Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Learning and Caring in Communities of Practice: Using Relationships and Collective Learning to Improve Primary Care for Patients with Multimorbidity

Learning and Caring in Communities of Practice: Using Relationships and Collective Learning to... Learning and Caring in Communities of Practice: Using Relationships and Collec- tive Learning to Improve Primary Care for Patients with Multimorbidity Hassan Soubhi, MD, PhD ABSTRACT Elizabeth A. Bayliss, MD, MSPH We introduce a primary care practice model for caring for patients with mul- 1 timorbidity. Primary care for these patients requires fl exibility and ongoing Martin Fortin, MD, MSc, CMFC coordination, and it often must be tailored to individual circumstances. Such Catherine Hudon, MD, CMFC complex and fl exible care could be accomplished within communities of prac- tice, whose participants are willing to learn from their shared practice, further Marjan van den Akker, PhD each other’s goals, share their stories of success and failure, and promote the Robert Thivierge, MD continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use Nancy Posel, RN, MEd an iterative approach to care improvement that integrates what they learn and David Fleiszer, MD do collectively over time. Clinicians in these communities would defi ne common Family Medicine Unit, University of Sher- goals, cocreate care plans, and engage in refl ective case-based learning. As com- brooke, Chicoutimi, Quebec, Canada munity members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a Kaiser Permanente, Denver, Colorado mix of methods, future research should explore the conditions that are necessary University of Maastricht, Maastricht, for collective learning within communities of clinicians who care for patients with The Netherlands multimorbidity and who develop new knowledge in practice. By understand- University of Montreal, Montreal, ing these conditions, we can foster the development of collective learning and Quebec, Canada improve primary care for these patients. Faculty of Medicine, McGill University, Ann Fam Med 2010;8:170-177. doi:10.1370/afm.1056. Montreal, Quebec, Canada INTRODUCTION elivering primary care to patients with multiple morbidities is challenging. These patients typically consult multiple clinicians, Duse multiple medications, and compared with patients with a single chronic illness, have higher psychological distress, longer hospital stays, increased use of emergency facilities, and higher rates of mortal- 2-21 Clinicians who care for them face competing demands, complexities ity. of polypharmacy, diffi culties in applying practice guidelines, and increased 22,23 potential for errors. Clinicians also face increased diagnostic and treat- ment challenges as different combinations of conditions can interact in Confl icts of interest: none reported 24-26 unpredictable ways. These challenges occur in the context of com- prehensive primary care that includes preventive care, coordination of CORRESPONDING AUTHOR specialist care, and consideration of patients’ priorities in a longitudinal, 26,27 mutually trusting relationship. Hassan Soubhi, MD, PhD University of Sherbrooke These challenges are only partially addressed by accurate disease-spe- Family Medicine Unit cifi c data and clinical guidelines: the former cannot guide comprehensive 305 St-Vallier decision making that acknowledges patients’ preferences and life context, Chicoutimi while the latter are often irrelevant for patients with multimorbidity. Our Quebec, Canada G7H 5H6 [email protected] guiding premise in this article is that caring for these patients is often a ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 170 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y knowledge-intensive activity which requires amplifi ca- concern, a set of problems, or a passion about a topic, tion of existing professional know-how and insights and who deepen their knowledge and expertise by into coordinating complex assessments and continuous interacting on an ongoing basis.” Members of such interprofessional care that often goes beyond biomedi- communities develop a shared repertoire of experi- cal needs. We propose a practice model based on (1) ences, stories, tools, and ways of addressing recurring the importance of relationships among clinicians in problems that constitute the collective knowledge and delivering effective patient-centered care, and (2) the memory of the group (Figure 1). fl exibility gained in an environment of constant reas- Cultivated among primary care professionals, sessment and case-based learning. In this model, pri- these communities would provide a social context in mary care professionals form communities of practice which clinicians share clinical cases, listen, refl ect, in which they defi ne common goals, cocreate care and receive feedback on processes of care for complex 37-40 plans, and engage in refl ective case-based learning and patients. Through ongoing conversations, com- practice. To discuss the application of this model in munity members would make sense of their experi- primary care, we will (1) introduce the model, (2) pres- ences and manage their knowledge by sharing their ent relevant theoretical and empirical evidence, (3) concerns, validating their clinical practices with each propose design strategies for its implementation, (4) other, and developing new care strategies. With time, contrast its features with other models currently in use, the accumulation of experiences would increase not and (5) discuss implications for future research and pri- only the group’s explicit knowledge (written docu- mary care practice redesign. ments, standardized care plans), but also their tacit knowledge or practical know-how that emerges through refl ective practice and the collection and COMMUNITIES OF PRACTICE: AN ITERATIVE 40-42 sharing of story narratives among professionals. APPROACH TO CARE IMPROVEMENT These narratives can include opinions, success and Suppose that you are a primary care physician car- failure stories, solutions to problems, and feedback ing for a panel of 2,000 patients of whom 30% suffer about tactics and methods. When shared among dif- from multimorbidity. When you face a challenging ferent users, these narratives can stimulate further 42,43 clinical problem, you turn to a specifi c group of col- validation and learning. In this sense, the com- leagues who share your interest in the care of complex munity becomes a self-organizing and self-renewing patients. These colleagues do not necessarily share knowledge management system through which clini- 36,44,45 your practice, but are only a telephone call away, and cians can improve practice outcomes. you have known them for years. You can count on their help as they understand the Figure 1. A communal and iterative strategy of care issues you face and will explore new ideas improvement within a community of practice. with you. You regularly discuss the latest developments in chronic care and each oth- er’s practice challenges. You meet either in Sharing information person or through regular teleconferences • Queries to discuss complex cases and develop inter- Developing solutions • Data professional care plans. Your group has a • Strategies • Information coordinator who organizes your care plans, • Care plans • Expertise professional approaches, and discussions • Stories into electronic case formats (e-cases) that can be circulated among group members, Learning community comprised of a group of archived for medical students’ learning, and professionals sharing a adapted for patient use. You also have a common interest librarian or information specialist privy to the group discussions who can synthesize information from the literature to inform refl ection and decision making within your Evaluating strategies Implementing strategies 32-35 and care plans and care plans group. This kind of scenario and the learning community that emerges from it form the basis of what Wenger calls a Community of Practice: “a group of people who share a ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 171 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y Another strand of organizational theory conceives EMPIRICAL EVIDENCE AND THEORY of primary care practices as complex adaptive sys- LINKING CARE PROCESS AND tems. These systems are defi ned as a collection ‘‘of OUTCOMES TO RELATIONSHIPS AND individual agents that have the freedom to act in ways ORGANIZATIONAL LEARNING that are not always predictable and whose actions are Overall, research suggests that fostering cohesive interconnected in such a way that the action of one 63-65 relationships, teamwork, refl ective practice, and orga- part changes the context for other agents.’’ Implied nizational learning can with time improve primary care is the creation of environments that enhance relation- 36,46-49 process, outcomes, and clinicians’ adaptability. ships and provide safe venues for people to voice Investigations into relationship-centered care emphasize their ideas and try out small changes that encourage the importance of clinicians’ refl ective relationships innovation. Data from a 5-year group-randomized with patients and with each other in supporting satisfy- clinical trial using a process of refl ective adaptation ing work environments, providing high-quality care, among care participants indicate that primary care attaining goals, and achieving superior organizational practices can become more refl ective and learn from 50,51 66 performance. In primary care practices, collaborative diverse perspectives of the participants. Mindful- culture and greater team cohesion have been associ- ness, facilitative leadership, high-quality relationships, ated with improved care access and continuity, better sense making, and feedback in reciprocal interactions control of diabetes and hyperlipidemia, and increased increased capacity for collective problem solving, as patient satisfaction. Improved primary care team well as personalized approaches to practice change, all effectiveness has also been related to strong leadership, of which support improvement and sustainable deliv- 67-70 clear goals, selection of skilled and motivated team ery of preventive services. 