Conducting The Direct Observation of Primary Care Study Insights from the Process of Conducting Multimethod Transdisciplinary Research in Community Practice

Original Research

Conducting The Direct Observation of Primary Care Study Insights from the Process of Conducting Multimethod Transdisciplinary Research in Community Practice

J Fam Pract. 2001 April;50(4):345-352

References

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PURPOSE: This paper shares insights from the process of conducting the Direct Observation of Primary Care (DOPC) Study. That study involved a multimethod approach for evaluating the structure, process, and health system context of family practice.

CONSENSUS PROCESS: The study participants (academic investigators, clinicians, and research nurses) met in groups. By reflecting on the study process, these groups identified insights that may be useful to other investigators planning or conducting primary care research.

LESSONS: The story of the DOPC study is one of collaboration leading to innovation and the development of ongoing relationships and a persistent research trajectory. Six factors were identified as important to the success of the primary care research process: (1) A generalist perspective; (2) involvement of community practices and practicing clinicians as research partners; (3) commitment to a transdisciplinary team process; (4) a multimethod approach; (5) openness to emerging insights; and (6) thinking big, but starting small.

CONCLUSIONS: A multimethod research process that involves collaboration between practicing clinicians, methodologists, and content experts can simultaneously test a priori hypotheses and discover important new insights about primary care practice.

The Direct Observation of Primary Care (DOPC) Study has contributed to the understanding of family practice and has fostered the development of new primary care research methods^1-6 and theoretical perspectives.^7-10 The study’s findings have important implications for improving patient care^11-23 and developing policies^9,24-31 that maximize the impact of a generalist patient-centered approach toward the health of individuals, families, and communities.⁹ This study has spawned a large portfolio of related inquiry, including an in-depth qualitative study of family practices, a multimethod community practice intervention trial, and a new family practice research center.

The DOPC Study story represents a unique confluence of ideas, people, and opportunities. However, we hope that readers might glean insights relevant to their lines of inquiry and that this article will stimulate the continued development of a unique primary care and family practice research agenda.*

The Dopc Story

Concept Development

In 1988, family practice researchers Kurt Stange and Stephen Zyzanski collaborated on a paper about the benefits of integrating quantitative and qualitative research methods.³² While writing a second manuscript on the topic, they invited Benjamin Crabtree and William Miller (emerging experts on the application of qualitative research methods to primary care) to collaborate.³³

At the same time, a group of family physicians and researchers affiliated with Case Western Reserve University in Cleveland, Ohio, was attempting to develop an innovative approach to improving clinical preventive service delivery in practice. With a grant from the Ohio Academy of Family Physicians Foundation, they conducted a survey on family physician agreement with United States Preventive Services Task Force recommendations.^34-36 The survey findings, conversations with respondents, and a review of the literature led to the conclusion that current approaches to improving clinical preventive service delivery were limited by a lack of understanding of the true nature of family practice³⁷ and that efforts to improve practice should be preceded by efforts to understand practice.^38,39 Before designing an intervention study, further insight into the “black box” of real world family practice was needed.^2,40

The research group, which now included family practice academicians, clinicians, and methodologists, began exploring the development of a research network backward from the traditionally successful models used by the Ambulatory Sentinel Practice Network (ASPN) and other networks.^41-44 Rather than developing the infrastructure around a network of clinicians that performs research by gathering data, this new network was developed around a large descriptive study of the content and context of family practice. Funding for a specific study would be easier to obtain than start-up costs for a practice-based research infrastructure. Also, given the demands of clinical practice,⁴⁵ a well-funded study in a regional network could collect more extensive data than a study conducted by individual practices, providing opportunities for spinoff studies and other clinician-initiated inquiries. The research team decided to explore research opportunities with national funding agencies, with close communications and extensive input from local practicing family physicians.

During this time, a series of primary care research conferences sponsored by the Agency for Health Care Policy and Research (AHCPR) provided fertile ground for exploring research ideas and methods from a multidisciplinary perspective. At one conference, research team member Carlos Jaén (an epidemiologist and family physician), team leader Kurt Stange, and Paul Nutting (director of primary care research at AHCPR at the time) discussed the research network and project. The recognition emerged that many worthwhile primary care activities, including preventive service delivery, are not carried out during patient visits because of the competing demands imposed by other activities. This competing demands mode¹⁷ of preventive service delivery and primary care provided an important initial theoretical framework for what would become the DOPC Study.