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

Considering clinical work and communities of practice as complex adaptive systems has many valuable implications. In this response, I will focus on one of them: seeing clinical work and learning differently.

Clinical work often entails conflicting activities that require a balance between head and heart, cognitive and non-cognitive abilities, technical skills and insightful compassion,system design and ethical dimensions of professional practice (Soubhi et al, 2009). The synthesis of all these seemingly opposed components is a task that is beyond the ability of any one isolated individual, particularly when you add to this complexity varying levels of task interdependence, uncertainty, and time constraints. All of this makes individual contribution difficult to isolate, a problem for policy when the sole concern is with physician productivity.

We can see learning in this context as something that happens in the head, a strongly individualistic view. But we can also see learning as a group performance, a participation in a community with a reciprocal influence on identity: how you perceive yourself, what you can do, and how you should behave (Wenger, 1998).

This is best exemplified with the third year medical student muddling through the new tribe he starts seeing every day, lead by an attending physician and a flock of senior residents and interns. I personally have never felt how visceral learning (which now I explain in hindsight as participation) can be as when, long ago as a medical student, I waited to be able to talk in those circles, and after a long while feel valued when the attending physician deigned to look at me and nod his head to approve what I was saying. Participation was the key and the witness to my progressive acceptance in a tribe lead by a high priest whose words everybody was waiting for.

I can list three implications of this complex adaptive view of learning as participation in a community of like-minded (like-constrained, like-socialized) people:

1.The group performance (as in a community of practice) is dependent on how the group succeeds in both knowledge and task integration: how they organize what they know and what they do (Soubhi et al, 2009). This in turn depends on a fluid, coordinated participation of all professionals involved: an open-ended, continuously evolving process.

2.Engagement in participation = engagement in learning = maximizing an identity utility (Akerlof & Kranton, 2010).

3.Successful leaders invest in the identification of their workers with the focus of their organizations. Having people fired up about something they care about can enhance group cohesion and help lower the need for monetary incentive (Akerlof & Kranton, 2010).

Wenger, E. (1998). Communities of practice: Learning, meaning, and identity. New York: Cambridge University Press.

Soubhi, H., Rege Colet, N., Gilbert, J. H. V., Lebel, P., Thivierge, R. L., Hudon, C., Fortin, M. (2009). Interprofessional learning in the trenches: Fostering collective capability.Journal of Interprofessional Care,23:1,52—57

Akerlof, G.A., Kranton, R.E. (2010). Identity Economics: How our identities shape our work, wages, and well-being. Princeton, New Jersey: Princeton University Press.

Competing interests:   None declared

I agree that communities of practice should be seen as a problem- solving device; natural, more or less spontaneous, but it can thrive or die because of workplace culture or senior leaders’ interventions.

I also agree about the importance of monetary incentives for collaboration among physicians to take place. However, I think we have more research exploring the link between monetary incentive and physician productivity than between incentive and collaboration. And I also believe that the link between monetary incentive and physician productivity is not as direct as we might think.

Call me naïve, call me romantic, but I believe that human civilization has persisted this long because on the whole the greater good for the group has been more frequently pursued/achieved than the greater good for the self-interested individual. This is just as true for physician practices and if we follow this line of reasoning, we may be more inclined to dig deeper into the link between monetary incentives and physicians’ productivity and get out of the blind spot to uncover a host of mediating variables.

One such variable is the level of cooperation among physicians, or better yet the balance between cooperation and competition. One falsifiable hypothesis may be that fee-for-service increases competition and decreases cooperation among physicians. Another may be that capitation (or salary) decreases competition and it may have no effect on cooperation.

Group characteristics represent another set of variables (possibly also acting as effect modifiers): heterogeneity, size, and most important of all, I think, is duration of the relationships between physicians. Note that with size of the group, we may run into an endogeneity problem because size of the group can influence capitation agreements which in turn can affect cooperation or the balance cooperation/competition.

Acknowledging that money is a recent invention among humans, I also believe we should ask: How does cooperation emerge among self-interested physicians? When and how do physicians share resources and engage in joint enterprises? How do they balance cooperation with competition and what kind of organizational environment can foster that balance?

