Integrating the family into routine patient care: a qualitative study.

BACKGROUND: The field of family medicine has been enriched by a family-oriented approach and the inclusion of family systems concepts. Keeping the family as a central focus of care has been a fundamental commitment of family medicine. This research examines how exemplary physicians ("exemplars") integrate a family-oriented approach into the routine care of individual patients. METHODS: Four family physician exemplars were observed. A total of 16 days was spent observing the physicians; 137 physician-patient encounters were audiotaped, transcribed, and analyzed. Grounded theory was used for analysis, and a model of a family-oriented approach was developed. RESULTS: Visits were classified by the reason for visit and the intensity of family-oriented talk and actions. There was modest variation among the physicians in terms of intensity and time spent with patients. Overall, 19% of patient encounters had a high intensity of family-orientedness; 34% were of low intensity. The average time spent with patients was 13 minutes, with visits ranging from 3 to 39 minutes in length. CONCLUSIONS: Our study demonstrated that physicians integrate family systems concepts into routine individual patient care. The findings identify characteristics of the family-oriented approach and those circumstances that promote and hinder it. Family physicians can adapt specific components of the family-oriented approach into their routine individual patient care.

Differences between diabetic patients who do and do not respond to a diabetes care intervention: a qualitative analysis.

BACKGROUND AND OBJECTIVES: We designed a qualitative case study to ascertain whether attitudes and views of diabetes differ between patients with diabetes who do and do not respond well to a diabetes care intervention. METHODS: Prospective epidemiological data were used to classify and sample graduates from an outpatient diabetes care program into one of two groups: 1) positive responders (n = 18) who had a 20% or greater improvement in glycemic control 6 months after the care program and 2) negative responders (n = 16) who had less than a 20% improvement in glycemic control 6 months after the care program. We collected data using depth interviews and focus groups. Transcriptions were summarized and analyzed using an editing approach. The themes from these two groups were summarized and compared to ascertain similarities and differences in attitudes and views of diabetes. RESULTS: Four major themes emerged from the analysis. Positive and negative responders differed a) in their views of diabetes and its treatment, b) on how they incorporated diabetes care into their daily routines, c) in "conversion experiences" in which some patients became suddenly much more aware of the serious threat of diabetes to their health, and d) in their views of their medical care providers. CONCLUSIONS: The conversion experiences observed in many of these subjects are not consistent with stage-of-change models of health-related behavior change. These data advance our understanding of patients' diabetes-related attitudes and behaviors and may be used by clinicians to monitor change in patients' attitudes and expectations over time and by researchers to develop and target novel patient-centered clinical interventions to improve patient satisfaction and clinical outcomes.

Patients, family physicians, and pain: visions from interview narratives.

BACKGROUND: Family physicians reportedly underestimate their patients' pain severity. Explanations for this remain unexamined. This study explores the understanding family physicians and their patients have of the common experience of pain. METHODS: We studied six culturally homogeneous private practice family physician-patient pairs from Connecticut using a qualitative, cross-sectional long interview design. Interviews were taped in the office or home and analyzed by the research team using an editing style derived from the constant comparative method. RESULTS: The patients described pain as spiritually awakening, experienced in the body, and part of everyday life with conceptual, behavioral, functional, and spiritual dimensions. The patients all claimed that physicians don't listen. The family physicians expressed a personal understanding of pain similar to the patient and a professional one which was more biomedical, concerned about addiction, and related to control of and connection with patients. Patients and physicians described the role of the doctor as a four-stage process of listening, knowing, responding, and taking time, but they meant different things. CONCLUSIONS: This study reveals family physicians and their patients struggling to communicate about pain. The role of family physician socialization, strategies for listening and sharing power in the clinical encounter, and a new four-dimensional classification of pain are briefly discussed.