The chief investigator, serving in a capacity of family physician-anthropologist, observed and participated in more than 900 patient encounters, and attended staff meetings, hospital rounds, utilization reviews, and in-service training. Participant observation at each site varied from 1 to 4 months and direct contact ranged from a minimum of 90 hours to a maximum of 350 hours. Individual long interviews were conducted at the sites with all health care providers (physicians, nurse practitioners, and physician assistants, [n=54]), administrators (n=18), nurses or nursing assistants (n=45), and ancillary staff (n=30). In addition to being interviewed individually, 24 physicians participated in focus groups using a prearranged moderator’s guide consisting of general questions supplemented by probes. Analyzed key texts included training and administrative manuals, brochures, financial and mission statements, policy guidelines, and historical documents from each site.
Informed consent was established through departmental memos or verbal discussions with physicians, administrators, and staff, as well as before every interview and focus group. Field notes of the participant-observer were recorded each day, while process notes were kept of interviews and focus groups. All focus groups and interviews, except those with ancillary staff, were also audiotaped for later transcription and analysis.
Data Analysis
Immersion-crystallization was used to analyze the data. This involves concentrated textual review of the data, with concerned reflection and intuitive insights, until reportable interpretations become apparent.18-19 Cycles of data collection followed by data analysis and refinement of study tools were repeated until interpretations were formulated and verified. Triangulation14,15,18-20 of data sources and searches for alternative interpretations and negative cases were also stressed as part of the analysis.
To assist with the verification of the accuracy of the interpretations, the investigator returned to each practice site to present findings and receive feedback. Most interpretations were confirmed during the ensuing discussions, and when inconsistencies arose, further review of the data and consideration of alternative interpretations was undertaken.
Results
The care providers at the sites generally reported the sense of “doing better, but feeling worse” during interviews, focus groups, and informal discussions: the salaries and status of family practitioners have improved dramatically in the last 5 years, but so has the sense of discontent. Primary care’s central role in managed care has led to an increased demand for the discipline, and recruiting primary caregivers is a high priority among hospital organizations. Family practice physicians for the first time have taken seats on health care institutional boards and have entered the upper echelons of administration. As one family medicine department chief noted, “Twenty years ago I felt like we were outside throwing stones at the institution; now we’re driving the bus.” Although they perceive that primary care has “come of age,” many speak of being less happy in their profession than in the past and complain of varying levels of demoralization. There were physicians at 4 of the 5 groups who had recently left the group to replace practicing family medicine with less demanding forms of primary care, alternative medicine, nursing home administration, or early retirement. Those that remain have many concerns and fears, most notably regarding rapid change, disruptions of relationships, increased demands, and interference in clinical decision making. To clarify which data sources support or refute these interpretations, notations are provided throughout the text: I = interviews; F = focus groups; P = participant-observations; E = patient encounters; and D = textual or historical documents.
Change and Disruption
In the words of the medical director of a family practice group in Massachusetts, “Revolutionary change happened here. Got on the slippery slope, starting thinking of medicine as a business, physicians started sounding like CEOs, all decisions started being in terms of dollars. You go down that path long enough, take small steps, and even though you know it’s wrong, you’ve taken so many little steps already, you go and do it…You’ve been talking the talk long enough, it doesn’t seem strange.” (I)
Even though the managed care organizations in the sites’ practice areas largely support the primary care provider concept, the practitioners speak of the current situation as an unmaintainable “transitory period of craziness” that they may be unable to survive (I, F, P). Providers in the sample share the sense of being in the midst of a “revolution” where it is difficult, if not impossible, to keep abreast of changes. As compared with previous periods of transition, change and disruption are now perceived as constant and unrelenting (I, F, P). Though many of these assertions are difficult to verify given the paucity of the historical record and the subjectivity of experience, clearly multiple key strategic health care alliances and structural arrangements have been altered (I, F, P, D). For example, 3 of the 5 medical centers associated with the practice sites either merged or were purchased during the 9-month study period; 2 of these linked with their former competitors. The hospitals with which the other 2 sites were affiliated underwent downsizing. In addition, 2 of the practices were recently sold to their affiliated hospitals, ending long periods of independent entrepreneurship (I, F, P, D).