In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices

Abstract

We highlight primary care innovations gathered from high-functioning primary care practices, innovations we believe can facilitate joy in practice and mitigate physician burnout. To do so, we made site visits to 23 high-performing primary care practices and focused on how these practices distribute functions among the team, use technology to their advantage, improve outcomes with data, and make the job of primary care feasible and enjoyable as a life's vocation. Innovations identifi ed include (1) proactive planned care, with previsit planning and previsit laboratory tests; (2) sharing clinical care among a team, with expanded rooming protocols, standing orders, and panel management; (3) sharing clerical tasks with collaborative documentation (scribing), nonphysician order entry, and streamlined prescription management; (4) improving communication by verbal messaging and in-box management; and (5) improving team functioning through co-location, team meetings, and work fl ow mapping. Our observations suggest that a shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication, can result in high-functioning teams, improved professional satisfaction, and greater joy in practice.

Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study

“…It includes new approaches as well as confirmation of previously described tools. 3,4,9,12,24,[27][28][29][30][31][32] These included using data to show the team how patient care improves with teamwork, incremental delegation by physicians, 3,4 engaging staff in workflow redesign, creating a safe culture for feedback and questions, 9 using outside coaches or practice facilitators, 27,28 huddles, 21,22 using EHR templates to guide data collection by MAs and nurses, and tracking task completion to help prevent sliding back to pre-teamwork behaviors. When task redistribution maintained patient care safety, job satisfaction and interpersonal continuity of care improved both for physicians and for MAs and nurses who appreciated greater involvement in patient education and decisions about team care processes.…”

“…External system challenges (e.g., fee-for-service payment, resources, regulations) 3,33 were most problematic because they were out of respondents' control. Others have suggested that when teams lack formal authority to alter such external systems, they are particularly reliant on effective clinical leadership, 34 so offering training to potential leaders in how to change care processes may help practices enhance performance and meet patients' needs in a manner consistent with scientific evidence until such external challenges are resolved.…”

“…Many believe that enhanced interprofessional teamwork can promote more efficient primary care delivery [1][2][3][4] Inter-professional teamwork has been defined as "the provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals along with patients, family caregivers and community services who work collaboratively on shared goals within and across settings to achieve care that is safe, effective, person-centered, timely, efficient and equitable." 1,5 The primary care team typically includes a lead clinician, such as a physician or nurse practitioner, and other key personnel including nurses, medical assistants (MAs), care managers, practice managers, clerical staff, as well as others, when available (e.g., behavioral health and pharmacists).…”

The Selling of Primary Care 2015

“…When these more meaningful measures are combined with team-based care and other workplace reforms, both efficiency and work satisfaction may improve. [42][43][44][45][46][47][48][49][50][51] Expansion of medical school capacity is already underway, 52 but is not expected to produce the necessary growth in primary care physicians because student selection for primary care careers is falling or stable. 22,[52][53][54][55] The Council on Graduate Medical Education recently estimated that the nation's needs will not be met until 40 % of practicing physicians are in primary care 5 -a percentage that cannot be achieved with the current 20 % selection rate.…”

“…Practices that display this more hopeful understanding of primary care feature efficient communication among team members, standardized work flows, rapid access for patients, continuity between patient and provider, patient-centered care, and team-based work in an environment staffed by highly effective professionals. 2,31,43,51 By analogy, a good clinic is like a superb physician role model who attracts students to his or her field. 64,65 Many schools would not chose to develop effective primary care practices just to draw students into primary care careers, and they should not.…”