53,54 members, and regular feedback on team’s progress. The organizational context of professional practice DESIGN STRATEGIES FOR COMMUNITIES can also affect care process and outcomes. Several OF PRACTICE IN PRIMARY CARE strands of organizational theory conceive of health 36,37,55-58 care organizations as learning systems. Learning A community of practice fosters a social context for organizations focus on collective learning: acquiring the learning among clinicians who face a common chal- knowledge and skills necessary for participants to work lenge and who collaborate over an extended period to together to achieve a common task. Learning organiza- share ideas, nurture relationships, and develop solu- tions foster open communication and trust among par- tions and innovations based on what they learn and 42,43 ticipants, encourage measured risk, and recognize tacit do collectively. Although what the participants 36,59 knowledge as an important source of learning. learn and do cannot be predicted, the context of their Preliminary evidence suggests that collective learn- practice can be designed with strategies that support ing can improve collaboration, job satisfaction, employee diverse participants and enhance collective learn- 40,55 retention, organizational effi ciency, innovation, and cus- ing. Two of these strategies have a basis in human 44,48 tomer satisfaction. Collective learning among physi- ecology: designing for community, and designing for cians has been linked to long-term small-group learning emergent learning and practice. The fi rst harnesses in which adult learners use their tacit knowledge—their the potential of relationships; the second focuses on personal, social, and professional experiences—in the collective learning over time. learning process. Journal clubs and Balint groups are 2 examples in which the use of narratives as learning tools Designing for Community can support the creation of collegial networks, increased Designing for community implies that primary care 60,61 self-effi cacy, and practice change. An ethnographic professionals cultivate cohesive relationships through study suggests that primary care clinicians rarely access regular contacts, defi nition of common goals, and 36,40,66 and use explicit evidence from research directly; rather, Such relationships recognition of shared skills. they rely on “mindlines,” defi ned as collectively rein- evolve best from small groups who build trust and forced, internalized, tacit guidelines. Mindlines are cohesiveness by identifying their joint interests in informed mainly by brief reading, personal experience, patients’ care and regular discussion of cases. These interactions with peers, opinion leaders, pharmaceuti- initial communities may then expand to include other 36,42 cal representatives, patients, and other sources of tacit members. The composition of a community would knowledge. In the study, mindlines were iteratively be guided by the type of knowledge required to negotiated through informal interactions in fl uid com- accomplish tasks. Thus communities that focus on the munities of practice, resulting in socially constructed care of patients with multimorbidity might consist of “knowledge in practice.” physicians in conjunction with a nurse care coordina- ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 172 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y tor and other professionals (eg, home care manager, With the assistance of a community coordina- pharmacist) who can contribute strategic perspectives tor (eg, nurse practitioner), the community uses the to alleviate care fragmentation. Communities can also e-case as a tool to facilitate refl ective practice, help cross organizational boundaries to include profession- develop a common language among the participants, als outside primary care practice. and encourage active participation by the patient and family. When relevant, an information special- Designing for Emergent Learning and Practice ist can help members access the literature to identify Clinical practice is an evolutionary process in which gaps in knowledge, overlaps and redundancies in care only effective solutions can thrive under the con- strategies, and specifi c roles for community members. straints of cost, effi ciency, and other human and These collaborative processes facilitate the transition 63,71-73 organizational factors. The content of what com- from uniprofessional care plans into interprofessional munity members learn results from their ongoing con- care plans and foster an iterative learning process that versations and interactions with their environments. combines structure with renewed improvisations in In this evolutionary process, successful solutions are the face of uncertainty, uniqueness, and confl icting 30,40,43,49,55,58,63,75-77 likely to emerge as members adopt the best solutions values. Given the potential for group through imitation of successful members or through case-based learning, refl ective practice sessions could an informed process of learning, experimentation, and be fi lmed for further review and improvements, as well continual trial of new and varied solutions. To design as a basis for student learning. for emergent learning means to provide an adaptive context that supports this kind of learning. ALTERNATIVE MODELS OF COMPLEX Two components of the social context of a commu- CARE DELIVERY nity of practice are essential for an effective design: the relationships among members and the various products Alternative models of primary care delivery for patients they develop and share—assessment tools, care plans, with multimorbidity have been proposed, most notably e-cases, reminders, fl owcharts, follow-up sheets, etc. the Guided Care Model (GCM), an expanded case In a sense, these artifacts help create order out of free- management model for elderly patients based on inno- 78-81 fl oating brainpower of the participants; they give form vations from the Chronic Care Model (CCM). Our to the group’s experience and provide a basis for con- model is similar to the GCM in that it may include a 55,74 tinual learning and experimentation. For example, nurse practitioner as coordinator and use the e-case in our preceding scenario, the community uses patients’ as a case management tool. It differs, however, from clinical cases to recruit and align the skills and exper- the GCM in its emphasis on knowledge management, tise of multiple professionals. When systematized, case-based learning, and the informal ties and shared such cases and the practice experience that derives motivation that bind community members together. from them are reifi ed into interactive Web-based ver- Our model also expands on the CCM to detail pos- sions, or e-cases, to support active participation in a sible contents of the “prepared proactive practice team” virtual environment and promote learning within inter- and the relationship of this team with the “informed, 30 80,82 professional teams. activated patient.” Figure 2 illustrates how an e-case As they facilitate knowledge could be developed and used by community members. management, communities of practice can improve on Figure 2. Meeting the challenge of interprofessional care through case-based refl ective learning in communities of practice. Initial Evaluation of Clinical Case Group Discussion and Refl ec- Follow-Up and Evaluation During the Visit tive Learning Initiate care plan and follow-up Physician and/or community coordi- Review of care plan to identify Measure outcomes and assess nator defi ne care goals and priori- gaps in information and evi- effi cacy ties in concert with the patient dence-based knowledge as Evaluate patient and profes- well as redundancies Coordinator create working list of sional progress colleagues and professionals to Formalize plan including defi n- Archive e-case and care plan for be involved in care ing expected processes, data patient and student learning collection, and outcomes Inclusion of initial uniprofessional and education assessments and care plan in Assign roles and responsibilities e-case to generate a blueprint Share plan with patient of interprofessional care plan th Adapted with permission from Posel N, Fleiszer D, Faremo S. Moving toward the development of interprofessional e-cases. Slice of Life Conference, 18 International Meeting for Medical Multimedia Developers and Educators. University of Lausanne, Lausanne, Switzerland, July 4-8, 2006. ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 173 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y CCM systems of decision support and clinical infor- that can contribute to collective learning by bridging mation. Their productive interactions with complex the gap between knowing and doing that many health patients would result not only from improved coor- care organizations still experience despite improve- dination and information technology, but also from ments in information technology. improved development, harvesting, and use of both explicit and tacit knowledge. RESEARCH IMPLICATIONS Communities of practice also differ from traditional practice teams. Learners in these communities form The preceding discussion provides theoretical and naturally occurring clinical groups that are defi ned by empirical grounding for the hypothesis that relation- knowledge rather than task. These groups exist not ships and collective learning within communities of because of an institutional mandate but because par- practice can improve primary care for patients with ticipation has value to its members. Such groups are multimorbidity. Future research should explore why likely to persist longer than teams formed for specifi c and how collective learning in naturally occurring tasks. In the traditional practice team, members may communities of practice varies with time. Primary not know each other, and physicians may not have care, similar to other practice settings, involves situ- time for team development. Communities of prac- ations where effective care strategies continue to be tice integrate teamwork into the group process and used and ineffective ones are weeded out. This process may mitigate these diffi culties. They tend to be self- draws attention to the selection process involved in organized, self-motivated, and self-renewing precisely the collective “sense making,” by which knowledge and because their members agree of their own accord to meanings are negotiated among professionals and sub- participate in an activity with a common purpose and sequently standardized in practice. Investigation of this value for group members and