Robin S. Gotler

Facilitating participatory decision-making: what happens in real-world community practice?

Background.Participatory decision-making (PDM), a widely held ideal, depends on physician facilitation of patient participation. However, little is known about how PDM facilitation is actualized in outpatient primary care. Objectives.The objective of this study was to describe the prevalence of physician facilitation of PDM in community family practices and associated physician, patient, and visit characteristics. Research Design.This was a cross-sectional observational study. Subjects.The study included 3,453 patients seen by 138 family physicians in 84 community practices. Main Outcome Measures.Research nurses directly observed PDM facilitation in consecutive adult outpatient visits. The association between PDM facilitation and patient, physician, and visit characteristics was assessed with multilevel multivariable regression. Results.PDM facilitation occurred during 25% of observed patient visits. Rates varied considerably among physicians, from 0% to 79% of visits. Patient satisfaction was not associated with PDM facilitation. In multivariable analyses, employed physicians, chronic illness visits, longer visit duration, and visits involving referral were independently associated with PDM facilitation. Visits in which greater time was spent planning treatment and conducting health education were also more likely to involve facilitation of PDM. Conclusions.Community family physicians facilitate PDM at highly variable rates but focus it on patients with the greatest medical needs and most complex levels of decision making. This selective approach appears to meet patient expectations, because PDM facilitation and patient satisfaction are not associated. If patient participation is to be more widely incorporated into outpatient primary care, it must be addressed within the complexity and multiple demands of community practice.

The Anatomy of Asthma Care Visits in Community Family Practice

Background: We know little about the activities that occur during asthma-related visits with primary care physicians. A better understanding of how time is spent during visits for asthma may facilitate the design of programs to enhance asthma disease management. Objective: To describe the content of asthma visits made to family physicians. Methods: Research nurses directly observed consecutive outpatient visits during two separate days in the offices of 138 community family physicians. Time was classified into 20 different behavioral categories using the Davis Observation Code, and compared for visits for asthma, visits for other chronic conditions, and visits for non-asthma-related acute illnesses during 3035 visits by patients of all ages. Results: Visits for asthma shared several characteristics with visits for other chronic conditions but were longer than visits for other chronic illnesses or for acute illness. Asthma visits were distinguished from both acute care and other chronic care visits by a greater percentage of time spent discussing patient compliance, evaluating patient knowledge, and providing smoking assessment and cessation advice. Conclusions: Visits for asthma are structured differently than acute care visits and specifically address issues important to asthma self-management. Future quality improvement initiatives should recognize, affirm, and enhance many current behaviors by family physicians, while working to expand specific areas of care that still fall short of asthma care guidelines.

The Wonder and the Mystery: Your Voices, Your Stories

The Annals is proud to announce the publication of its first book: The Wonder and the Mystery: 10 Years of Reflections from the Annals of Family Medicine.1 The Wonder and the Mystery is an anthology of intimate personal stories and innovative ideas published in the Annals’ Reflections section. It includes a wide range of articles, from influential pieces on urgent topical issues to exceptional stories of unique individuals. The stories shed light on small moments and major life transitions. In the process, they help us find meaning in our own physical, emotional, and spiritual journeys. Together, the articles in The Wonder and the Mystery deepen our understanding of “the vibrant, unpredictable place where primary care and life intersect.”2 This unique collection is framed by the insights of Rachel Naomi Remen, whose Foreword might just remind readers of the “sense of wonder, of awe, of aliveness”3 that drew them to primary care. Sharing reflections is an integral part of the Annals’ effort to shed light on the core of family medicine and primary care. When clinicians, researchers, and patients allow us a glimpse into their thoughts, practices, and lives—their personal and professional stories—we are enriched. As family physician Jeffrey Borkan reminds us, “Whether we aim to change health care or just provide a record of our acts, stories may provide a mechanism for finding meaning, sustaining ourselves, and furthering our professional roles and that of our field.4 Reflections are an ongoing feature of the Annals, and we invite you to share your stories and ideas. Whether you are a seasoned author, a back-of-the-envelope jotter, or new to reflective writing, we encourage you to consider submitting an article to the Reflections section. We welcome: Stories of personal experience that, implicitly or explicitly, shed light on health, health care, or the human condition Persuasive essays that present a well-reasoned, well-referenced point of view or course of action Explanatory essays that share information, describe a topic, or offer a definition. Explanatory essays must offer a topic, perspective, or approach that is unique or highly relevant All Reflections articles should use a concise writing style, have a clear, focused message, and relate to health or primary health care. Personal stories and innovative ideas deepen the Annals and enrich our lives. We look forward to reading your reflections. We also invite you to read the remarkable insights of your colleagues in The Wonder and the Mystery. Ordering details are available at http://www.AnnFamMed.org.

In This Issue: The Science, Art, and Policy of Primary Care

This issue highlights the art and science of primary care, the role of policy in “nurtur[ing] and support[ing] the idea of primary care,”[1][1] and the rich insights that develop when these domains intersect. As the number of cancer screening tests increases with advances in technology and

In this Issue: Mixed Methods and Diverse Perspectives

This issue features 6 research articles that use a multimethod design[1][1]–[6][2] and an editorial[7][3] that presents a typology of how to publish multimethod research. These studies show how qualitative and quantitative methods can inform and complement each other. For example, the in-depth

Tips for readers, reviewers, and authors advancing health and primary health care.

Annals authors, reviewers, and readers are part of a learning community that is working to advance health and improve primary health care. Below we share tips to help each group enhance their role in this community. We invite you to refine and expand these tips by joining the discussion at

Transformation and Renewal

The September/October issue of Annals1 stimulated a wide range of reflections, kudos, and critiques. Despite their diversity, many comments shared a focus on innovation and change, the same focus that pervades family medicine as it attempts to “transform and renew the discipline…to meet the needs of patients in a changing health care environment.”2

Call for Papers: Clinical Research

Since its inception, the Annals of Family Medicine has sought research on clinical topics: new knowledge that fills a gap in our understanding of how health and illness are gained and lost, how patients present and progress in primary care, and how diagnosis and treatment of patients in primary care