Communities of practice seem to offer such an environment and because they are formed around a common interest, they are potentially maintained for as long as members find value in their participation. Both of these statements are falsifiable. I will end with another: the form the practice takes follows value, i.e. whatever the group values we will see more of it.

Competing interests:   None declared

Soubhi et al's paper is a good starting point for a long overdue deeper discussion about the pressing issues facing medicine and general practice/family medicine in particular. It is difficult for the format of a rapid response to be concise or sufficiently comprehensive on the underlying issues so large and complex as "Communities of Practice":

• How do we perceive the nature of health, especially for patients with chronic conditions?
• How do we understand the nature of knowledge in medicine?
• What are the dynamics of practice? If medical care is not instrumental for most patients, is the consultation "an exercise in sense-making" or a learning experience? Who is learning, and who is learning what? and
• How do we conceptualise our workplace, and how do we handle change within the various levels in our organisations? How is leadership different from management?

The authors' approach touches on the notion of systems and complexity sciences for which they need to be commended. However in their elaborations they largely fall back on "standard linear" approaches resulting "in a circle". I would contend that each of the issues listed are "complex adaptive" in nature, that each forms a "sub-system" in its own right within the larger "system of medical care"[1] – we need to consider new ways to "visualise (and thereby understand) complex adaptive systems" that reflect their structure and relationships.

Some work has been done on these issues in recent years.

• Health is a personal construct, reconstructed over and over again along the person"s illness trajectory. Regaining health is the personal (though facilitated) journey of "making sense" of the experience of various health conditions irrespective of their cause, and irrespective of medical interventions that may or may not be curative in terms of the underlying pathology [2-4].
• Knowledge is not only overt or tacit, but multidimensional and context dependent. Understanding knowledge as complex provides a framework for the integration of multiple perspectives on any issue of concern [5].
• The consultation is a meeting place of different experts, the prevailing dynamics of the exchanges in the consultation constitute learning, it fundamentally changes each participant, it leaves them with a different understanding of the issues, each makes sense anew in this particular context [2,6]. This is no more true than in the context of patients with multiple morbidities [7].
• Organisations can only be fully understood in complex adaptive terms. They require a common understanding and purpose, successful leaders maintain their organisation's focus [8-9].

1. Sturmberg JP, Martin CM. Complexity and health - yesterday's traditions, tomorrow's future. Journal of Evaluation in Clinical Practice. 2009;15(3):543-548.
2. Sturmberg JP. The personal nature of health. Journal of Evaluation in Clinical Practice. 2009;15(4):766-769.
3. Scott JG, et al. Understanding Healing Relationships in Primary Care. Annals of Family Medicine. 2008;6(4):315-322.
4. Sturmberg JP, with contribution by Martin CM. The Foundations of Primary Care. Daring to be Different. 2007, Oxford San Francisco: Radcliffe Medical Press.
5. Sturmberg JP, Martin CM. Knowing - in Medicine. Journal of Evaluation in Clinical Practice. 2008;14(5):767-770.
6. Mennin S. Self-organisation, integration and curriculum in the complex world of medical education. Medical Education. 2010;44(1):20-30.
7. Martin C, et al. Care for chronic illness in Australian general practice - focus groups of chronic disease self-help groups over 10 years: implications for chronic care systems reforms. Asia Pacific Family Medicine. 2009;8(1):1.
8. Heifetz R. Leadership Without Easy Answers. 1994, Cambridge, Ma: Harvard University Press.
9. Mintzberg H. Cover Leadership: Notes on Managing Professionals. Knowledge workers respond to inspiration not supervision. Harvard Business Review. 1998;76(6):140-147.

Competing interests:   None declared

This is a thought-provoking paper, but I think it is critical to consider how funding and workplace structure can affect "Communities of Practice," along with what knowledge such communities pass along.

Under fee-for-service payment, there is little incentive to work collaboratively, let alone develop - and test - new ideas and ways of managing care collectively. Time spent on such activities is not reimbursed. I currently see patients in a teaching health center where residents are frequently given conflicting recommendations on successive encounters with a patient by different preceptors, even for relatively straightforward issues where there is good evidence. Our system fails abysmally at communicating crucial information across transitions between inpatient and outpatient care, despite working together and having a common employer.

