This issue of JFP presents the results of the Prevention and Competing Demands in Primary Care Study with guest editors Benjamin Crabtree, PhD, Will Miller, MD, MA, and Kurt Stange, MD, PhD. This is the very best kind of research—designed and executed by an interdisciplinary team of family practice researchers and participating community-based family practices. The researchers spent thousands of hours observing family physicians and their staffs as they went about the task of caring for families, using a process described by Crabtree and colleagues.1
For clinicians, reading these articles can be like looking in the mirror, and will bring to mind many specific patient encounters. Use this as an opportunity for reflection: How can I do a better job of meeting the needs of our patients? How does my practice differ from those around me? Is my variation appropriate or inappropriate?
Variation in family practice is an important theme of this landmark study. Most agree there is too much variability in the translation of scientific evidence into practice: The same patient with an upper respiratory infection may or may not receive a chest x-ray, an antibiotic, a decongestant, or a follow-up visit, depending on which family physician she sees. At the same time, a rigid application of protocols will not necessarily improve outcomes—particularly if they eliminate the variation that comes from attempts to meet the unique needs of patients, families, and communities.
Miller and coworkers2 applied complexity science to our practices and gained some valuable insights. Sometimes small changes can yield great benefits, and large efforts can generate little improvement in outcomes. Understanding these complex systems gives us a framework for developing locally applicable quality improvement approaches.
You will see your own patients in the 8 archetypes proposed to describe the different kinds of “frequent fliers” in the study by Smucker and colleagues.3 The identification of these archetypes is important for future research and for understanding our own practices.
Like the frequent attender, the patient in emotional distress is an important part of our daily clinical life. Robinson and coworkers4 discovered 4 different approaches that physicians use in dealing with these patients. Which do you use? Knowing may help you to meet patient needs not addressed by your current approach.
Most quality improvement interventions focus on one behavior at a time without considering the competing demands and opportunities inherent in the family practice approach. Jaén and colleagues5 found, for example, there are often good reasons for not asking about smoking habits. Our patients might be better served by focusing our efforts on particularly teachable moments and attending to other aspects of primary care that are more urgent.
Most family physicians agree that too often we use antibiotics unnecessarily. In their fascinating study, Scott and coworkers6 observed almost 300 such patient encounters and classified the approaches that patients take to pressure physicians for antibiotics. Recognizing the (sometimes subtle) pressure to prescribe antibiotics is key to educating our patients and increasing the appropriateness of our prescribing behavior.
Two additional articles in this series appear in full on the JFP Web site at www.jfponline.com. The study by Main and colleagues7 identifies 6 ways that family members who accompany patients have an impact on patient care. The second article by Aita and coworkers8 takes a careful look at staffing in 18 family practices to understand how decisions are made and the implications for meeting patient needs with different types of staff members.
The Prevention and Competing Demands in Primary Care Study presented here offers important insights for all family physicians and for those who seek to understand family practice. These insights can help us take the important first steps toward improving the care of our patients.