Physician-System Relationships: Stumbling Blocks and Promising Practices

Using Complexity Theory to Guide Medical School Evaluations

Contemporary medical school evaluations are narrow in focus and often do not consider the wider systems implications of the relationship between learning and teaching, research, clinical care, and community engagement. The result is graduates who lack the necessary knowledge and skills for the modern health care system and an educational system that is limited in its ability to learn and change.To address this issue, the authors apply complexity theory to medical school evaluation, using four key factors-nesting, diversity, self-organization, and emergent outcomes. To help medical educators apply this evaluation approach in their own settings, the authors offer two tools-a modified program logic model and sensemaking. In sensemaking, they use the organic metaphor of the medical school as a neuron situated within a complex neural network to enable medical educators to reframe the way they think about program evaluation. The authors then offer practical guidance for applying this model, including describing the example of addressing graduates' engagement in the health care system. The authors consider the input of teachers, the role of culture and curriculum, and the clinical care system in this example.Medical school evaluation is reframed as an improvement science for complex social interventions (medical school is such an intervention) in this model. With complexity theory's focus on emergent outcomes, evaluation takes on a new focus, reimagining medical students as reaching their future potential as change agents, who transform health systems and the lives of patients.

A social network analysis of healthcare professional relationships in a French hospital

PURPOSE

This paper aims to describe relationships among healthcare professionals in a French public hospital using social network analysis (SNA) and to improve health service quality by strengthening health service management and leadership.

DESIGN/METHODOLOGY/APPROACH

This study was based on a questionnaire sent to randomly selected French public hospital professionals and administrators. Network composition measures were obtained using a name generator. Analysis focused on three main indicators: "centrality", "prestige", and "clique participants". The SNA was carried out using UCINET and statistical analyses were performed with SPSS version 15.0.

FINDINGS

A total of 104 questionnaires were returned and analysed. Centrality, prestige and clique indicators were highly correlated (all p-value were less than 0.01). Physicians had the highest scores for the three indicators. Older age (> or = 45 years) was associated with higher centrality and clique numbers scores. Transversal activity was associated with higher scores than other specific activities (hospitalisation, ambulatory care), except for emergency care.

ORIGINALITY/VALUE

The paper shows how networks and SNA techniques provide novel and useful means to understand communication and collaboration between hospital professionals.

The Buffering Effect of Hope on Clinicians' Behavior: A Test in Pediatric Primary Care

Although trait hope is thought to motivate goal directed actions in the face of impediments, few studies have examined directly hope's role in overcoming obstacles, and none have done so while accounting for related goal constructs. We describe a study of 127 pediatric primary care providers who over the course of a year were asked to identify new cases of asthma and confirm previously diagnosed active disease by completing for each of their patients a brief survey validated for this purpose. These clinicians also completed measures of hope, self-efficacy, conscientiousness, and perceived obstacles to implementing a pediatric asthma management program. As predicted by hope theory, the agency component of hope buffered clinicians from perceived obstacles by facilitating the identification of asthma cases among high hope clinicians in the face of obstacles. This buffering effect remained after controlling for self-efficacy and conscientiousness. We discuss the study findings in terms of current theories of goal directed behavior and implications for delivering hope-related interventions, and we offer a testable hypothesis regarding when agency and pathways thinking facilitate goal-related behavior.

Making sense of primary care practices' capacity for change

A deeper understanding of the forces that shape the motivation and willingness of primary care practices to adopt and implement new procedures-their "capacity for change"-may better guide development of interventions to foster adoption and implementation of evidence-based care. This study applies and evaluates the utility of a previously described framework for making sense of this complex construct in a diverse sample of primary care practices. A multidisciplinary team of 3 analysts examined ethnographic field notes that describe 15 single-physician or multiphysician practices in different organizational settings. Examples of the 4 components within the framework (ie, staff motivations, resources, opportunities for change, and external influences) and their interactions were identified. Cross-practice comparisons identified emerging themes relevant to capacity for change. Not surprisingly, variation among examples of individual components of change capacity across practices was present. Patterns among these components, however, seemed less informative in making sense of practices' capacity for change than patterns across component interactions. For example, the ability of practice members to recognize and act on opportunities for change seemed to be shaped by the extent to which motivations were broadly shared within the practice and by tangible and intangible resources (eg, leadership style, relationships among practice members, and financial resources of the practice). Revised operational definitions for framework components and careful reflection on the nature of their interactions helped make sense of practices' capacity for change in our sample and will enable future hypothesis testing to refine our understanding of factors that influence the translation of scientific knowledge in primary care settings.

Influence of primary care practice and provider attributes on preventive service delivery

BACKGROUND

While visits to the doctor's office are appropriate times to advise patients on health behaviors, these opportunities are often missed. Lapses in care quality are no longer attributed solely to individuals, but are also increasingly understood to be the result of organizational factors. This research examines the influence that both practice and provider attributes have on the delivery of preventive services for health behaviors.

