Objectives To elucidate pathways to healing for people having suffered injury to the integrity of their function as a human being. Methods A team of physician-analysts conducted thematic analyses of in-depth interviews of 23 patients who experienced healing, as identified by six primary care physicians purposefully selected as exemplary healers. Results People in the sample experienced healing journeys that spanned a spectrum from overcoming unspeakable trauma and then becoming healers themselves to everyday heroes functioning well despite ongoing serious health challenges. The degree and quality of suffering experienced by each individual is framed by contextual factors that include personal characteristics, timing of their initial or ongoing wounding in the developmental life cycle and prior and current relationships. In the healing journey, bridges from suffering are developed to healing resources/skills and connections to helpers outside themselves. These bridges often evolve in fits and starts and involve persistence and developing a sense of safety and trust. From the iteration between suffering and developing resources and connections, a new state emerges that involves hope, self-acceptance and helping others. Over time, this leads to healing that includes a sense of integrity and flourishing in the pursuit of meaningful goals and purpose. Conclusion Moving from being wounded, through suffering to healing, is possible. It is facilitated by developing safe, trusting relationships and by positive reframing that moves through the weight of responsibility to the ability to respond.

Extensive research has focused on understanding family dynamics of men with prostate cancer. However, little qualitative work has examined the role of family ties on men’s prostate cancer decisions across the spectrum of screening, diagnosis, and treatment. Using data from a larger study, we qualitatively explored the influence of family ties on men’s prostate cancer decisions. Semistructured interviews were conducted with men ages ≥50 ( N = 64), and data were analyzed using a grounded theory approach and a series of immersion/crystallization cycles. Three major themes of spousal/family member influence were identified: (a) spousal/family member alliance marked by open communication and shared decision making, (b) men who actively opposed spouse/family member pressure and made final decisions themselves, and (c) men who yielded to spouse/family member pressure. Our findings provide insights into men’s relational dynamics that are important to consider for the shared decision-making process across the prostate cancer spectrum.

False positive results are among the most common adverse outcomes of cancer screening tests. Up to 75% of men with an elevated prostate specific antigen (PSA) have had a negative prostate biopsy. Adverse emotional effects of false positive prostate cancer screening have been documented using surveys, but there is nothing in this literature describing the lived experience of having a false positive PSA. In a qualitative interview study of sixteen men who had false positive PSAs, we found that all subjects experienced transient anxiety while waiting for the results of their prostate biopsies. In addition there were three persistent emotional responses: (1) increased fear of cancer; (2) relief with increased vigilance; (3) relief with less worry about elevated PSA. The attitude and recommendations of urologists influenced the emotional responses. Some men expressed frustration with the PSA as a screening test. Many men had multiple negative prostate biopsies. These data suggest that there should be more effort to develop guidelines for subsequent prostate biopsies after an initial negative biopsy, and more effort to encourage primary care clinicians and urologists to discuss emotional risks of PSA testing with their patients.

Shared decision making is recommended before prostate cancer screening. Little is known regarding reasons why men choose to get or not get prostate cancer screening, particularly in white or Hispanic men. We conducted semi-structured in-depth interviews of 64 men, age 50 years and over, purposively sampled from men who were never screened for prostate cancer or who screened abnormal in northern New Jersey. Qualitative analysis was iterative using a grounded theory approach involving a series of immersion/crystallization cycles. Men who had abnormal PSA tests either actively sought out screening because of family history of prostate cancer or received their screening as part of a routine physical examination. Men who were never screened avoided testing primarily because they perceived they were at low risk due to lack of urinary symptoms, lack of family history of prostate cancer, or beliefs that healthy behaviors can prevent prostate cancer. Other reasons for not getting screened included: fear of cancer, embarrassment over digital rectal exam, confusion over the screening procedure, and skepticism over the benefits of screening. Some men were willing to get screened if structural barriers were removed, their doctor recommended it, or if they were prompted by urinary symptoms. None had discussions with physicians about potential risks of prostate cancer screening. Men received their health information through lay media, friends or family members. Educating men in the community through mass media about benefits and limitations of prostate cancer screening may be more effective to promote and facilitate shared decision making with their physicians.

The dominant unspoken philosophical basis of medical care in the United States is a form of Cartesian reductionism that views the body as a machine and medical professionals as technicians whose job is to repair that machine. The purpose of this paper is to advocate for an alternative philosophy of medicine based on the concept of healing relationships between clinicians and patients. This is accomplished first by exploring the ethical and philosophical work of Pellegrino and Thomasma and then by connecting Martin Buber's philosophical work on the nature of relationships to an empirically derived model of the medical healing relationship. The Healing Relationship Model was developed by the authors through qualitative analysis of interviews of physicians and patients. Clinician-patient healing relationships are a special form of what Buber calls I-Thou relationships, characterized by dialog and mutuality, but a mutuality limited by the inherent asymmetry of the clinician-patient relationship. The Healing Relationship Model identifies three processes necessary for such relationships to develop and be sustained: Valuing, Appreciating Power and Abiding. We explore in detail how these processes, as well as other components of the model resonate with Buber's concepts of I-Thou and I-It relationships. The resulting combined conceptual model illuminates the wholeness underlying the dual roles of clinicians as healers and providers of technical biomedicine. On the basis of our analysis, we argue that health care should be focused on healing, with I-Thou relationships at its core.

