Clinical Uncertainty in Primary Care: the Challenge of Collaborative Engagement

Clinical Uncertainty in Primary Care: The challenge of collaborative engagement

Chapter 98

Practice Inquiry: Uncertainty Learning in Primary Care Practice

On-line Resource #2

The CME Programs: Practice Inquiry - Improving Clinical Judgment and Clinical Practice, at the Department of Family & Community Medicine at University of California, San Francisco,and at Kaiser Permanente Medical Center Oakland, California

Lucia S. Sommers, DrPH

The Practice Inquiry CME Program at UCSF based in the Department of Family and Community Medicine began in 2005 preceded by 2 ½ years of pilot work. As of summer 2012, seven PI groups are part of the program. Two PI groups have been meeting in Kaiser Permanente Medical Centers based in the Departmentof Medicine; one group has been CME- certified since 2005 and the other group is currently applying for accredited CME status.In the US, most states require physicians and mid-level practitioners to obtain ‘CME credits’ in order for licensure renewal.

Practice Inquiry Groups

1. Maxine Hall Health Center (San Francisco))

1. Asian Health Services

1. Kaiser Permanente (Oakland)

1. Lakeshore

1. Potrero Hill Health Center

1. Baywest

1. Axis Health

1. Sutter East Bay Foundation

1. Kaiser Permanente (Richmond)

PCP- primary care physician, NP- nurse practitioner, PA – physician assistant, LS- Lucia Sommers

Funding: $500annual accreditation review feewaived by UCSF as a community service in the interest of supporting non-commercial, practice-based CME; no fees at Kaiser Permanente

CME Program Clinician Educational Objectives:

• To share uncertainties in managing difficult/complex patients with colleagues
• To practice blending multiple clinical judgment input into strategies for engaginguncertainty
• To identify recurring uncertainties requiring clinic-wide educational/ system interventions

CME Program Group Participation Requirements:

• Minimum of 3 clinicians to count as CME credit-worthy (Category 1 CME credit)
• Facilitator present (4th group member or external person of group’s choosing)
• Case log maintained (See example case log below.)
• Participant comments via annual PI Feedback Questionnaire (See Figure 1 attached.)

Key Statistics:

• Largest number of groups in any one year: 14
• Number of groups meeting for at least 3 years: 10
• Number of groups meeting for at least 5 years: 6
• Number of groups meeting regularly for at least 18 months no longer participating: 3

Program Evaluation:

• Case Series Analysis (150 cases)
• Uncertainty type: 33% diagnostic, 25% management uncertainties, 23% diagnostic/management; 19% clinician-patient relation
• 15% - adverse outcome; 8% End-of-life
• Top 7 condition types: morbid obesity, chronic pain, use of the prostate specific antigen (PSA) test, lipid abnormalities, and incidental findings on studies, bi-polar disorders, and patients with both diabetes and hypertension.

(See On-Line Resource #3“Practice Inquiry Clinical Uncertainty Taxonomy” fora description of the work underway to categorize 350 uncertainty cases using an automated data collection and categorization tool.)

• Seven-Year Trend Analysis (Data collected via annual PI Feedback Questionnaire; see Figure 1, attached.)

Practice Inquiry Clinician Self-Report Trend Analysis

*5-point Likert scale, 5 = highest value

**Examples

• “Blind older female with chronic renal disease and diabetes needing to use insulin but refusing. Came here daily for injections but can’t continue forever.. Patient refusing to self-inject; no family. Group advised to offer oral meds and if in the end the patient refuses, then to just accept that it’s the patient’s choice”
• “Elderly female with anemia - will check an additional test and then stop worrying about it”
• “Long-term use of Fosamax in patients who have been on it for >5 years; I’ll repeat Dexa and consider DC-ing med”
• “Patient with newly diagnosed lupus. Since patient not be able to be seen by specialist for a couple of months, what should I be doing if the patient is not having a flare…Patient has mildly elevated ESR. Question: without symptoms, need to lower ESR?Group thought ‘no.’“
• “Patient with chronic pain, depression, poor motivation. Brought to the group – came away with different interpretation of patient behavior – ultimately more successful management of the patient”

1