Applied Evidence

A survivor’s guide for primary care physicians

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Building office relationships and interacting with the “local landscape” are the keys to resiliency. Here’s how to do both.



Practice recommendations
  • Building strong relationships among physicians and staff improves the practice’s ability to deal with the uncertainties of a rapidly changing environment (B).
  • Interacting proactively with the economic, social, political, and cultural environment—the practice landscape—provides opportunities for adaptation and ongoing learning (C).

Strength of recommendation (SOR)

  1. Good-quality patient-oriented evidence
  2. Inconsistent or limited-quality patient-oriented evidence
  3. Consensus, usual practice, opinion, disease-oriented evidence, case series

“Everyday Primary Care,” a popular, urban 3-physician family medicine office, has served mostly middle- and working-class people for more than 25 years. Most of the patients have grown older with Drs. Newman and Cope and now have a substantial chronic disease burden. Dr. Varimore, Dr. Cope’s son, has recently joined the practice. He replaced a long-time partner who left in frustration to do emergency medicine.

On a typical day, Dr. Cope enters the crowded waiting room, sighs, and walks quickly toward the nurses’ station where her third scheduled patient has just arrived; her first 2 patients are already waiting in examining rooms. In her tiny office, stacks of charts, phone messages, and forms await her attention. Phones ring constantly. Rushing to see her first patient, Dr. Cope squeezes past her nursing assistant in the narrow hallway. She catches a glimpse of her partner, Dr. Newman, at the end of the corridor. They grunt a word of greeting, but say nothing more. In fact, the physicians and their staff have barely spoken to each other in days.

The 2 older physicians were hopeful that Dr. Varimore would infuse fresh energy into the practice, but the only thing that has changed with his arrival is an increase in the number of patients they see and the expenses of running the office. When the door finally closes at the end of a long day, everyone leaves feeling exhausted and alone.

A toxic atmosphere

The situation at Everyday Primary Care is not unusual.1 These are unhealthy times for most primary care practices. Despite the critical role that primary care is expected to play in health care reform, there is tremendous uncertainty about the future viability of primary care practice.1-6 An alarming number of primary care physicians are leaving practice or taking early retirement as frustration and exhaustion move deeply into our community.1,7,8 Staff turnover is high and disruptive. Primary care physicians feel buffeted by conflicting patient demands, insurance coverage restrictions, inadequate Medicare reimbursement, multiple and often inconsistent practice guidelines, and onerous government regulations. Primary care practices suffer from a culture of despair that impedes decision-making. These practices—and the physicians who struggle to keep them viable—need to develop resilience to survive in this hostile climate and improve the quality of care they provide.

Research-based strategies. This article suggests strategies for primary care practices to move forward—whatever proposed reforms emerge from the current debate. The strategies we propose derive from specific, concrete observations gathered during a 15-year program of research that included nearly 500 primary care offices.9-16 (In fact, Everyday Primary Care is an actual practice that participated in 1 of our studies, though we’ve changed its name and the names of the physicians.) Our research was funded by the National Institutes of Health (NIH) and included both descriptive and intervention projects. Our studies provided in-depth descriptions of a wide variety of primary care practices, as well as new models for describing change.10,14,15 The practices varied in how they delivered preventive services, in their cancer-related prevention and screening activities, and in the way they managed chronic disease.11,14,17-19 Yet across all these variations, we found a pattern in which educated, well-trained professionals and staff wanted to provide good care, but found themselves thwarted in their efforts to succeed.

What’s going on here? We sought to understand what was really happening in these primary care practices and to formulate strategies to help them become better for patients, staff, and clinicians.

We came up with 2 fundamental insights:

  • Practices that focus on building strong internal relationships are better able to deal with surprise and uncertainty.
  • Practices that are proactive in interacting with the changing environment will find multiple ways to achieve effective health care delivery.

Work on building those relationships

In our research, we repeatedly observed that careful attention to the relationships among all the people (clinical and nonclinical staff) working within each practice is critical to improving practice processes and outcomes.20 We wanted to learn why relationships mattered so much and how they could be improved. What we found can best be explained by taking another look at Everyday Primary Care.


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