patients. As Hildreth process would help discover the conditions that are and Kimble state it, “members of a community of prac- necessary for collective learning to emerge. Appropri- tice have more in common with a troupe of altruistic ate actions would then help foster the development of volunteers than a band of paid employees.” Learning collective learning in primary care practice. in this context is less about absorbing information than Research would typically ask such questions as, becoming part of a community; what holds members under what conditions would primary care practitio- together are a common sense of purpose and account- ners cooperate, cultivate communities of practice to 85,86 ability and a need to know what each other knows. solve patients’ problems collaboratively, and develop Finally, communities of practice have similarities knowledge in practice? Current research suggests that with clinical microsystems, a quality improvement con- such collective learning occurs through the develop- 74,87 cept. Clinical microsystems are the small systems ment of trust and effective communication that enables (human, technological, fi nancial resources) that form participants to recognize their interdependencies, share around the patient to provide care for variable periods common understandings, and subsequently empower 74 51,66 as patient’s needs evolve. Like communities of prac- the group to address a range of patient care issues. tice, clinical microsystems involve understanding what An alternative hypothesis is that this kind of learn- group members do to be able to identify specifi c areas ing may be linked to effective sharing and use of tacit for improvement. Clinical microsystems also integrate knowledge that are facilitated by working together over learning and practice through group members’ com- time. Studies on the evolution of cooperation among mitment to refl ection on work and learning and to con- people who pursue their self-interest suggest that the tinual care design. foundation of cooperation is less about trust, than the Unlike clinical microsystems, however, commu- In primary care, team durability of the relationship. nities of practice are founded on the premise that tenure—defi ned as the number of years that physicians learning is about social participation and the human in a primary care site had worked with one another— connection of groups of people facing similar chal- and shared responsibility for a panel of patients have lenges—the relationship ties among community been associated with improved cancer screening and members drive the learning. In addition, our model diabetes management. Team tenure has also been asso- 83,89 incorporates the use of relevant literature. Whereas ciated with patient satisfaction. improved access to the literature helps integrate exter- Investigating these learning processes will likely nal inputs of knowledge (explicit knowledge), the require a mix of qualitative and quantitative methods. e-case, coupled with regular refl ective sessions, helps Longitudinal approaches would help account for the clarify and integrate internal inputs from participants’ complex dynamics of ongoing human relationships practical know-how (tacit knowledge). As such, com- and knowledge exchange. Detailed observations may munities of practice represent key relational structures explore the ways in which clinicians derive and use ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 174 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y their knowledge in practice. For example, investiga- ing alternative care strategies, and accomplishing tasks 29,40,43 tions could examine how primary care physicians by iterative exploration. Testing the added value develop mindlines and how they test them to eliminate of communities of practice in primary care remains an harmful ones and standardize others into routine prac- empirical issue worth exploring in future research. tice. Studying multiple and diversifi ed primary care To read or post commentaries in response to this article, see it settings would also help explore what actually works online at http://www.annfammed.org/cgi/content/full/8/2/170. best in a variegated environment to better understand which kind of mindlines are likely to fl ourish for which Key words: Primary health care; multimorbidity; community of practice; kind of patients with multimorbidity. Repeated obser- interprofessional practice; collective learning; complex adaptive systems vations would be useful to track cumulative learning Submitted November 11, 2008; submitted, revised, June 19, 2009; and specifi c outcomes for particular profi les of multi- accepted July 23, 2009. morbidity. Further, experimental evidence should also be sought for improved care processes and patient outcomes by comparing communities of practice with References usual practice teams, and by investigating the added 1. Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M. Multi- value of an information specialist in the community in morbidity’s many challenges. BMJ. 2007;334(7602):1016-1017. terms of improved decision making and the integration 2. Bodenheimer T. Disease management—promises and pitfalls. N Engl J Med. 1999;340(15):1202-1205. of research-based knowledge into practice. 3. Wright N, Smeeth L, Heath I. Moving beyond single and dual diagnosis in general practice: many patients have multiple morbidi- Implications for Primary Care Practice Redesign ties, and their needs have to be addressed. BMJ. 2003;326(7388): Redesigning practices based on a community of prac- 512-514. tice model will require the following components: max- 4. Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medica- imizing the allocation of clinical responsibility based tion use in the community-dwelling elderly: fi ndings from the 1996 Medical Expenditure Panel Survey. JAMA. 2001;286(22):2823-2829. on clinicians’ knowledge base and training; senior lead- 5. Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions ers’ supporting community development and iterative of barriers to self-care by persons with comorbid chronic diseases. change; and inviting experimentation with different Ann Fam Med. 2003;1(1):15-21. payment models. Some of these changes are already 6. Hansagi H, Olsson M, Sjöberg S, Tomson Y, Göransson S. Frequent underway in many practices, with the increasing incor- use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med. 2001;37(6):561-567. poration of midlevel clinicians and use of small cycles 74,83 of practice change. 7. Moroney JT, Tseng CL, Paik MC, Mohr JP, Desmond DW. Treatment for the secondary prevention of stroke in older patients: the infl u- In the proposed model, clinicians at all levels would ence of dementia status. J Am Geriatr Soc. 1999;47(7):824-829. form communities that address recurring sets of prob- 8. Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Stange KC. Conti- lems together; specifi cally, clinicians caring for more nuity of primary care: to whom does it matter and when? Ann Fam complex patients may have increased time available Med. 2003;1(3):149-155. to devote to their communities of practice. Because 9. Starfi eld B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner JP. Comorbidity: implications for the importance of primary care in these communities are built on voluntary networks of ‘case’ management. Ann Fam Med. 2003;1(1):8-14. interest, they should, with support from senior leaders, 10. Flocke SA, Frank SH, Wenger DA. Addressing multiple problems in continually generate value and renewed excitement the family practice offi ce visit. J Fam Pract. 2001;50(3):211-216. about collective learning to attract and engage mem- 11. Fortin M, Bravo G, Hudon C, et al. Relationship between multimor- bers. Critical assessment of cost-related outcomes bidity and health-related quality of life of patients in primary care. would be particularly important to insure maintenance Qual Life Res. 2006;15(1):83-91. of redesigned practices. To accelerate collective learn- 12. Fortin M, Lapointe L, Hudon C, Vanasse A, Ntetu AL, Maltais D. Multimorbidity and quality of life in primary care: a systematic ing and the evolution of practices, there is a need for review. Health Qual Life Outcomes. 2004;2:51. appropriate feedback mechanisms related to different 13. Fortin M, Bravo G, Hudon C, Lapointe L, Dubois MF, Almirall J. payment modalities, eg, pay for performance, payment Psychological distress and multimorbidity in primary care. Ann Fam for complex patients’ visits, care-coordination fees, and Med. 2006;4(5):417-422. various incentives for knowledge production and shar- 14. West DW, Satariano WA, Ragland DR, Hiatt RA. Comorbidity and ing within and between primary care practices. breast cancer survival: a comparison between black and white women. Ann Epidemiol. 1996;6(5):413-419. Caring for patients with multimorbidity invites 15. Extermann M. Measurement and impact of comorbidity in older improvements on existing care models based on ongoing cancer patients. Crit Rev Oncol Hematol. 2000;35(3):181-200. learning and continual evaluation. Self-organized com- 16. Incalzi RA, Capparella O, Gemma A, et al. The interaction between munities of practice illustrate 1 possible model. Clini- age and comorbidity contributes to predicting the mortal- cians in these communities would improve patient care ity of geriatric patients in the acute-care hospital. J Intern Med. by building relationships, refl ecting on practice, select- 1997;242(4):291-298. ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 175 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y 17. Poses RM, McClish DK, Smith WR, Bekes C, Scott WE. Prediction 40. Soubhi H. Toward an ecosystemic approach to chronic care design of survival of critically ill patients by admission comorbidity. J Clin and practice in primary care. Ann Fam Med. 2007;5(3):263-269. Epidemiol. 1996;49(7):743-747. 41. Lockyer J, Gondocz ST, Thivierge RL. Knowledge translation: the 18. Librero J, Peiró S, Ordiñana R. Chronic comorbidity and outcomes role and place of practice refl ection. J Contin Educ Health Prof. 2004; of hospital care: length of stay, mortality, and readmission at 30 24(1):50-56. and 365 days. J Clin Epidemiol. 1999;52(3):171-179. 42. Donaldson A, Lank E, Maher J. Making the invisible visible: how a voluntary organization is learning from its work with groups and 19. Rochon PA, Katz JN, Morrow LA, et al. Comorbid illness is associ- communities. J Change Manag. 