Patricia Thille

Beyond Fighting Fires and Chasing Tails? Chronic Illness Care Plans in Ontario, Canada

PURPOSE Recent work has conceptualized new models for the primary care management of patients with chronic illness. This study investigated the experience of family physicians and patients with a chronic illness management initiative that involved the joint formulation of comprehensive individual patient care plans. METHODS A qualitative evaluation, framed by phenomenology, immediately followed a randomized controlled trial examining the effect of external facilitators in enhancing the delivery of chronic condition care planning in primary care. The study, set in Ontario family practices, used semistructured in-depth interviews with a purposive sample of 13 family physicians, 20 patients, and all 3 study facilitators. Analysis used independent transcript review and constant comparative methods. RESULTS Despite the intervention being grounded in patient-centered principles, family physicians generally viewed chronic illness management from a predominantly biomedical perspective. Only a few enthusiasts viewed systematic care planning as a new approach to managing patients with chronic illness. Most family physicians found the strategy to be difficult to implement within existing organizational and financial constraints. For these participants, care planning conflicted with preexisting concepts of their role and of their patient’s abilities to become partners in care. The few patients who noticed the process spoke favorably about their experience. CONCLUSIONS Although the experiences of the enthusiastic family physicians were encouraging, we found important individual-level barriers to chronic illness management in primary care. These issues seemed to transcend existing organizational and resource constraints.

Giving Patients Responsibility or Fostering Mutual Response-Ability: Family Physicians’ Constructions of Effective Chronic Illness Management:

Current visions of family medicine and models of chronic illness management integrate evidence-based medicine with collaborative, patient-centered care, despite critiques that these constructs conflict with each other. With this potential conflict in mind, we applied a critical discursive psychology methodology to present discursive patterns articulated by 13 family physicians in Ontario, Canada, regarding care of patients living with multiple chronic illnesses. Physicians constructed competing versions of the terms “effective chronic illness management” and “patient involvement.” One construction integrated individual responsibility for health with primacy of “evidence,” resulting in a conceptualization consistent with paternalistic care. The second constructed effective care as involving active partnership of physician and patient, implying a need to foster the ability of both practitioners and patients to respond to complex challenges as they arose. The former pattern is inconsistent with visions of family medicine and chronic illness management, whereas the latter embodies it.

Self-management support in primary care: Enactments, disruptions, and conversational consequences

A common refrain in chronic disease management is that patients and clinicians need to enact new roles: patients as their own caregivers; clinicians as professional supporters of patient self-management activities. These roles are central to self-management support (SMS), an approach that emphasizes a clinical partnership, and promotes patient identification and achievement of realistic and short-term behavioral goals. With SMS, behavior change is the desired end, not the means to a desired biomedical end. Shifting SMS concepts into clinical practice has proven to be difficult and inconsistent, creating potential, unknown risks or harms to patients. We completed a discourse analysis of 16 clinical dialogues between diabetic patients and clinicians, collected during a study of six Ontario Family Health Teams, to explore the questions of risks and harms relating to SMS implementation. We observed varying degrees of incomplete implementation of SMS, as well as interactions that actively negated the core principles. Contrary to SMS principles, clinicians tended to emphasize behavioral changes as means to achieve biomedical ends, though to varying degrees. We present two appointments in detail, highlighting how linking behavior change closely with biomedical measures often elicited face-saving defenses from patients. The subsequent dialogue shifted attention away from problem solving and behavior change into active negotiation of responsibility and identity. Interactions that oriented more to SMS concepts elicited fewer defensive maneuvers from patients. Our analysis helps explicate one additional mechanism by which self-management talk threatens the clinical relationship, and highlights a promising method to mitigate this threat.

Examining organizational change in primary care practices: experiences from using ethnographic methods

BACKGROUND Qualitative methods are an important part of the primary care researchers toolkit providing a nuanced view of the complexity in primary care reform and delivery. Ethnographic research is a comprehensive approach to qualitative data collection, including observation, in-depth interviews and document analysis. Few studies have been published outlining methodological issues related to ethnography in this setting. OBJECTIVE This paper examines some of the challenges of conducting an ethnographic study in primary care setting in Canada, where there recently have been major reforms to traditional methods of organizing primary care services. METHODS This paper is based on an ethnographic study set in primary care practices in Ontario, Canada, designed to investigate changes to organizational and clinical routines in practices undergoing transition to new, interdisciplinary Family Health Teams (FHTs). The study was set in six new FHTs in Ontario. This paper is a reflexive examination of some of the challenges encountered while conducting an ethnographic study in a primary care setting. RESULTS Our experiences in this study highlight some potential benefits of and difficulties in conducting an ethnographic study in family practice. Our study design gave us an opportunity to highlight the changes in routines within an organization in transition. A study with a clinical perspective requires training, support, a mixture of backgrounds and perspectives and ongoing communication. CONCLUSIONS Despite some of the difficulties, the richness of this method has allowed the exploration of a number of additional research questions that emerged during data analysis.

Farmwomen's Discourses on Family Food Provisioning: Gender, Healthism, and Risk Avoidance

This paper examines the dominant discourses utilized by 21 farmwomen with children in three regions of Canada in relation to their talk of household food provisioning. We define food provisioning as the acquisition, preparation, and consumption of food that draws on personal, family, and community resources and supports. Farmwomen expressed their position as gatekeeper of the family meal through traditional gender role discourses. Feeding their families was constructed as a task that determined the health of their family members; it reflects the dominance of a healthism discourse wherein being “healthy” is the desired end that is constructed to be under the control of the individual (mother/wife). Farmwomens description of farming practices relied heavily on the dominant discourse of food safety/risk avoidance, which they used to justify a protectionist orientation to agriculture. Although uniquely positioned to express a dual consumer/producer role, farmwomen instead spoke of an individualistic orientation to health as consumers, and employed system-oriented discourses of the food safety system as producers.