Kate Dubé

Team Structure and Culture Are Associated With Lower Burnout in Primary Care

Purpose: Burnout is a threat to the primary care workforce. We investigated the relationship between team structure, team culture, and emotional exhaustion of clinicians and staff in primary care practices. Methods: We surveyed 231 clinicians and 280 staff members of 10 public and 6 university-run primary care clinics in San Francisco in 2012. Predictor variables included team structure, such as working in a tight teamlet, and perception of team culture. The outcome variable was the Maslach emotional exhaustion scale. Generalized estimation equation models were used to account for clustering at the clinic level. Results: Working in a tight team structure and perceptions of a greater team culture were associated with less clinician exhaustion. Team structure and team culture interacted to predict exhaustion: among clinicians reporting low team culture, team structure seemed to have little effect on exhaustion, whereas among clinicians reporting high team culture, tighter team structure was associated with less exhaustion. Greater team culture was associated with less exhaustion among staff. However, unlike for clinicians, team structure failed to predict exhaustion among staff. Conclusions: Fostering team culture may be an important strategy to protect against exhaustion in primary care and enhance the benefit of tight team structures.

“We never thought of a vasectomy”: a qualitative study of men and women's counseling around sterilization

BACKGROUND Sterilization is the most commonly used method of contraception in the United States; however, little is known about how providers counsel about these procedures or the information patients desire. In this study, we explore male and female experiences of sterilization counseling and their perspectives on ideal sterilization counseling. STUDY DESIGN In-depth individual and group interviews were conducted with 37 heterosexual couples between the ages of 25 and 55 years. Each couple had reached their desired family size. Interviews were recorded and transcribed using NVivo software and analyzed using modified grounded theory. RESULTS Men and women differed in their experiences of sterilization counseling. Women commonly received counseling on female sterilization but not vasectomy, while men rarely discussed either form of sterilization with their providers. Both men and women desired more information about sterilization. CONCLUSIONS Contraceptive counseling of couples who have completed childbearing does not routinely include men or the option of vasectomy, despite the advantages of this method with respect to safety, efficacy and cost. Family planning and primary care providers have an important role in ensuring that couples are aware of all their options and can make an informed decision about their contraception.

He's a real man: a qualitative study of the social context of couples' vasectomy decisions among a racially diverse population.

Vasectomy has advantages with respect to safety and cost when compared with female sterilization. The reasons underlying the overall low use of vasectomy, particularly among Black and Latinos, have not been adequately explored. The goals of this study were to (a) explore the social context of vasectomy decisions and (b) generate hypotheses about the social factors contributing to differences in vasectomy use by race/ethnicity. Fourteen group and nine couples interviews were conducted. Participants were 37 heterosexual couples aged 25 to 55 years who had reached their desired family size and self-identified as Black, Latino, or White. Participants discussed reasons that men and women would or would not select male sterilization. Reasons to select vasectomy included a desire to care for their current family, sharing contraceptive responsibility, and infidelity. Reasons not to select vasectomy included negative associations with the term sterilization, loss of manhood, and permanence. Misconceptions about vasectomy included misunderstandings about the vasectomy procedure and adverse postvasectomy sexual function. In addition, Black and Latino participants cited perceived ease of reversibility of female sterilization and lack of support around vasectomy as reasons not to choose it. Improving communication and social support for vasectomy, particularly among Black and Latino communities, may improve vasectomy utilization. Misconceptions regarding female and male sterilization should be targeted in counseling sessions to ensure men, women, and couples are making informed contraceptive decisions.

“How Can We Talk about Patient-centered Care without Patients at the Table?” Lessons Learned from Patient Advisory Councils

Context and Objective: Patient advisory councils (PACs) are a strategy for primary care clinics to engage patients in practice improvement. However, there is scant research on how PACs function. This study aimed to understand how PACs are organized and identify common challenges and perceived benefits of high-functioning PACs. Setting and Population: Key informants identified 8 primary care clinics in California with high-functioning PACs. Leaders from each of the 8 clinics nominated 1 clinic staff member and 1 PAC patient member to be interviewed. Study Design: Semistructured, one-on-one interviews were conducted at each clinic site or by phone. Interviews were dual-coded using modified grounded theory. Common themes were identified that would be pertinent to the development of future best practices for running PACs. Results: Common characteristics of high-functioning PACs included careful attention to participant recruitment, facilitation strategies guiding diverse personalities toward a common purpose, and assigning accountability for practice improvement projects. Interviewees identified a variety of positive outcomes that ranged from tangible improvements to the waiting area to a more patient-centered staff culture. Conclusions: PACs show potential for promoting patient-centered practice improvements in primary care. Lessons learned from high-functioning PACs can inform a common set of strategies to assist practices in creating and sustaining effective advisory councils.

The Road to Excellence for Primary Care Resident Teaching Clinics.

Primary care residency programs and their associated primary care clinics face challenges in their goal to simultaneously provide a good education for tomorrow’s doctors and excellent care for today’s patients. A team from the Center for Excellence in Primary Care at the University of California, San Francisco, conducted site visits to 23 family medicine, internal medicine, and pediatric residency teaching clinics. The authors found that a number of programs have transformed themselves with respect to engaged leadership, resident scheduling, continuity of care for patients and residents, team-based care, and resident engagement in practice improvement. In this Commentary, the authors highlight the features of transforming programs that are melding inspiring resident education with excellent patient care. The authors propose a model, the 10 + 3 Building Blocks of Primary Care Teaching Clinics, to illustrate the themes that characterize transforming primary care residency programs.

Re: The Use of Medical Scribes in Health Care Settings: A Systematic Review and Future Directions.

In the May/June issue of Journal of the American Board of Family Medicine , Shultz and Holmstrom[1][1] performed a systematic review of the literature investigating the effects of medical scribes on health care productivity, clinical quality, revenue, time efficiency, and patient–clinician

Clinician perspectives on working with health coaches: A mixed methods approach.

We sought to understand how health coaches affect the work of primary care clinicians and influence their perception of patient care. As a mixed methods hypothesis-generating study, we administered a structured post-visit survey and conducted in-depth individual interviews with primary care clinicians who worked with health coaches at two urban community health centers. Survey responses were compared using t tests. Interviews were transcribed and analyzed using Atlas.ti software and modified grounded theory. Surveys were completed by 15 of 17 clinicians for 61% of eligible patient visits (269/441). Compared to usual care patients, clinicians rated visits with health-coached patients as less demanding (2.44 vs. 3.06, p < .001) and were more likely to feel that they had adequate time with their patient (3.96 vs. 3.57, p < .001). Qualitative findings expanded upon these results and uncovered four key health coach activities thought to improve patient care. Through developing a rapport with patients over time and working with patients between medical visits, health coaches (a) empower patients by offering self-management support, (b) bridge communication gaps between clinicians and patients, (c) assist patients in navigating the health care system, and (d) act as a point of contact for patients.

The Panel Management Questionnaire: A Tool to Measure Panel Management Capability

Primary care practices are turning toward team-based strategies such as panel management, in which nonclinicians address routine preventive and chronic disease care tasks for a group of patients. No known validated instruments have been published for measuring panel management implementation. The authors developed the 12-item Panel Management Questionnaire (PMQ) measuring 4 domains. Data were assembled from self-administered cross-sectional surveys of 136 staff and 204 clinicians in 9 county and 5 university adult primary care clinics. Staff and clinician PMQ scores in each clinic were correlated. The clinic-level median PMQ score was positively associated with a composite clinic quality measure.