2005;5(2):191-206. ated with survival and length of hospital stay in patients with chronic disability. A prospective comparison of three comorbidity 43. Soubhi H, Colet NR, Gilbert JH, et al. Interprofessional learning indices. Med Care. 1996;34(11):1093-1101. in the trenches: fostering collective capability. J Interprof Care. 2009;23(1):52-57. 20. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard 44. Hildreth P, Kimble C. Knowledge Networks: Innovation Through Com- Medical Practice Study I. N Engl J Med. 1991;324(6):370-376. munities of Practice. London, UK: Idea Group Publishing; 2004. 21. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Hamil- 45. St-Onge H, Wallace D. Leveraging Communities of Practice For Strate- ton JD. The Quality in Australian Health Care Study. Med J Aust. gic Advantage. Boston, MA: Butterworth-Heinemann; 2003. 1995;163(9):458-471. 46. Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a 22. Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology set of hospitals known for good nursing care. Med Care. 1994; of medical error. BMJ. 2000;320(7237):774-777. 32(8):771-787. 47. Shortell SM, Jones RH, Rademaker AW, et al. Assessing the impact 23. Bar-Yam Y. System Care: Multiscale Analysis of Medical Errors - Elimi- of total quality management and organizational culture on multiple nating Errors and Improving Organizational Capabilities. NECSI Technical outcomes of care for coronary artery bypass graft surgery patients. Report 2004-09-01. New England Complex Systems Institute; 2004. Med Care. 2000;38(2):207-217. 24. Rolland JS. Toward a psychosocial typology of chronic and life- 48. Senge P. The Fifth Discipline: The Art & Practice of the Learning Orga- threatening illness. Fam Syst Med. 1984;2(3):245-262. nization. New York, NY: Currency Doubleday; 1990. 25. Katerndahl DA. Is your practice really that predictable? Nonlinear- 49. Schön D. The Refl ective Practitioner. How Professionals Think in Action. ity principles in family medicine. J Fam Pract. 2005;54(11):970-977. London: Temple Smith; 1983. 26. Star fi eld B, Shi L, Macinko J. Contribution of primary care to health 50. Safran DG, Miller W, Beckman H. Organizational dimensions of systems and health. Milbank Q. 2005;83(3):457-502. relationship-centered care. Theory, evidence, and practice. J Gen 27. World Health Organization. World Health Report 2008—Primary Intern Med. 2006;21(Suppl 1):S9-S15. Health Care: Now More Than Ever. Geneva: WHO; 2008. 51. Hoff T. The Power of Frontline Workers in Transforming Organizations. 28. Van Spall HGC, Toren A, Kiss A, Fowler RA. Eligibility criteria of New York, NY: The Upstate New York Veterans Health Administra- randomized controlled trials published in high-impact general med- tion: IBM Center for Healthcare Management; 2003. ical journals: a systematic sampling review. JAMA. 2007;297(11): 52. Cohen JE, Hann M, Hacker J. Universities and tobacco money. BMJ. 1233-1240. 2001;323(7303):1-2. 29. Fraser SW, Greenhalgh T. Coping with complexity: educating for 53. Ross F, Rink E, Furne A. Integration or pragmatic coalition? An capability. BMJ. 2001;323(7316):799-803. evaluation of nursing teams in primary care. J Interprof Care. 2000;14(3):259-267. 30. Posel N, Fleiszer D, Wiseman J, et al. Using electronic cases to teach healthcare professionals and students about interprofessional- 54. Borrill CS, Carletta J, Carter AJ, et a. The Effectiveness of Health Care ism. J Interprof Care. 2008;22(1):111-114. Teams in the National Health Service. Birmingham, UK: Ashton Centre for Health Service Organization Research; 2001. 31. Davidoff F, Florance V. The informationist: a new health profession? [editorial]. Ann Intern Med. 2000;132(12):996-998. 55. Wenger E. Communities of Practice: Learning, Meaning, and Identity. New York, NY: Cambridge University Press; 1998. 32. Lamb G. A decade of clinical librarianship. Clin Lib Q. 1982;1(1):2-4. 56. Miller DR. The architecture of simplicity. Acad Manage Rev. 1993; 33. Scura G, Davidoff F. Case-related use of the medical literature. Clini- 18(1):116-138. cal librarian services for improving patient care. JAMA. 1981;245(1): 50-52. 57. Smith EA. Communities of competence: new resources in the work- place. J Workplace Learn. 2005;17(1/2):7-23. 34. Marshall JC. The impact of the hospital library on clinical decision 58. Smith R. Towards a knowledge based health service. BMJ. 1994; making: the Rochester study. Bull Med Libr Assoc. 1992;80(2): 309(6949):217-218. 169-178. 59. Gee JP. Communities of practice in the new capitalism. J Learn Sci. 35. Veenstra RJ. Clinical medical librarian impact on patient care: 2000;9(4):515-523. a one-year analysis. Bull Med Libr Assoc. 1992;80(1):19-22. 60. Pereles L, Lockyer J, Fidler H. Permanent small groups: group 36. Wenger E, McDermott R, Snyder WM. Cultivating Communities of dynamics, learning, and change. J Contin Educ Health Prof. 2002; Practice: A Guide to Managing Knowledge. Boston, MA: Harvard Busi- 22(4):205-213. ness School Press; 2002. 61. Rabin S, Maoz B, Elata-Alster G. Doctors’ narratives in Balint 37. Bohmer RMJ, Edmondson AC. Organizational learning in health groups. Br J Med Psychol. 1999;72(Pt 1):121-125. care. Health Forum J. 2001;44(2):32-35. 62. Gabbay J, le May A. Evidence based guidelines or collectively con- 38. Parboosingh JT. Physician communities of practice: where learning structed “mindlines?” Ethnographic study of knowledge manage- and practice are inseparable. J Contin Educ Health Prof. 2002;22(4): ment in primary care. BMJ. 2004;329(7473):1013. 230-236. 63. Plsek PE, Greenhalgh T. Complexity science: The challenge of com- 39. Schon D. Teaching artistry through refl ection-in-action. In: Tsoukas plexity in health care. BMJ. 2001;323(7313):625-628. H, ed. New Thinking in Organizational Behaviour: From Social Engineer- ing to Refl ective Action. Oxford, England: Butterworth-Heinemann 64. Wilson T, Holt T, Greenhalgh T. Complexity science: complexity and Ltd; 1994:1-22. clinical care. BMJ. 2001;323(7314):685-688. ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 176 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y 65. Plsek PE, Wilson T. Complexity, leadership, and management in 78. Boult C, Karm L, Groves C. Improving chronic care: the guided care healthcare organisations. BMJ. 2001;323(7315):746-749. model. Permanente J. 2008;12(1):50-54. 66. Stroebel CK, McDaniel RRJ, Crabtree B, Miller W, Nutting PA, 79. Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of Stange KC. How complexity science can inform a refl ective process leading chronic disease management programs: are they consistent for improvement in primary care practices. Jt Comm J Qual Saf. with the literature? Manag Care Q. 1999;7(3):56-66. 2005;31:438-446. 80. Wagner EH, Austin BT, Von Korff M. Organizing care for patients 67. Miller WL, McDaniel RRJ Jr, Crabtree BF, Stange KC. Practice jazz: with chronic illness. Milbank Q. 1996;74(4):511-544. understanding variation in family practices using complexity sci- 81. Dorr DA, Wilcox A, Burns L, Brunker CP, Narus SP, Clayton PD. ence. J Fam Pract. 2001;50(10):872-878. Implementing a multidisease chronic care model in primary care 68. Scott J, Tallia A, Crosson JC, et al. Social network analysis as an using people and technology. Dis Manag. 2006;9(1):1-15. analytic tool for interaction patterns in primary care practices. Ann 82. Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collabor- Fam Med. 2005;3(5):443-448. ative management of chronic illness. Ann Intern Med. 1997;127(12): 69. Goodwin MA, Zyzanski SJ, Zronek S, et al; The Study to Enhance 1097-1102. Prevention by Understanding Practice (STEP-UP). A clinical trial of 83. Bodenheimer T, Grumbach K. Improving Primary Care. Strategies and tailored offi ce systems for preventive service delivery. Am J Prev Tools for a Better Practice. New York, NY: McGraw-Hill Companies, Med. 2001;21(1):20-28. Inc; 2007. 70. Cohen D, McDaniel RRJ Jr, Crabtree BF, et al. A practice change 84. Lave J, Wenger E. Situated Learning. Legitimate Peripheral Participa- model for quality improvement in primary care practice. J Healthc tion. Cambridge: University of Cambridge Press; 1991. Manag. 2004;49(3):155-168, discussion 169-170. 85. Kimble C, Hildreth P. Communities of Practice: Going One Step Too 71. Bar-Yam Y. Making Things Work. Solving Complex Problems in a Com- Far? Proceedings 9e colloque de l’AIM. Evry, France; 2004. plex World. Brookline, MA: NESCSI, Knowlege Press; 2004. 86. Brown S, Gray S. The people are the company. Fast Company. 1995; 72. Axelrod R, Cohen MD. Harnessing Complexity. Organizational Implica- 1. http://www.fastcompany.com/magazine/01/people.html?page= tions of a Scientifi c Frontier. New York, NY: Basic Books; 2000. 0%2C0. 73. Axelrod R. The Evolution of Cooperation. New York, NY: Basic Books; 87. Committee on Quality of Health Care in America. Institute of Medi- cine. Crossing the Quality Chasm: A New Health System for the 21st 74. Nelson EC, Batalden PB, Godfrey MM. Quality By Design: A Micro- Century. Washington, DC: National Academy Press; 2001. systems Approach. San Francisco, CA: Jossey-Bass; 2007. 88. McGlynn EA, Asch SM, Adams J, et al. The quality of health care 75. Shaughnessy AF, Slawson DC, Becker L. Clinical jazz: harmoniz- delivered to adults in the United States. N Engl J Med. 2003;348 ing clinical experience and evidence-based medicine. J Fam Pract. (26):2635-2645. 1998;47(6):425-428. 89. Parkerton PH, Smith DG, Straley HL. Primary care practice coordi- 76. Kolb DA. Experiential Learning: Experience as the Source of Learning nation versus physician continuity. Fam Med. 2004;36(1):15-21. and Development. Englewood Cliffs, NJ: Prentice-Hall; 1984. 90. Kernick D, Stead J, Dixon M. Moving the research agenda to where 77. Haidet P. Jazz and the ‘art’ of medicine: improvisation in the medi- it matters. BMJ. 1999;319(7204):206-207. cal encounter. Ann Fam Med. 2007;5(2):164-169. ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Annals of Family Medicine Unpaywall

Learning and Caring in Communities of Practice: Using Relationships and Collective Learning to Improve Primary Care for Patients with Multimorbidity

Download PDF
8 pages

Loading next page...
 
/lp/unpaywall/learning-and-caring-in-communities-of-practice-using-relationships-and-GgwyN0mcRE

References

References for this paper are not available at this time. We will be adding them shortly, thank you for your patience.

