Voices from Left of the Dial: Reflections of Practice-based Researchers

Data Analysis

Stories from clinicians who had signed the consent form and completed the demographic survey were included in this report. Using grounded theory approach,¹⁷ 2 independent reviewers (LJF and MAH) read each story and categorized the main response themes qualitatively. A third reviewer (JM) reviewed the stories and analyses. He agreed with the primary themes, suggesting that the first theme corresponded to the tenets of SDT, and made suggestions about the presentation of the information. We used an iterative method until consensus was reached.

Coders summarized responses within 3 domains:

1. the main motivation for participation and remaining involved,

2. a primary impact area resulting from the participation; and

3. a secondary benefit or impact area also achieved through the participation.

After the stories were coded into these domains, the reviewers compared their results for each story classification. We selected only one theme for each story. In the few cases where there was disagreement about the classifications (fewer than 3 stories), the reviewers discussed the differences and came to an agreement.

Clinician Characteristics

Clinicians participating in the PBRN Clinician Stories Project were predominantly male (76%) and family physicians (90%). Their mean age was close to 50 years (mean, 48.8 years; range, 33–66 years). Most had participated in several PBRN studies, with more than 52% having participated in at least 6 or more studies. The majority of clinicians had been in practice for more than 5 years (92%) and had been in a PBRN for at least 5 years (68%). The size of the practices varied from 9 participants in solo practice to 14 in practice groups with more than 5 clinicians. Participants practiced in both private clinics (60%) and public clinics (40%).

Thematic Areas for Motivation

Through the stories of PBRN clinicians we identified a number of themes that motivated clinicians to choose a practice path that included PBR. These themes related to satisfaction with certain aspects of the PBRN experience. Three tables detail the themes within each of these domains: (1) themes associated with personal satisfaction from participation (Table 1); (2) themes associated with satisfaction with improving local (practice-level) clinical care (Table 2); and (3) themes associated with satisfaction in achieving community-oriented primary care-related activities and making health system-level changes (Table 3). Each table contains a summary of the clinician responses within the identified principal themes, the types of satisfaction related to the PBRN experience reflected on in the story, and exemplar quotes.

The motivations associated with personal satisfaction described in Table 1 reflect the basic psychological needs for competence, autonomy, and relatedness identified by the SDT.^11,12 Respondents mentioned improving their clinical skills (competence) because of PBRN participation. Others indicated a desire to improve the quality and relevance of academic research without having to work in an academic environment (autonomy). Many said the PBRNs created relationships between community clinicians and academicians that helped them withstand the challenges of day-to-day practice (relatedness).

The themes from the stories related to improving local, clinic-based care place high value on improving the quality of care for patients and improving systems of care, including enhanced information technology and patient/disease registries. The stories describe research as a tool to improve quality of care, often having benefits beyond those perceived as directly related to the study. The research studies provide access to tools, knowledge, practice change facilitators, and mentors as a benefit of participation. Changes in local clinic care are possible because the PBRN studies take into account relevance to local care, practice staffing, and workflow. Competence in chronic illness care and disease management was a common theme in this domain.

Clinicians report that the PBR studies are relevant to the health of their community, and they are developing competence in the provision of population health care. Clinicians noted that PBRNs could address the gap between academia and community practice and influence the timely delivery of health care, as in an example of flu vaccination success facilitated by PBR, as well as the delivery of health care to unique populations served by the practice, such as migrants, the elderly, and those living in more remote rural areas. PBRN studies cited in these stories reported opportunities for clinician and practice collaboration with major health plans and community health foundations. Being a part of a research community is a motivator for participation in a PBRN.

