle changes, the patient may have more information than the physician on his/her utility of consumption; moreover, differences in discounting future health may contribute significantly to differences between patients' preferences and physicians' recommendations.

Testing the hypothesis

The expectation of differences in internal discount rate between patients and their physicians is discussed.

Implications of the hypothesis

This utility model provides a conceptual basis for the finding that educational approaches alone may not effect changes in patient behavior and suggests other economic variables that could be targeted in the attempt to produce healthier behavior.

Background

Professional medical organizations recommend individualized patient decision making about prostate cancer screening. Little is known about primary care physicians' use of pre-screening discussions to promote informed decision making for prostate cancer screening. The aim of this study is to explore physicians' use of pre-screening discussions and reasons why physicians would or would not try to persuade patients to be screened if they initially refuse testing.

Methods

Primary care physicians completed a self-administered survey about prostate cancer screening practices for informed decision making.

Results

Sixty-six physicians (75.9%) completed the survey, and 63 were used in the analysis. Thirteen physicians (20.6%) reported not using prescreening discussions, 45 (71.4%) reported the use of prescreening discussions, and 3 (4.8%) reported neither ordering the PSA test nor discussing it with patients. Sixty-nine percent of physicians who reported not having discussions indicated they were more likely to screen African American patients for prostate cancer, compared to 50% of physicians who reported the use of discussions (Chi-square(1) = 1.62, p = .20). Similarly, 91% of physicians who reported not having discussions indicated they are more likely to screen patients with a family history of prostate cancer, compared to 46% of those who reported the use of discussion (Chi-square(1) = 13.27, p < .001). Beliefs about the scientific evidence and efficacy of screening, ethical concerns regarding patient autonomy, and concerns about time constraints differed between physicians who would and would not try to persuade a patient to be tested.

Conclusion

Although guidelines recommend discussing the risks and benefits of prostate cancer screening, physicians report varying practice styles. Future research needs to consider the nature of discussions and the degree to which informed decision making is being achieved in clinical practice.

Background

The impact of high physician workload and job stress on quality and outcomes of healthcare delivery is not clear. Our study explored whether high workload and job stress were associated with lower performance in general practices in the Netherlands.

Methods

Secondary analysis of data from 239 general practices, collected in practice visits between 2003 to 2006 in the Netherlands using a comprehensive set of measures of practice management. Data were collected by a practice visitor, a trained non-physician observer using patients questionnaires, doctors and staff. For this study we selected five measures of practice performance as outcomes and six measures of GP workload and job stress as predictors. A total of 79 indicators were used out of the 303 available indicators. Random coefficient regression models were applied to examine associations.

Results and discussion

Workload and job stress are associated with practice performance.

Workload: Working more hours as a GP was associated with more positive patient experiences of accessibility and availability (b = 0.16). After list size adjustment, practices with more GP-time per patient scored higher on GP care (b = 0.45). When GPs provided more than 20 hours per week per 1000 patients, patients scored over 80% on the Europep questionnaire for quality of GP care.

Job stress: High GP job stress was associated with lower accessibility and availability (b = 0.21) and insufficient practice management (b = 0.25). Higher GP commitment and more satisfaction with the job was associated with more prevention and disease management (b = 0.35).

Conclusion

Providing more time in the practice, and more time per patient and experiencing less job stress are all associated with perceptions by patients of better care and better practice performance. Workload and job stress should be assessed by using list size adjusted data in order to realise better quality of care. Organisational development using this kind of data feedback could benefit both patients and GP.

ABSTRACT

OBJECTIVE

To explore family physicians’ perspectives on collaborative practice 12 months after pharmacists were integrated into their family practices.

DESIGN

Qualitative design using focus groups followed by semistructured interviews.

SETTING

Seven physician-led group family practices in urban, suburban, and semirural Ontario communities.

PARTICIPANTS

Twelve purposively selected family physicians participating in the IMPACT (Integrating family Medicine and Pharmacy to Advance primary Care Therapeutics) project.

METHODS

We conducted 4 exploratory focus groups to gather information on collaborative practice issues in order to construct our interview guide. We later interviewed 12 physicians 1 year into the integration process. Focus groups and interviews were audiotaped and transcribed verbatim. Four researchers used immersion and crystallization techniques to identify codes for the data and thematic editing to distil participants’ perspectives on physician-pharmacist collaborative practice.

