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DiscussionSpecial Reports

In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices

Christine A. Sinsky, Rachel Willard-Grace, Andrew M. Schutzbank, Thomas A. Sinsky, David Margolius and Thomas Bodenheimer
The Annals of Family Medicine May 2013, 11 (3) 272-278; DOI: https://doi.org/10.1370/afm.1531
Christine A. Sinsky
1Medical Associates Clinic and Health Plans, Dubuque, Iowa
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  • For correspondence: csinsky1@mahealthcare.com
Rachel Willard-Grace
2Center for Excellence in Primary Care, University of California, San Francisco, California
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Andrew M. Schutzbank
3Beth Israel Deaconess Medical Center, Boston, Massachusetts
4Iora Health, Cambridge, Massachusetts
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Thomas A. Sinsky
1Medical Associates Clinic and Health Plans, Dubuque, Iowa
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David Margolius
2Center for Excellence in Primary Care, University of California, San Francisco, California
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Thomas Bodenheimer
2Center for Excellence in Primary Care, University of California, San Francisco, California
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Article Figures & Data

Tables

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    Table 1

    Specialty, Setting, and Clinicians at Study Sites

    On-Site Visits
    SiteSpecialtySettingNo. of Physicians
    In-person visits
     Ambulatory Practice of the FutureGIMaUrban2
     Brigham and Woman’s HospitalGIMUrban7
     Cleveland Clinic StrongsvilleFMbSuburban103
     Clinica Family Health ServicesFMRural46
     Clinic OleFMRural15
     Fairview Rosemont ClinicGIM/FMUrban2
     Group Health OlympiaFMUrban36
     Harvard Vanguard MedfordGIMSuburban14
     La Clinica de la RazaFMUrban16a
     Martin’s Point-Evergreen WoodsGIMRural4a
     Mayo Red CedarFMRural13
     Medical Associates ClinicGIMUrban115
     Mercy Clinics EastFMUrban7
     Multnomah County Health DepartmentIMUrban40
     Newport News Family PracticeFMUrban5
     Quincy, Office of the FutureFMRural2
     Sebastopol Community Health CentersFMRural8a
     Southcentral FoundationFMUrban115
     ThedaCare-OshkoshFMUrban5.
     University of Utah-RedstoneIMRural5
     West Los Angeles VAIMUrban12a
    Virtual visits
     Allina-CambridgeFM/IMRural
     North Shore Physicians GroupFM/GIMUrban200
    • FM=family medicine; GIM=general internal medicine; IM=internal medicine; VA=Veterans Affairs.

    • ↵a Includes physicians, physician assistants, nurse practitioners.

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    Table 2

    Problems and Innovations

    ProblemInnovation
    Unplanned visits with overfull agendasPrevisit planning
    Preappointment laboratory tests
    Inadequate support to meet the patient demand for careSharing the carea
     Expanded nurse or medical assistant rooming protocol
     Standing orders
     Extended responsibility for health coaching, care coordination, and integrated behavioral health to nonphysician members of the team
     Team responsibility for panel management
    Great amounts of time spent documenting and complying with administrative and regulatory requirementsScribing
    Assistant order entry
    Standardized prescription renewal
    Computerized technology that pushes more work to the physicianIn-box management
    Verbal messaging
    Teams that function poorly and complicate rather than simplify the workImproving team communication through
     Co-location
     Huddles
     Regular team meetings
    Improving team functioning
     Systems planning
     Work flow mapping
    • ↵a These roles require 2- or 3-to-1 clinical support per physician.

Additional Files

  • Tables
  • Supplemental Appendixes 1-3

    Supplemental Appendix 1. Study Sites; Supplemental Appendix 2. Site Visit Guide; Supplemental Appendix 3. Future Research Agenda

    Files in this Data Supplement:

    • Supplemental data: Appendix 1 - PDF file, 3 pages, 143 KB
    • Supplemental data: Appendix 2 - PDF file, 2 pages, 172 KB
    • Supplemental data: Appendix 3 - PDF file, 3 pages, 143 KB
  • The Article in Brief

    In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices

    Christine A. Sinsky , and colleagues

    Background As American physicians spend more time on large volumes of clerical work that does not utilize their training, they face burnout, which in turn threatens patient care. In this study, researchers gather innovations they believe can facilitate joy in practice and reduce physician burnout.

    What This Study Found A shift from a physician-centric model of work distribution and responsibility to a shared-care model with higher levels of clinical support per physician and frequent forums for communication can result in high-functioning teams, improved professional satisfaction, and, potentially, greater joy in practice. Site visits to 23 high-performing family practices revealed 5 key innovations: (1) proactive planned care, with previsit planning and previsit laboratory tests; (2) shared clinical care among a team with expanded protocols, standing orders, and panel management; (3) shared clerical tasks with collaborative documentation, nonphysician order entry, and streamlined prescription management; (4) improved communication by verbal messaging and in-box management; and (5) improved team functioning through co-location, team meetings, and work flow mapping.

    Implications

    • These innovations, the authors assert, can address barriers to the healing relationship between physician and patient, take advantage of the resources of the health care team, and improve care for patients, thereby enhancing physician joy in practice.
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The Annals of Family Medicine: 11 (3)
The Annals of Family Medicine: 11 (3)
Vol. 11, Issue 3
May/June 2013
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In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices
Christine A. Sinsky, Rachel Willard-Grace, Andrew M. Schutzbank, Thomas A. Sinsky, David Margolius, Thomas Bodenheimer
The Annals of Family Medicine May 2013, 11 (3) 272-278; DOI: 10.1370/afm.1531

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In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices
Christine A. Sinsky, Rachel Willard-Grace, Andrew M. Schutzbank, Thomas A. Sinsky, David Margolius, Thomas Bodenheimer
The Annals of Family Medicine May 2013, 11 (3) 272-278; DOI: 10.1370/afm.1531
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