1. Meaning and Belonging to the Primary Care Profession and Culture

The stories reflect the unique path taken by these clinicians and include issues of overcoming practice isolation, straddling academia while not losing the integrity of “outside” practice, developing and maintaining critical thinking skills, staying connected to colleagues and to the salient health topics that need to be addressed to improve primary care outcomes, and membership in a stimulating learning community. The value of mentorship was frequently mentioned. It is important that PBRNs encourage clinician commitments, and additional commitments will be required from those who can provide mentorship outside of academia, where there are more established avenues. Recurrent themes that relate specifically to meaning and belonging within this group of clinicians include the family physician as a scientist; being validated, recognized, connected, and belonging; and being stimulated and energized. The family physicians who shared stories were not always able to find enough stimulation from like-minded colleagues in their local practice and community. Several physicians (Beasley, Friedler, Beaufait, and Bujold), who had a long history of PBR, noted that connecting with a PBRN provided a means to connect with other “unique” family physicians; some clinicians identified the link to academia through the PBRN as providing an important relationship that offered balance to the daily challenges of clinical practice.

2. Generating an Evidence Base for Primary Care

These clinicians placed a high value on improving the quality of care to their patients and improving systems of care, including enhanced information technology.

3. Ensuring that the Primary Care Evidence Base is Locally Relevant and Contributes to Policy and Population Health

Clinicians valued community-oriented outcomes that focus on public health, such as an increase in flu vaccination rates for the entire community, and on developing research that was responsive to the needs and concerns of the clinician's entire community and communities within communities. Story clinicians noted value in collaboration, including establishing active partnerships with major health plans and a community health foundation. One clinician noted that Centers for Medicare and Medicaid Services is interested in their disease management strategy.

Personal satisfaction motivations to participation in PBRNs, particularly those aligned with meaning and belonging to the primary care profession and culture, correspond with Deci's and Ryan's^11,12 SDT to explain how human beings become proactive and engaged. The 3 innate psychological needs of competence, autonomy, and relatedness describe the forces behind intrinsic motivation and mental health. Social contexts such as PBRNs facilitate satisfaction of these 3 needs and correlate with optimal motivation. The stories we describe include:

1. Competence: intellectual stimulation, “the physician as the critical scientist,” creating and applying a primary care evidence base, and staying up to date.

2. Autonomy: enjoyment of research without the hassle of academic work-life.

3. Relatedness: the importance and influence of mentors, belonging to a group of like-minded individuals, and social gatherings (convocations). The PBRN provides an antidote to the intellectual isolation and loneliness associated with day-to-day primary care practice.

The clinicians represented in these stories participate in PBRNs because it is interesting and satisfying and they are in control of their choices. Although there is little published work regarding motivations to participate in PBR, the factors described are similar to those in earlier reports. In a study of ASPN practices, Green et al²¹ found a desire to be a part of a group doing relevant PBR and recruitment by an esteemed individual to be the most important reasons for joining a PBRN. The interviews with 11 ASPN members emphasized the personal and professional rewards of participation.⁸ They described the value of being part of the bigger picture, enhanced academic credibility, and critical thinking and being able to contribute answers to relevant research questions. Whereas the majority of studies done in ASPN were descriptive and disease and symptom oriented, PBRNs today are most often involved in the dissemination and implementation of studies designed to enhance the delivery of preventive health services and chronic illness care. With too much work and too little time, the interest in and relevance of changing systems of care is high among family physicians. Our stories describe PBRNs as facilitators of change and show the high value these family physicians place on their relationship with the PBRN. One PBRN study identified membership in a PBRN as a determinate of staying in rural practice longer.²²

Study Limitations

We were able to recruit family physicians from only 12 networks, and these physicians probably reflect a high degree of engagement. There was considerable variation in the effort to recruit stories among the PBRN directors. There is considerable consistency among the stories we analyzed, and the themes described reflect the broader community of family physicians participating in PBR.

It is likely that these stories reflect the values of a group of individuals who have found common ground in participating in PBR. Although these stories describe unique paths, clinicians who participate in PBRNs share a number of motivational factors. It is our hope that the voices of these family physicians will influence others to participate in PBR.