FINDINGS

The focus groups revealed concerns relating to operational efficiencies, medicolegal implications, effects on patient-physician relationships, and work satisfaction. The follow-up semistructured interviews revealed ongoing operational challenges, but several issues had resolved and clinical and practice-level benefits surfaced. Clinical benefits included having colleagues to provide reliable drug information, gaining fresh perspectives, and having increased security in prescribing. Practice-level benefits included group education, liaison with community pharmacies, and an enhanced sense of team. Persistent operational challenges included finding time to learn about pharmacists’ role and skills and insufficient space in practices to accommodate both professionals.

CONCLUSION

Physicians’ perspectives on collaborative practice 12 months after pharmacists were integrated into their family practices were positive overall. Some ongoing operational challenges remained. Several of the early concerns about collaborative practice had been resolved as physicians discovered the benefits of working with pharmacists, such as increased security in prescribing.

Background

Interactions between physicians and drug representatives are common, even though research shows that physicians understand the conflict of interest between marketing and patient care. Little is known about how physicians resolve this contradiction.

Objective

To determine physicians’ techniques for managing cognitive inconsistencies within their relationships with drug representatives.

Design, Setting, and Participants

Six focus groups were conducted with 32 academic and community physicians in San Diego, Atlanta, and Chicago.

Measurements

Qualitative analysis of focus group transcripts to determine physicians’ attitudes towards conflict of interest and detailing, their beliefs about the quality of information conveyed and the impact on prescribing, and their resolution of the conflict between detailers’ desire to sell product and patient care.

Results

Physicians understood the concept of conflict of interest and applied it to relationships with detailers. However, they maintained favorable views of physician–detailer exchanges. Holding these mutually contradictory attitudes, physicians were in a position of cognitive dissonance. To resolve the dissonance, they used a variety of denials and rationalizations: They avoided thinking about the conflict of interest, they disagreed that industry relationships affected physician behavior, they denied responsibility for the problem, they enumerated techniques for remaining impartial, and they reasoned that meetings with detailers were educational and benefited patients.

Conclusions

Although physicians understood the concept of conflict of interest, relationships with detailers set up psychological dynamics that influenced their reasoning. Our findings suggest that voluntary guidelines, like those proposed by most major medical societies, are inadequate. It may be that only the prohibition of physician–detailer interactions will be effective.

Background

Interactions between physicians and drug representatives are common, even though research shows that physicians understand the conflict of interest between marketing and patient care. Little is known about how physicians resolve this contradiction.

Objective

To determine physicians’ techniques for managing cognitive inconsistencies within their relationships with drug representatives.

Design, Setting, and Participants

Six focus groups were conducted with 32 academic and community physicians in San Diego, Atlanta, and Chicago.

Measurements

Qualitative analysis of focus group transcripts to determine physicians’ attitudes towards conflict of interest and detailing, their beliefs about the quality of information conveyed and the impact on prescribing, and their resolution of the conflict between detailers’ desire to sell product and patient care.

Results

Physicians understood the concept of conflict of interest and applied it to relationships with detailers. However, they maintained favorable views of physician–detailer exchanges. Holding these mutually contradictory attitudes, physicians were in a position of cognitive dissonance. To resolve the dissonance, they used a variety of denials and rationalizations: They avoided thinking about the conflict of interest, they disagreed that industry relationships affected physician behavior, they denied responsibility for the problem, they enumerated techniques for remaining impartial, and they reasoned that meetings with detailers were educational and benefited patients.

Conclusions

Although physicians understood the concept of conflict of interest, relationships with detailers set up psychological dynamics that influenced their reasoning. Our findings suggest that voluntary guidelines, like those proposed by most major medical societies, are inadequate. It may be that only the prohibition of physician–detailer interactions will be effective.

Patient-centered care has received new prominence with its inclusion by the Institute of Medicine as 1 of the 6 aims of quality. Seven attributes of patient-centered primary care are proposed here to improve this dimension of care: access to care, patient engagement in care, information systems, care coordination, integrated and comprehensive team care, patient-centered care surveys, and publicly available information. The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care finds that one fourth of primary care physicians currently incorporate these various patient-centered attributes in their practices. To bring about marked improvement will require a new system of primary care payment that blends monthly patient panel fees with traditional fee-for-service payment, and new incentives for patient-centered care performance. A major effort to test this concept, develop a business case, provide technical assistance and training, and diffuse best practices is needed to transform American health care.