Publisher
Unpaywall
ISSN
1544-1709
DOI
10.1370/afm.1056
Publisher site
See Article on Publisher Site

Abstract

Learning and Caring in Communities of Practice: Using Relationships and Collec- tive Learning to Improve Primary Care for Patients with Multimorbidity Hassan Soubhi, MD, PhD ABSTRACT Elizabeth A. Bayliss, MD, MSPH We introduce a primary care practice model for caring for patients with mul- 1 timorbidity. Primary care for these patients requires fl exibility and ongoing Martin Fortin, MD, MSc, CMFC coordination, and it often must be tailored to individual circumstances. Such Catherine Hudon, MD, CMFC complex and fl exible care could be accomplished within communities of prac- tice, whose participants are willing to learn from their shared practice, further Marjan van den Akker, PhD each other’s goals, share their stories of success and failure, and promote the Robert Thivierge, MD continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use Nancy Posel, RN, MEd an iterative approach to care improvement that integrates what they learn and David Fleiszer, MD do collectively over time. Clinicians in these communities would defi ne common Family Medicine Unit, University of Sher- goals, cocreate care plans, and engage in refl ective case-based learning. As com- brooke, Chicoutimi, Quebec, Canada munity members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a Kaiser Permanente, Denver, Colorado mix of methods, future research should explore the conditions that are necessary University of Maastricht, Maastricht, for collective learning within communities of clinicians who care for patients with The Netherlands multimorbidity and who develop new knowledge in practice. By understand- University of Montreal, Montreal, ing these conditions, we can foster the development of collective learning and Quebec, Canada improve primary care for these patients. Faculty of Medicine, McGill University, Ann Fam Med 2010;8:170-177. doi:10.1370/afm.1056. Montreal, Quebec, Canada INTRODUCTION elivering primary care to patients with multiple morbidities is challenging. These patients typically consult multiple clinicians, Duse multiple medications, and compared with patients with a single chronic illness, have higher psychological distress, longer hospital stays, increased use of emergency facilities, and higher rates of mortal- 2-21 Clinicians who care for them face competing demands, complexities ity. of polypharmacy, diffi culties in applying practice guidelines, and increased 22,23 potential for errors. Clinicians also face increased diagnostic and treat- ment challenges as different combinations of conditions can interact in Confl icts of interest: none reported 24-26 unpredictable ways. These challenges occur in the context of com- prehensive primary care that includes preventive care, coordination of CORRESPONDING AUTHOR specialist care, and consideration of patients’ priorities in a longitudinal, 26,27 mutually trusting relationship. Hassan Soubhi, MD, PhD University of Sherbrooke These challenges are only partially addressed by accurate disease-spe- Family Medicine Unit cifi c data and clinical guidelines: the former cannot guide comprehensive 305 St-Vallier decision making that acknowledges patients’ preferences and life context, Chicoutimi while the latter are often irrelevant for patients with multimorbidity. Our Quebec, Canada G7H 5H6 [email protected] guiding premise in this article is that caring for these patients is often a ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 170 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y knowledge-intensive activity which requires amplifi ca- concern, a set of problems, or a passion about a topic, tion of existing professional know-how and insights and who deepen their knowledge and expertise by into coordinating complex assessments and continuous interacting on an ongoing basis.” Members of such interprofessional care that often goes beyond biomedi- communities develop a shared repertoire of experi- cal needs. We propose a practice model based on (1) ences, stories, tools, and ways of addressing recurring the importance of relationships among clinicians in problems that constitute the collective knowledge and delivering effective patient-centered care, and (2) the memory of the group (Figure 1). fl exibility gained in an environment of constant reas- Cultivated among primary care professionals, sessment and case-based learning. In this model, pri- these communities would provide a social context in mary care professionals form communities of practice which clinicians share clinical cases, listen, refl ect, in which they defi ne common goals, cocreate care and receive feedback on processes of care for complex 37-40 plans, and engage in refl ective case-based learning and patients. Through ongoing conversations, com- practice. To discuss the application of this model in munity members would make sense of their experi- primary care, we will (1) introduce the model, (2) pres- ences and manage their knowledge by sharing their ent relevant theoretical and empirical evidence, (3) concerns, validating their clinical practices with each propose design strategies for its implementation, (4) other, and developing new care strategies. With time, contrast its features with other models currently in use, the accumulation of experiences would increase not and (5) discuss implications for future research and pri- only the group’s explicit knowledge (written docu- mary care practice redesign. ments, standardized care plans), but also their tacit knowledge or practical know-how that emerges through refl ective practice and the collection and COMMUNITIES OF PRACTICE: AN ITERATIVE 40-42 sharing of story narratives among professionals. APPROACH TO CARE IMPROVEMENT These narratives can include opinions, success and Suppose that you are a primary care physician car- failure stories, solutions to problems, and feedback ing for a panel of 2,000 patients of whom 30% suffer about tactics and methods. When shared among dif- from multimorbidity. When you face a challenging ferent users, these narratives can stimulate further 42,43 clinical problem, you turn to a specifi c group of col- validation and learning. In this sense, the com- leagues who share your interest in the care of complex munity becomes a self-organizing and self-renewing patients. These colleagues do not necessarily share knowledge management system through which clini- 36,44,45 your practice, but are only a telephone call away, and cians can improve practice outcomes. you have known them for years. You can count on their help as they understand the Figure 1. A communal and iterative strategy of care issues you face and will explore new ideas improvement within a community of practice. with you. You regularly discuss the latest developments in chronic care and each oth- er’s practice challenges. You meet either in Sharing information person or through regular teleconferences • Queries to discuss complex cases and develop inter- Developing solutions • Data professional care plans. Your group has a • Strategies • Information coordinator who organizes your care plans, • Care plans • Expertise professional approaches, and discussions • Stories into electronic case formats (e-cases) that can be circulated among group members, Learning community comprised of a group of archived for medical students’ learning, and professionals sharing a adapted for patient use. You also have a common interest librarian or information specialist privy to the group discussions who can synthesize information from the literature to inform refl ection and decision making within your Evaluating strategies Implementing strategies 32-35 and care plans and care plans group. This kind of scenario and the learning community that emerges from it form the basis of what Wenger calls a Community of Practice: “a group of people who share a ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 171 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y Another strand of organizational theory conceives EMPIRICAL EVIDENCE AND THEORY of primary care practices as complex adaptive sys- LINKING CARE PROCESS AND tems. These systems are defi ned as a collection ‘‘of OUTCOMES TO RELATIONSHIPS AND individual agents that have the freedom to act in ways ORGANIZATIONAL LEARNING that are not always predictable and whose actions are Overall, research suggests that fostering cohesive interconnected in such a way that the action of one 63-65 relationships, teamwork, refl ective practice, and orga- part changes the context for other agents.’’ Implied nizational learning can with time improve primary care is the creation of environments that enhance relation- 36,46-49 process, outcomes, and clinicians’ adaptability. ships and provide safe venues for people to voice Investigations into relationship-centered care emphasize their ideas and try out small changes that encourage the importance of clinicians’ refl ective relationships innovation. Data from a 5-year group-randomized with patients and with each other in supporting satisfy- clinical trial using a process of refl ective adaptation ing work environments, providing high-quality care, among care participants indicate that primary care attaining goals, and achieving superior organizational practices can become more refl ective and learn from 50,51 66 performance. In primary care practices, collaborative diverse perspectives of the participants. Mindful- culture and greater team cohesion have been associ- ness, facilitative leadership, high-quality relationships, ated with improved care access and continuity, better sense making, and feedback in reciprocal interactions control of diabetes and hyperlipidemia, and increased increased capacity for collective problem solving, as patient satisfaction. Improved primary care team well as personalized approaches to practice change, all effectiveness has also been related to strong leadership, of which support improvement and sustainable deliv- 67-70 clear goals, selection of skilled and motivated team ery of preventive services. 