Conducting The Direct Observation of Primary Care Study Insights from the Process of Conducting Multimethod Transdisciplinary Research in Community Practice
Lessons learned from the dopc process
Some of the lessons learned from the process of conducting the DOPC study are summarized in the Table 1. These lessons can be grouped into 6 categories, as follows.
A generalist perspective. A generalist perspective that places research questions in the context of the competing opportunities and complexity of family practice is needed for true family practice and primary care research.65 Although this perspective is essential if we are to diminish the current chasm between discovery and practice, it has not been supported by those who fund research. One strategy for addressing this funding issue is to identify topics and multimethod approaches that allow simultaneous pursuit of both categorical and generalist perspectives.
Involvement. The involvement of community practices and practicing clinicians as partners is essential for research about primary care practice.66, 67 New knowledge from discoveries in the settings in which most people get most of their medical care will help end the dichotomy between research and dissemination. Practice-based research networks can help bridge this gap by asking and answering questions from the perspective and setting in which the findings will be applied.68,69 (It is worth noting, however, that most successful research networks are built around a group of clinicians who are committed to conducting research in their practices. Developing a network around a particular study, as with the RAPP network, requires attention to fostering clinician ideas and nurturing relationships that extend beyond the initial study.) Greater involvement of nonclinician health care professionals, patients, and communities can also increase the relevance of research to meet the population’s health care needs.67,70
Transdisciplinary team process. A transdisciplinary team process in which diverse specialized expertise is integrated toward a common goal can be a tremendous resource for innovation and productivity. Development of a transdisciplinary team is a long-term process that requires trust, shared vision, open leadership, idea sharing, and group meetings. In addition, team members with particular expertise must be willing to commit to creating new knowledge that transcends their disciplinary perspectives.71 Such collaboration creates the mentality of a bigger pie in which the size of each participants’ piece is increased, rather than a mentality of finite resources in which a bigger piece for one member creates a shortage for another.72
Multimethodology. A multimethod approach in which quantitative and qualitative methods are integrated creates the opportunity to generate new methods, assure rigor, and maximize the efficiency of new discovery.6,32,33,47 Multimethod approaches allow testing of a priori hypotheses while creating new understanding.
Openness. Openness to emerging insights is fostered by the generalist perspective, by participatory multimethod research approaches, and by building the project from pilot data and knowledge of previous work. In the DOPC study, openness to new methods led to the “Eureka!” moment of deciding to do direct observation. The involvement of clinician and nurse perspectives in study design and conduct and the inductive use of qualitative data to discover the relevance of complexity science to understanding and enhancing primary care practice also reflected the study’s openness to new approaches.
Thinking big, but starting small. This creates a larger vision that can guide and inspire individual decisions and creates an overall research trajectory built on incremental steps. The DOPC Study began with a large idea of improving practice. Grounding in real world practice led to development of innovative new methods to try to understand primary care practice and ongoing efforts to improve practice. These major undertakings, however, were built on a foundation of small pilot studies and multiple interactions among researchers and practicing family physicians.
Applying these insights to other studies may help to advance the generation of new knowledge about family practice and primary care.73
Acknowledgments
This research was supported by grants from the National Cancer Institute (1R01 CA60962, 2R01 CA60962 and K24 CA81931), the Agency for Health Care Policy and Research (1R01 HS08776), the Ohio Academy of Family Physicians, the American Academy of Family Physicians, Generalist Physician Faculty Scholar Awards to Drs Stange and Jaén from the Robert Wood Johnson Foundation, and a Family Practice Research Center Grant from the American Academy of Family Physicians. The authors are grateful to the RAPP physicians, other clinicians, office staffs, and patients, without whose participation our study would not have been possible. We are also indebted to the many people who have participated and continue to participate in the genesis of related ideas and scholarly output that continues to emerge from the original study. Members of the DOPC Writing group also include: Authors from the Academic Research Team: Stephen J. Zyzanski, PhD, Department of Family Medicine, Case Western Reserve University, Cleveland, Ohio; Benjamin F. Crabtree, PhD, Department of Family Medicine, UMDNJ-RWJ Medical School, New Brunswick, NJ; William L. Miller, MD, MA, Department of Family Practice, Lehigh Valley Hospital, Allentown, Pa; Carlos Roberto Jaén, MD, PhD, Center for Urban Research in Primary Care, SUNY, Buffalo, NY; Susan A. Flocke, PhD, Department of Family Medicine, Case Western Reserve University, Cleveland, Ohio; Robert B. Kelly, MD, MS, Department of Family Practice, MetroHealth Medical Center, Cleveland, Ohio; William R. Gillanders, MD, Family Practice Residency Program, Sutter Health, Sacramento, Calif; Valerie Gilchrist, MD, Department of Family Practice, NorthEast Ohio Universities College of Medicine, Rootstown, Ohio; Jason Chao, MD, MS, Department of Family Medicine, Case Western Reserve University; J. Christopher Shank, MD, Methodist/Indiana University Family Practice Residency, Indianapolis, Ind; Daniel L. Dunn, PhD, Integrated Health Care Information Service, Cambridge, Mass; Jack H. Medalie, MD, MPH, Department of Family Medicine, Case Western Reserve University, Cleveland, Ohio; Doreen Langa, BA, American University School of Law, Washington, DC; Virginia Aita, PhD, Department of Family Practice, University of Nebraska Medical Center, Omaha; Meredith A. Goodwin, MS, Department of Family Medicine, Case Western Reserve University, Cleveland, Ohio; and Robin S. Gotler, MA, Department of Family Medicine, Case Western Reserve University, Cleveland, Ohio. Research Nurse Team Authors: Lisa B. Ballou, RN, FNP; Catherine M. Corrigan, RN; Luzmaria Jaén, RN; Sherry Patzke, RN; Frances F. Powers, RN; Kathleen L. Schneeberger, RN; Kelly Warner, RN; and Susan Zronek, RN. Authors from the RAPP Board of Directors: Robert Blankfield, MD; Henry Bloom, MD; Valerie Gilchrist, MD; Gwen Haas, MD; Patricia Kellner, MD; Sa Koo Lee, MD; Conrad Lindes, MD; Dennis McCluskey, MD; Thomas Mettee, MD; Albert Miller, MD; Michael Rabovsky, MD; and Archie Wilkinson, MD.