METHODS

This study used data collected from the Prescription for Health initiative sponsored by the Robert Wood Johnson Foundation. Quantitative data on 52 primary care practices and 318 healthcare providers were gathered from September 2003 to September 2004, and were analyzed upon completion of data collection. Hierarchical linear modeling was used to examine associations between both practice and provider attributes and preventive service delivery.

RESULTS

Practice staff participation in decisions regarding quality improvement, practice change, and clinical operations positively influenced the effect of work relationships and negatively influenced the effect of practice size on service delivery. Nurse practitioners and allied health professionals reported more frequent delivery of services compared to physicians. Last, use of reminder systems and patient registries were positively associated with preventive service delivery.

CONCLUSIONS

This study offers preliminary support for staff participation in practice decisions as a positive aspect of teamwork and collaboration. Findings also suggest leveraging nonphysician clinical staff and organized clinical systems to improve the delivery of preventive services for health behaviors.

A qualitative examination of primary care providers' and physician managers' uses and views of research evidence

OBJECTIVE

To examine the reasons and search strategies related to physicians' search for evidence and to compare clinician and physician manager approaches.

DESIGN

Qualitative analysis of verbatim transcripts of four focus groups in 2002. Study setting. Clinicians and managers in community practices in Southern California.

PARTICIPANTS

Pediatricians, family practitioners, and general internists (i.e. child and adult primary care providers) in non-academic practice and physician managers whose primary responsibility involved making management decisions within a moderate to large sized health care delivery system (e.g. health plan, community hospital, large group practice).

MAIN OUTCOME MEASURES

Themes related to clinician and manager reasons for using evidence and approach to selecting among evidence sources.

RESULTS

Clinicians and managers differed substantially in their reasons for using evidence. Whereas clinicians consistently invoked clinical intuition as a guide to most routine clinical decisions, managers articulated both motivation and interest in using medical research to guide decision-making, most commonly prompted by cost. Both clinicians and managers rated trustworthiness as a paramount consideration in arbitrating between evidence sources, because neither group evinced comfort with the complexity of primary literature. Both groups expressed a preference for tested, convenient, and respected evidence sources such as expert colleagues and professional societies.

CONCLUSIONS

Because clinicians invoke intuition in confronting the challenges of daily practice, evidence-based medicine interventions that target managers are likely to have larger effects on health outcomes than those that target primary care providers and individual patient treatment. Ensuring trustworthiness of evidence is of the utmost importance. Because both groups express discomfort with the format of primary evidence sources, strategies should probably not rely on individual appraisal.

Alternative models of hospital-physician affiliation as the United States moves away from tight managed care

Using concepts from organizational economics and sociology, this article compares the medical staff, hospital-owned physician practice, and hybrid models of hospital-physician coordination, as well as the pressures for affiliation during the premanaged care, tight managed care, and loose managed care eras. Case studies of two hospital systems in New York City and two in San Diego illustrate the concepts. Although pressures for tighter hospital-physician affiliation now are weaker than during the era of tight managed care, they are greater than they were before managed care. Hospitals are not reverting to exclusive use of the medical staff model of affiliation but rather are maintaining a mix of medical staff, owned physician practice, and hybrid models. Hospitals probably will continue to seek tighter affiliations with physicians to increase coordination, enhance negotiating leverage with health plans, and gain admissions.

Physician and health system integration

Incentives for vertical integration in the health care industry have led many hospitals to consolidate into health systems and profess a desire for closer alignment with affiliated physicians. In this study of fourteen organized delivery systems and their 11,000 physicians in sixty-nine medical groups, we found that many health systems did not align well with physicians. Even systems ostensibly committed to alignment emphasized structural relationships that did not enhance physician-system alignment and paid inadequate attention to issues of importance to physicians. This gap between the goal and reality of physician-system alignment appears to be the result of systems' responding to a changing mix of policies, not all of which foster integration.

Factors associated with physician involvement in care management

BACKGROUND

Enthusiasm for the concept of care management (CM) has led to unprecedented growth in the number of guidelines and protocols, but provider organizations have struggled to enlist the active support and participation of physicians in CM activities.

OBJECTIVES

To empirically examine the factors influencing physician participation in and attitudes toward CM activities.

METHODS

Data on 1,514 physicians were used to predict physician attitudes toward CM and their perceptions of group CM behaviors. Dependent variables were modeled using two-stage Heckman selection bias models with fixed effects corrections. Independent predictors included physician- and group-level controls as well as six potential CM participation and attitude facilitators.

RESULTS

Physician participation in the implementation phase of CM activities was positively related to participation and attitude. However, physician participation in the development phase may be negatively related to later participation in CM activities. Management involvement in development phase has mixed effects (positive or no effect), but their involvement in the implementation phase was somewhat negatively related to CM participation and attitude. Financial incentives for participation in CM activities and presence of a useful management information system also appeared to be positively related to attitude and participation.

CONCLUSIONS

Appropriate physician and management involvement, as well as financial incentives and useful management information systems may facilitate physician participation in CM activities. Physician involvement in implementation of CM practices appears to be important, whereas their involvement in the development phase may be negatively related to later attitudes and participation. The findings call for a more in-depth understanding of the timing of physician input in CM activities.