53,54 members, and regular feedback on team’s progress. The organizational context of professional practice DESIGN STRATEGIES FOR COMMUNITIES can also affect care process and outcomes. Several OF PRACTICE IN PRIMARY CARE strands of organizational theory conceive of health 36,37,55-58 care organizations as learning systems. Learning A community of practice fosters a social context for organizations focus on collective learning: acquiring the learning among clinicians who face a common chal- knowledge and skills necessary for participants to work lenge and who collaborate over an extended period to together to achieve a common task. Learning organiza- share ideas, nurture relationships, and develop solu- tions foster open communication and trust among par- tions and innovations based on what they learn and 42,43 ticipants, encourage measured risk, and recognize tacit do collectively. Although what the participants 36,59 knowledge as an important source of learning. learn and do cannot be predicted, the context of their Preliminary evidence suggests that collective learn- practice can be designed with strategies that support ing can improve collaboration, job satisfaction, employee diverse participants and enhance collective learn- 40,55 retention, organizational effi ciency, innovation, and cus- ing. Two of these strategies have a basis in human 44,48 tomer satisfaction. Collective learning among physi- ecology: designing for community, and designing for cians has been linked to long-term small-group learning emergent learning and practice. The fi rst harnesses in which adult learners use their tacit knowledge—their the potential of relationships; the second focuses on personal, social, and professional experiences—in the collective learning over time. learning process. Journal clubs and Balint groups are 2 examples in which the use of narratives as learning tools Designing for Community can support the creation of collegial networks, increased Designing for community implies that primary care 60,61 self-effi cacy, and practice change. An ethnographic professionals cultivate cohesive relationships through study suggests that primary care clinicians rarely access regular contacts, defi nition of common goals, and 36,40,66 and use explicit evidence from research directly; rather, Such relationships recognition of shared skills. they rely on “mindlines,” defi ned as collectively rein- evolve best from small groups who build trust and forced, internalized, tacit guidelines. Mindlines are cohesiveness by identifying their joint interests in informed mainly by brief reading, personal experience, patients’ care and regular discussion of cases. These interactions with peers, opinion leaders, pharmaceuti- initial communities may then expand to include other 36,42 cal representatives, patients, and other sources of tacit members. The composition of a community would knowledge. In the study, mindlines were iteratively be guided by the type of knowledge required to negotiated through informal interactions in fl uid com- accomplish tasks. Thus communities that focus on the munities of practice, resulting in socially constructed care of patients with multimorbidity might consist of “knowledge in practice.” physicians in conjunction with a nurse care coordina- ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 172 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y tor and other professionals (eg, home care manager, With the assistance of a community coordina- pharmacist) who can contribute strategic perspectives tor (eg, nurse practitioner), the community uses the to alleviate care fragmentation. Communities can also e-case as a tool to facilitate refl ective practice, help cross organizational boundaries to include profession- develop a common language among the participants, als outside primary care practice. and encourage active participation by the patient and family. When relevant, an information special- Designing for Emergent Learning and Practice ist can help members access the literature to identify Clinical practice is an evolutionary process in which gaps in knowledge, overlaps and redundancies in care only effective solutions can thrive under the con- strategies, and specifi c roles for community members. straints of cost, effi ciency, and other human and These collaborative processes facilitate the transition 63,71-73 organizational factors. The content of what com- from uniprofessional care plans into interprofessional munity members learn results from their ongoing con- care plans and foster an iterative learning process that versations and interactions with their environments. combines structure with renewed improvisations in In this evolutionary process, successful solutions are the face of uncertainty, uniqueness, and confl icting 30,40,43,49,55,58,63,75-77 likely to emerge as members adopt the best solutions values. Given the potential for group through imitation of successful members or through case-based learning, refl ective practice sessions could an informed process of learning, experimentation, and be fi lmed for further review and improvements, as well continual trial of new and varied solutions. To design as a basis for student learning. for emergent learning means to provide an adaptive context that supports this kind of learning. ALTERNATIVE MODELS OF COMPLEX Two components of the social context of a commu- CARE DELIVERY nity of practice are essential for an effective design: the relationships among members and the various products Alternative models of primary care delivery for patients they develop and share—assessment tools, care plans, with multimorbidity have been proposed, most notably e-cases, reminders, fl owcharts, follow-up sheets, etc. the Guided Care Model (GCM), an expanded case In a sense, these artifacts help create order out of free- management model for elderly patients based on inno- 78-81 fl oating brainpower of the participants; they give form vations from the Chronic Care Model (CCM). Our to the group’s experience and provide a basis for con- model is similar to the GCM in that it may include a 55,74 tinual learning and experimentation. For example, nurse practitioner as coordinator and use the e-case in our preceding scenario, the community uses patients’ as a case management tool. It differs, however, from clinical cases to recruit and align the skills and exper- the GCM in its emphasis on knowledge management, tise of multiple professionals. When systematized, case-based learning, and the informal ties and shared such cases and the practice experience that derives motivation that bind community members together. from them are reifi ed into interactive Web-based ver- Our model also expands on the CCM to detail pos- sions, or e-cases, to support active participation in a sible contents of the “prepared proactive practice team” virtual environment and promote learning within inter- and the relationship of this team with the “informed, 30 80,82 professional teams. activated patient.” Figure 2 illustrates how an e-case As they facilitate knowledge could be developed and used by community members. management, communities of practice can improve on Figure 2. Meeting the challenge of interprofessional care through case-based refl ective learning in communities of practice. Initial Evaluation of Clinical Case Group Discussion and Refl ec- Follow-Up and Evaluation During the Visit tive Learning Initiate care plan and follow-up Physician and/or community coordi- Review of care plan to identify Measure outcomes and assess nator defi ne care goals and priori- gaps in information and evi- effi cacy ties in concert with the patient dence-based knowledge as Evaluate patient and profes- well as redundancies Coordinator create working list of sional progress colleagues and professionals to Formalize plan including defi n- Archive e-case and care plan for be involved in care ing expected processes, data patient and student learning collection, and outcomes Inclusion of initial uniprofessional and education assessments and care plan in Assign roles and responsibilities e-case to generate a blueprint Share plan with patient of interprofessional care plan th Adapted with permission from Posel N, Fleiszer D, Faremo S. Moving toward the development of interprofessional e-cases. Slice of Life Conference, 18 International Meeting for Medical Multimedia Developers and Educators. University of Lausanne, Lausanne, Switzerland, July 4-8, 2006. ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 173 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y CCM systems of decision support and clinical infor- that can contribute to collective learning by bridging mation. Their productive interactions with complex the gap between knowing and doing that many health patients would result not only from improved coor- care organizations still experience despite improve- dination and information technology, but also from ments in information technology. improved development, harvesting, and use of both explicit and tacit knowledge. RESEARCH IMPLICATIONS Communities of practice also differ from traditional practice teams. Learners in these communities form The preceding discussion provides theoretical and naturally occurring clinical groups that are defi ned by empirical grounding for the hypothesis that relation- knowledge rather than task. These groups exist not ships and collective learning within communities of because of an institutional mandate but because par- practice can improve primary care for patients with ticipation has value to its members. Such groups are multimorbidity. Future research should explore why likely to persist longer than teams formed for specifi c and how collective learning in naturally occurring tasks. In the traditional practice team, members may communities of practice varies with time. Primary not know each other, and physicians may not have care, similar to other practice settings, involves situ- time for team development. Communities of prac- ations where effective care strategies continue to be tice integrate teamwork into the group process and used and ineffective ones are weeded out. This process may mitigate these diffi culties. They tend to be self- draws attention to the selection process involved in organized, self-motivated, and self-renewing precisely the collective “sense making,” by which knowledge and because their members agree of their own accord to meanings are negotiated among professionals and sub- participate in an activity with a common purpose and sequently standardized in