Understanding Practice from the Ground Up

Discussion

The complexity of primary care practices is best understood from multiple perspectives,²⁹ a principle that guided the initial selection of a multimethod comparative case study design for this investigation. The MAP that emerged from this comparative case study design has a number of strengths and weaknesses. A particular asset of the design was our ability to investigate specific phenomena within their context rather than isolated from it.²⁹ The design also encouraged the investigators to pursue emerging insights, thus informing multiple perspectives that might not have otherwise been considered, although this may be somewhat limited by the purposeful sampling strategy that focuses on maximizing information about a particular topic.

Limitations

A limitation for broader implementation of this research design is the intensity of data collection and analysis, which are difficult to accomplish without considerable resources and a research team with diverse skills. There might also be some concerns about the ways that the data collection process alters practice behavior; however, the prolonged observational time frame and the multiple data sources for “triangulation” are designed to limit any potential Hawthorne effect. That is, by collecting and systematically comparing data from multiple sources, including direct observation, different forms of interviews, and existing documents, the investigators were able to identify inconsistencies in patterns of behavior.^17,19

Although the data collection, analysis, and feedback process appeared to increase a practice’s self-reflection, our study limited the input of patient and practice participants in the design, analysis, and interpretation and thus does not approach the participatory research paradigm espoused by McCauley and colleagues.³⁰ Still, our study moved from being primarily observational descriptive research into a more collaborative and interventional project, in part at the request of the participants. This suggests a model and method for future research in the arena of health care process and outcome improvement with the practices as collaborators. The MAP characterized in this paper offers a means for simultaneously describing, understanding, and improving the richly complex and varied processes and outcomes of primary care. By more actively engaging the practices in the research process, the MAP also points toward a new more collaborative model of practice-based research.

Conclusions

The comprehensive data in the P&CD study provide a unique opportunity to understand and describe multiple perspectives from the clinician, patient, encounter, practice, community, and health system spheres. Each of the papers in this issue of JFP used some of these comprehensive data to study one or more of these spheres. For example, the encounter field notes were the primary source of data for exploring how “family” presents in encounters³¹Several of the authors used subsets of patients, including patients presenting with acute respiratory track infections,³³ smokers,³⁴ and frequent attenders.³⁵ These authors each supplemented the encounter field notes with data from the medical record reviews, medical record field notes, and patient exit cards. The complete data set including practice field notes, practice genograms, physician and staff interviews, office environment checklists, and encounter field notes were used to describe staff training, roles, and functions.³⁶ This is only a part of the research adventure available in this type of data. We hope many others will join in the excitement.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776) and a Research Center grant from the American Academy of Family Physicians. Drs Crabtree, Miller and Stange are associated with the Center for Research in Family Practice and Primary Care, Cleveland, New Brunswick, Allentown, and San Antonio. We are grateful to the physicians, staff, and patients from the 18 practices, without whose participation this study would not have been possible. We also wish to thank Connie Gibbs and Jen Rouse, who spent many hours in the practices collecting data, and Diane Dodendorf and Jason Lebsack, who spent countless hours coordinating transcription and data management activities, for their dedicated work. We are especially indebted to Mary McAndrews, who transcribed hundreds of taped interviews and dictated field notes. The ongoing analyses that ensured the quality and comprehensiveness of the data were made possible through the dedicated work of Helen McIlvain, PhD; Jeffrey Susman, MD; Virginia Aita, PhD; Kristine McVea, MD; Elisabeth Backer, MD; Paul Turner, PhD; and Louis Pol, PhD. Finally, we thank the members of the advisory committee: Valerie Gilchrist, MD; Paul Nutting, MD, MPH; Carlos Jaén, MD, PhD; Kurt Stange, MD, PhD; William Miller, MD, MA; Reuben McDaniel, PhD; and Ruth Anderson, RN, PhD.