I have worked in settings where there were much more organized efforts to coordinate care; this was driven by organizational culture - fundamentally motivated by capitated payment, where care coordination can pay off. However, while there was a much more concerted effort to standardize practice, the standards we were pushed to adopt and adhere to were not always evidence-based best practices, as opposed to "this is how we do it here." The practice variations literature has documented the existence of regional patterns that are independent of patient characteristics (and best evidence).

I don't think can can depend on Communities of Practice to develop spontaneously or to "do the right thing" without as much care and oversight as we'd put into any other practice innovation effort. If the incentives are not there, they will not happen; superstition can be as sticky as knowledge.

Competing interests:   None declared

A useful paper. With regards learning, organisational learning and communities of practice I wonder whether there is some reframing needed around these concepts with the growth in the use of mobile media and social networking. There is a growing body of research around the ability to influence in weak and strong networks. Current trends are challenging those of us working in these fields. Additionally, I feel we can do much more in involving or integrating the patient in the community of practice. For an example of how healthcare communities of practice, behaviours and learning might look like in the future then “The Future of Health Care is Social” 10/6/2009, Fastcompany http://www.fastcompany.com/future-of-health-care is a good start.

Competing interests:   None declared

Here a few shifts in perspective we might have if we change how we see knowledge:

1.Knowing the ropes, knowing how to behave around the water cooler, knowing how to deal with Joe`s resentment represent the kind of knowledge we might call social or cultural. This is different from clinical or technical knowledge. And yet, the cultural knowledge may facilitate or hinder access to the technical. I may let you know what I know out of professional accountability, or if I feel you are trustworthy, or if I know you will reciprocate, or if I know you are the boss and I`d better be good to you.

2.Learning is not just an individual affair, it is also collective. Just like Alice in Wonderland (1) who thinks with a chorus of voices, we also reflect and learn in chorus with others as we participate in what others do, think, and learn.

3.There is knowledge that changes quickly and there is knowledge that changes slowly. The group (collective learning) may be helpful when knowledge changes quickly.

4.Knowledge (clinical, scientific, or cultural) is not just translated to a group; it is transformed by the group. Understanding how knowledge is transformed is key to integrating learning to practice. Communities of practice can be helpful in this regard.

(1). Lewis Carroll. Alice in Wonderland and Through the Looking- Glass. 2004. Fine Creative Media, Inc.

Competing interests:   None declared

This is a very interesting and important paper that draws on the authors extensive experience as researchers and practitioners considering the management of patients with multimorbidity. As part of the effort to understand how we can improve the management of multimorbidity we have undertaken qualitative research with family practitioners and pharmacists to explore the practitioner perspective. 1 One of the main themes that emerged was professional isolation and clinical uncertainty. The uncertainty relates both to a lack of formal evidence relating to care of patients with multiple conditions but also to poor inter-professional communication and fragmentation of care. Communities of Practice have the potential to address these serious concerns through the implicit support for participating practitioners but also through the coordination of e- cases that will help build an evidence base. The e-cases will also be a very valuable resource for those seeking to teach clinicians about ‘real world’ problems. While I agree that clinicians would, in general, be happy to participate in these Communities of Practice, the presence of a dedicated administrator or case manager can harness these good intentions into structured activity. The ongoing Cochrane review examining the effectiveness of interventions for multimorbidity2 indicates that there is limited evidence to support any particular intervention at present. To date all interventions identified have been complex and multifaceted. Within the proposed Communities of Practice model there is an opportunity to research individual elements of complex interventions using cluster designs, for example, interventions such as extending consultation length, pharmacy support for medicines management or the use of community based information specialists embedded within the community. The challenge for the Communities of Practice model is to integrate the growing knowledge of the communities that is both tacit and explicit, into the evidence base needed to improve outcomes for people with multimorbidity.

1SM Smith, S O’Kelly, T O’Dowd. “Pandora’s box” – a qualitative exploration of GPs and pharmacists managing patients with multimorbidity in primary care. British Journal of General Practice. (in press)

2Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Interventions to improve outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews: Protocol 2007 Issue 2

Competing interests:   None declared