practice. Investigation of this value for group members and patients. As Hildreth process would help discover the conditions that are and Kimble state it, “members of a community of prac- necessary for collective learning to emerge. Appropri- tice have more in common with a troupe of altruistic ate actions would then help foster the development of volunteers than a band of paid employees.” Learning collective learning in primary care practice. in this context is less about absorbing information than Research would typically ask such questions as, becoming part of a community; what holds members under what conditions would primary care practitio- together are a common sense of purpose and account- ners cooperate, cultivate communities of practice to 85,86 ability and a need to know what each other knows. solve patients’ problems collaboratively, and develop Finally, communities of practice have similarities knowledge in practice? Current research suggests that with clinical microsystems, a quality improvement con- such collective learning occurs through the develop- 74,87 cept. Clinical microsystems are the small systems ment of trust and effective communication that enables (human, technological, fi nancial resources) that form participants to recognize their interdependencies, share around the patient to provide care for variable periods common understandings, and subsequently empower 74 51,66 as patient’s needs evolve. Like communities of prac- the group to address a range of patient care issues. tice, clinical microsystems involve understanding what An alternative hypothesis is that this kind of learn- group members do to be able to identify specifi c areas ing may be linked to effective sharing and use of tacit for improvement. Clinical microsystems also integrate knowledge that are facilitated by working together over learning and practice through group members’ com- time. Studies on the evolution of cooperation among mitment to refl ection on work and learning and to con- people who pursue their self-interest suggest that the tinual care design. foundation of cooperation is less about trust, than the Unlike clinical microsystems, however, commu- In primary care, team durability of the relationship. nities of practice are founded on the premise that tenure—defi ned as the number of years that physicians learning is about social participation and the human in a primary care site had worked with one another— connection of groups of people facing similar chal- and shared responsibility for a panel of patients have lenges—the relationship ties among community been associated with improved cancer screening and members drive the learning. In addition, our model diabetes management. Team tenure has also been asso- 83,89 incorporates the use of relevant literature. Whereas ciated with patient satisfaction. improved access to the literature helps integrate exter- Investigating these learning processes will likely nal inputs of knowledge (explicit knowledge), the require a mix of qualitative and quantitative methods. e-case, coupled with regular refl ective sessions, helps Longitudinal approaches would help account for the clarify and integrate internal inputs from participants’ complex dynamics of ongoing human relationships practical know-how (tacit knowledge). As such, com- and knowledge exchange. Detailed observations may munities of practice represent key relational structures explore the ways in which clinicians derive and use ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 174 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y their knowledge in practice. For example, investiga- ing alternative care strategies, and accomplishing tasks 29,40,43 tions could examine how primary care physicians by iterative exploration. Testing the added value develop mindlines and how they test them to eliminate of communities of practice in primary care remains an harmful ones and standardize others into routine prac- empirical issue worth exploring in future research. tice. Studying multiple and diversifi ed primary care To read or post commentaries in response to this article, see it settings would also help explore what actually works online at http://www.annfammed.org/cgi/content/full/8/2/170. best in a variegated environment to better understand which kind of mindlines are likely to fl ourish for which Key words: Primary health care; multimorbidity; community of practice; kind of patients with multimorbidity. Repeated obser- interprofessional practice; collective learning; complex adaptive systems vations would be useful to track cumulative learning Submitted November 11, 2008; submitted, revised, June 19, 2009; and specifi c outcomes for particular profi les of multi- accepted July 23, 2009. morbidity. Further, experimental evidence should also be sought for improved care processes and patient outcomes by comparing communities of practice with References usual practice teams, and by investigating the added 1. Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M. Multi- value of an information specialist in the community in morbidity’s many challenges. BMJ. 2007;334(7602):1016-1017. terms of improved decision making and the integration 2. Bodenheimer T. Disease management—promises and pitfalls. N Engl J Med. 1999;340(15):1202-1205. of research-based knowledge into practice. 3. Wright N, Smeeth L, Heath I. Moving beyond single and dual diagnosis in general practice: many patients have multiple morbidi- Implications for Primary Care Practice Redesign ties, and their needs have to be addressed. BMJ. 2003;326(7388): Redesigning practices based on a community of prac- 512-514. tice model will require the following components: max- 4. Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medica- imizing the allocation of clinical responsibility based tion use in the community-dwelling elderly: fi ndings from the 1996 Medical Expenditure Panel Survey. JAMA. 2001;286(22):2823-2829. on clinicians’ knowledge base and training; senior lead- 5. Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions ers’ supporting community development and iterative of barriers to self-care by persons with comorbid chronic diseases. change; and inviting experimentation with different Ann Fam Med. 2003;1(1):15-21. payment models. Some of these changes are already 6. Hansagi H, Olsson M, Sjöberg S, Tomson Y, Göransson S. Frequent underway in many practices, with the increasing incor- use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med. 2001;37(6):561-567. poration of midlevel clinicians and use of small cycles 74,83 of practice change. 7. Moroney JT, Tseng CL, Paik MC, Mohr JP, Desmond DW. Treatment for the secondary prevention of stroke in older patients: the infl u- In the proposed model, clinicians at all levels would ence of dementia status. J Am Geriatr Soc. 1999;47(7):824-829. form communities that address recurring sets of prob- 8. Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Stange KC. Conti- lems together; specifi cally, clinicians caring for more nuity of primary care: to whom does it matter and when? Ann Fam complex patients may have increased time available Med. 2003;1(3):149-155. to devote to their communities of practice. Because 9. Starfi eld B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner JP. Comorbidity: implications for the importance of primary care in these communities are built on voluntary networks of ‘case’ management. Ann Fam Med. 2003;1(1):8-14. interest, they should, with support from senior leaders, 10. Flocke SA, Frank SH, Wenger DA. Addressing multiple problems in continually generate value and renewed excitement the family practice offi ce visit. J Fam Pract. 2001;50(3):211-216. about collective learning to attract and engage mem- 11. Fortin M, Bravo G, Hudon C, et al. Relationship between multimor- bers. Critical assessment of cost-related outcomes bidity and health-related quality of life of patients in primary care. would be particularly important to insure maintenance Qual Life Res. 2006;15(1):83-91. of redesigned practices. To accelerate collective learn- 12. Fortin M, Lapointe L, Hudon C, Vanasse A, Ntetu AL, Maltais D. Multimorbidity and quality of life in primary care: a systematic ing and the evolution of practices, there is a need for review. Health Qual Life Outcomes. 2004;2:51. appropriate feedback mechanisms related to different 13. Fortin M, Bravo G, Hudon C, Lapointe L, Dubois MF, Almirall J. payment modalities, eg, pay for performance, payment Psychological distress and multimorbidity in primary care. Ann Fam for complex patients’ visits, care-coordination fees, and Med. 2006;4(5):417-422. various incentives for knowledge production and shar- 14. West DW, Satariano WA, Ragland DR, Hiatt RA. Comorbidity and ing within and between primary care practices. breast cancer survival: a comparison between black and white women. Ann Epidemiol. 1996;6(5):413-419. Caring for patients with multimorbidity invites 15. Extermann M. Measurement and impact of comorbidity in older improvements on existing care models based on ongoing cancer patients. Crit Rev Oncol Hematol. 2000;35(3):181-200. learning and continual evaluation. Self-organized com- 16. Incalzi RA, Capparella O, Gemma A, et al. The interaction between munities of practice illustrate 1 possible model. Clini- age and comorbidity contributes to predicting the mortal- cians in these communities would improve patient care ity of geriatric patients in the acute-care hospital. J Intern Med. by building relationships, refl ecting on practice, select- 1997;242(4):291-298. ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 175 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y 17. Poses RM, McClish DK, Smith WR, Bekes C, Scott WE. Prediction 40. Soubhi H. Toward an ecosystemic approach to chronic care design of survival of critically ill patients by admission comorbidity. J Clin and practice in primary care. Ann Fam Med. 2007;5(3):263-269. Epidemiol. 1996;49(7):743-747. 41. Lockyer J, Gondocz ST, Thivierge RL. Knowledge translation: the 18. Librero J, Peiró S, Ordiñana R. Chronic comorbidity and outcomes role and place of practice refl ection. J Contin Educ Health Prof. 2004; of hospital care: length of stay, mortality, and readmission at 30 24(1):50-56. and 365 days. J Clin Epidemiol. 1999;52(3):171-179. 42. Donaldson A, Lank E, Maher J. Making the invisible visible: how a voluntary organization is learning from its work with groups and 19. Rochon PA, Katz JN, Morrow LA, et al. Comorbid illness is associ- communities. J Change Manag. 2005;5(2):191-206. ated with survival and length of hospital stay in patients with chronic disability. A prospective comparison of three comorbidity 43. Soubhi H, Colet NR, Gilbert JH, et al. Interprofessional learning indices. Med Care. 1996;34(11):1093-1101. in the trenches: fostering collective capability. J Interprof Care. 2009;23(1):52-57. 20. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard 44. Hildreth P, Kimble C. Knowledge Networks: Innovation Through Com- Medical Practice Study I. N Engl J Med. 1991;324(6):370-376. munities of Practice. London, UK: Idea Group Publishing; 2004. 21. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Hamil- 45. St-Onge H, Wallace D. Leveraging Communities of Practice For Strate- ton JD. The Quality in Australian Health Care Study. Med J Aust. gic Advantage. Boston, MA: Butterworth-Heinemann; 2003. 1995;163(9):458-471. 46. Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a 22. Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology set of hospitals known for good nursing care. Med Care. 1994; of medical error. BMJ. 2000;320(7237):774-777. 32(8):771-787. 47. Shortell SM, Jones RH, Rademaker AW, et al. Assessing the impact 23. Bar-Yam Y. System Care: Multiscale Analysis of Medical Errors - Elimi- of total quality management and organizational culture on multiple nating Errors and Improving Organizational Capabilities. NECSI Technical outcomes of care for coronary artery bypass graft surgery patients. Report 2004-09-01. New England Complex Systems Institute; 2004. Med Care. 2000;38(2):207-217. 24. Rolland JS. Toward a psychosocial typology of chronic and life- 48. Senge P. The Fifth Discipline: The Art & Practice of the Learning Orga- threatening illness. Fam Syst Med. 1984;2(3):245-262. nization. New York, NY: Currency Doubleday; 1990. 25. Katerndahl DA. Is your practice really that predictable? Nonlinear- 49. Schön D. The Refl ective Practitioner. How Professionals Think in Action. ity principles in family medicine. J Fam Pract. 2005;54(11):970-977. London: Temple Smith; 1983. 26. Star fi eld B, Shi L, Macinko J. Contribution of primary care to health 50. Safran DG, Miller W, Beckman H. Organizational dimensions of systems and health. Milbank Q. 2005;83(3):457-502. relationship-centered care. Theory, evidence, and practice. J Gen 27. World Health Organization. World Health Report 2008—Primary Intern Med. 2006;21(Suppl 1):S9-S15. Health Care: Now More Than Ever. Geneva: WHO; 2008. 51. Hoff T. The Power of Frontline Workers in Transforming Organizations. 28. Van Spall HGC, Toren A, Kiss A, Fowler RA. Eligibility criteria of New York, NY: The Upstate New York Veterans Health Administra- randomized controlled trials published in high-impact general med- tion: IBM Center for Healthcare Management; 2003. ical journals: a systematic sampling review. JAMA. 2007;297(11): 52. Cohen JE, Hann M, Hacker J. Universities and tobacco money. BMJ. 1233-1240. 2001;323(7303):1-2. 29. Fraser SW, Greenhalgh T. Coping with complexity: educating for 53. Ross F, Rink E, Furne A. Integration or pragmatic coalition? An capability. BMJ. 2001;323(7316):799-803. evaluation of nursing teams in primary care. J Interprof Care. 2000;14(3):259-267. 30. Posel N, Fleiszer D, Wiseman J, et al. Using electronic cases to teach healthcare professionals and students about interprofessional- 54. Borrill CS, Carletta J, Carter AJ, et a. The Effectiveness of Health Care ism. J Interprof Care. 2008;22(1):111-114. Teams in the National Health Service. Birmingham, UK: Ashton Centre for Health Service Organization Research; 2001. 31. Davidoff F, Florance V. The informationist: a new health profession? [editorial]. Ann Intern Med. 2000;132(12):996-998. 55. Wenger E. Communities of Practice: Learning, Meaning, and Identity. New York, NY: Cambridge University Press; 1998. 32. Lamb G. A decade of clinical librarianship. Clin Lib Q. 1982;1(1):2-4. 56. Miller DR. The architecture of simplicity. Acad Manage Rev. 1993; 33. Scura G, Davidoff F. Case-related use of the medical literature. Clini- 18(1):116-138. cal librarian services for improving patient care. JAMA. 1981;245(1): 50-52. 57. Smith EA. Communities of competence: new resources in the work- place. J Workplace Learn. 2005;17(1/2):7-23. 34. Marshall JC. The impact of the hospital library on clinical decision 58. Smith R. Towards a knowledge based health service. BMJ. 1994; making: the Rochester study. Bull Med Libr Assoc. 1992;80(2): 309(6949):217-218. 169-178. 59. Gee JP. Communities of practice in the new capitalism. J Learn Sci. 35. Veenstra RJ. Clinical medical librarian impact on patient care: 2000;9(4):515-523. a one-year analysis. Bull Med Libr Assoc. 1992;80(1):19-22. 60. Pereles L, Lockyer J, Fidler H. Permanent small groups: group 36. Wenger E, McDermott R, Snyder WM. Cultivating Communities of dynamics, learning, and change. J Contin Educ Health Prof. 2002; Practice: A Guide to Managing Knowledge. Boston, MA: Harvard Busi- 22(4):205-213. ness School Press; 2002. 61. Rabin S, Maoz B, Elata-Alster G. Doctors’ narratives in Balint 37. Bohmer RMJ, Edmondson AC. Organizational learning in health groups. Br J Med Psychol. 1999;72(Pt 1):121-125. care. Health Forum J. 2001;44(2):32-35. 62. Gabbay J, le May A. Evidence based guidelines or collectively con- 38. Parboosingh JT. Physician communities of practice: where learning structed “mindlines?” Ethnographic study of knowledge manage- and practice are inseparable. J Contin Educ Health Prof. 2002;22(4): ment in primary care. BMJ. 2004;329(7473):1013. 230-236. 63. Plsek PE, Greenhalgh T. Complexity science: The challenge of com- 39. Schon D. Teaching artistry through refl ection-in-action. In: Tsoukas plexity in health care. BMJ. 2001;323(7313):625-628. H, ed. New Thinking in Organizational Behaviour: From Social Engineer- ing to Refl ective Action. Oxford, England: Butterworth-Heinemann 64. Wilson T, Holt T, Greenhalgh T. Complexity science: complexity and Ltd; 1994:1-22. clinical care. BMJ. 2001;323(7314):685-688. ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010 176 C A R ING F O R PAT I EN T S WI T H MULT IM OR BIDI T Y 65. Plsek PE, Wilson T. Complexity, leadership, and management in 78. Boult C, Karm L, Groves C. Improving chronic care: the guided care healthcare organisations. BMJ. 2001;323(7315):746-749. model. Permanente J. 2008;12(1):50-54. 66. Stroebel CK, McDaniel RRJ, Crabtree B, Miller W, Nutting PA, 79. Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of Stange KC. How complexity science can inform a refl ective process leading chronic disease management programs: are they consistent for improvement in primary care practices. Jt Comm J Qual Saf. with the literature? Manag Care Q. 1999;7(3):56-66. 2005;31:438-446. 80. Wagner EH, Austin BT, Von Korff M. Organizing care for patients 67. Miller WL, McDaniel RRJ Jr, Crabtree BF, Stange KC. Practice jazz: with chronic illness. Milbank Q. 1996;74(4):511-544. understanding variation in family practices using complexity sci- 81. Dorr DA, Wilcox A, Burns L, Brunker CP, Narus SP, Clayton PD. ence. J Fam Pract. 2001;50(10):872-878. Implementing a multidisease chronic care model in primary care 68. Scott J, Tallia A, Crosson JC, et al. Social network analysis as an using people and technology. Dis Manag. 2006;9(1):1-15. analytic tool for interaction patterns in primary care practices. Ann 82. Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collabor- Fam Med. 2005;3(5):443-448. ative management of chronic illness. Ann Intern Med. 1997;127(12): 69. Goodwin MA, Zyzanski SJ, Zronek S, et al; The Study to Enhance 1097-1102. Prevention by Understanding Practice (STEP-UP). A clinical trial of 83. Bodenheimer T, Grumbach K. Improving Primary Care. Strategies and tailored offi ce systems for preventive service delivery. Am J Prev Tools for a Better Practice. New York, NY: McGraw-Hill Companies, Med. 2001;21(1):20-28. Inc; 2007. 70. Cohen D, McDaniel RRJ Jr, Crabtree BF, et al. A practice change 84. Lave J, Wenger E. Situated Learning. Legitimate Peripheral Participa- model for quality improvement in primary care practice. J Healthc tion. Cambridge: University of Cambridge Press; 1991. Manag. 2004;49(3):155-168, discussion 169-170. 85. Kimble C, Hildreth P. Communities of Practice: Going One Step Too 71. Bar-Yam Y. Making Things Work. Solving Complex Problems in a Com- Far? Proceedings 9e colloque de l’AIM. Evry, France; 2004. plex World. Brookline, MA: NESCSI, Knowlege Press; 2004. 86. Brown S, Gray S. The people are the company. Fast Company. 1995; 72. Axelrod R, Cohen MD. Harnessing Complexity. Organizational Implica- 1. http://www.fastcompany.com/magazine/01/people.html?page= tions of a Scientifi c Frontier. New York, NY: Basic Books; 2000. 0%2C0. 73. Axelrod R. The Evolution of Cooperation. New York, NY: Basic Books; 87. Committee on Quality of Health Care in America. Institute of Medi- cine. Crossing the Quality Chasm: A New Health System for the 21st 74. Nelson EC, Batalden PB, Godfrey MM. Quality By Design: A Micro- Century. Washington, DC: National Academy Press; 2001. systems Approach. San Francisco, CA: Jossey-Bass; 2007. 88. McGlynn EA, Asch SM, Adams J, et al. The quality of health care 75. Shaughnessy AF, Slawson DC, Becker L. Clinical jazz: harmoniz- delivered to adults in the United States. N Engl J Med. 2003;348 ing clinical experience and evidence-based medicine. J Fam Pract. (26):2635-2645. 1998;47(6):425-428. 89. Parkerton PH, Smith DG, Straley HL. Primary care practice coordi- 76. Kolb DA. Experiential Learning: Experience as the Source of Learning nation versus physician continuity. Fam Med. 2004;36(1):15-21. and Development. Englewood Cliffs, NJ: Prentice-Hall; 1984. 90. Kernick D, Stead J, Dixon M. Moving the research agenda to where 77. Haidet P. Jazz and the ‘art’ of medicine: improvisation in the medi- it matters. BMJ. 1999;319(7204):206-207. cal encounter. Ann Fam Med. 2007;5(2):164-169. ✦ ✦ ✦ ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 8, NO. 2 MARCH/APRIL 2010

Journal

The Annals of Family Medicine – Unpaywall

Published: Mar 1, 2010

There are no references for this article.