Without insight into the primary care environment, further improvements in influenza immunization rates are unlikely. We conducted a comparative case study of family medicine offices during the 2003 influenza immunization season. Practice 1 (P1) served an urban African American population, practice 2 (P2) served a suburban non-minority population, practice 3 (P3) served an urban Hispanic population. Influenza immunization rates among patients age 65 years and older in P1, P2, and P3 were 32%, 33%, and 67% by medical chart. Rates were highest in P3, where medical staff supported vaccination, promoted communication with patients and staff, and made use of systems to identify eligible patients. Characteristics that appear to affect influenza immunization in the primary care environment include the presence of a practice champion, issues of communication and collaboration, and the use of systems approaches. These data support the need for investigation of how these factors affect population level disparities.

Background: Closing the gap between evidence and practice demands interventions targeting the whole practice. These system level interventions require more complex designs and require greater practice involvement. Current descriptions of trials use research designs that either limit practice involvement or make use of large health system resources.Objective: To share insights on retention of practices in a complex clinical trial aimed at improving care of multiple chronic conditions in 60 diverse community primary care practices not supported by large health system resources.Research Design: Qualitative cross case analysis of field notes from meetings of a diverse research team.Results: Five interrelated factors were found to be important to the success of the study implementation process: (1) developing structure and activities for relationship building; (2) attention to consistent communication; (3) timely information sharing; (4) evolution of a cross-functional research team; (5) provision of technical assistance. Specific strategies were identified to overcome challenges to study implementation.Conclusions: Diverse community primary care practices without support from health system resources will complete participation in complex trials. Researchers need not avoid answering questions requiring complex study designs; however, successful implementation requires an individualized approach tailored to the needs and characteristics of each practice.

Background: Obesity is associated with increased colorectal cancer incidence and mortality. Previous studies using telephone survey data showed that obese women were less likely to receive colorectal cancer screening. It is unknown if this is true among patients in primary care practices. Methods: Retrospective chart reviews were conducted in 2003-2004 of men and women in 22 suburban New Jersey and Pennsylvania primary care practices. Data from patients age 50 years and over (n = 1297) were analyzed using hierarchical logistic regression. The outcome measure was receipt of colorectal cancer screening (fecal occult blood test within 1 year, sigmoidoscopy within 5 years, colonoscopy within 10 years, or barium enema within 5 years) among obese and non-obese patients. Results: Overall, 39% of patients were obese and 29% received colorectal cancer screening. After controlling for age, gender, total number of co-morbidities, number of visits in the past 2 years, and number of years in the practice, obese patients had 25% decreased odds of being screened for colorectal cancer compared to non-obese patients (OR 0.75, 95% Cl, 0.62-0.91). The relationship of obesity and colorectal cancer screening did not differ according to gender. Number of visits (OR 1.04, 95% Cl, 1.01-1.06) and male gender(OR 1.53, 95% Cl, 1.19-1.97) was associated with increased odds of receiving colorectal cancer screening. Conclusion: Identification of physician and patient barriers to colorectal cancer screening is needed, particularly in obese patients, so that effective interventions may be developed to increase screening in this high-risk group. (c) 2006 International Society for Preventive Oncology. Published by Elsevier Ltd. All rights reserved.

Background: Gender disparities in cardiovascular disease (CVD) management have become increasingly apparent in recent years. Previous research has focused on inpatient disparities, but little is known about how patient gender affects assessment, treatment, and management of patients for hyperlipidemia and cardiovascular risk in primary care settings. Patients with coronary artery disease (CAD) and hyperlipidemia are at high risk for cardiovascular and cerebrovascular morbidity. We sought to examine the effect of patient gender on assessment, treatment, and target maintenance of hyperlipidemia among patients with CAD in a primary care setting. Methods: Chart abstraction was done for 715 patients with CAD in 55 family practices in New Jersey and eastern Pennsylvania as part of the Using Learning Teams for Reflective Adaptation (ULTRA) project. Hyperlipidemia assessment, treatment, and target adherence scores were determined for those at-risk patients based on National Heart, Lung, and Blood Institute (NHLBI) recommended National Cholesterol Education Program (NCEP) ATP III guidelines. Generalized linear models were used to determine the association of hyperlipidemia guideline adherence with patient gender, using comorbidities and age as confounders. Results: After controlling for comorbidities and age, women were less likely to be assessed for lipids (p = 0.0462). There was no difference in treatment (p = 0.1074) or target laboratory values (p = 0.3949). Conclusions: Women with CAD are less often assessed for lipids than men in primary care practices. More intensive efforts may be necessary to educate physicians and patients about cardiovascular risk for women.

PURPOSE Social network analysis (SNA) provides a way of quantitatively analyzing relationships among people or other information-processing agents. Using 2 practices as illustrations, we describe how SNA can be used to characterize and compare communication patterns in primary care practices. METHODS Based on data from ethnographic field notes, we constructed matrices identifying how practice members interact when practice-level decisions are made. SNA software (UCINet and KrackPlot) calculates quantitative measures of network structure including density, centralization, hierarchy and clustering coefficient. The software also generates a visual representation of networks through network diagrams. RESULTS The 2 examples show clear distinctions between practices for all the SNA measures. Potential uses of these measures for analysis of primary care practices are described. CONCLUSIONS SNA can be useful for quantitative analysis of interaction patterns that can distinguish differences among primary care practices.

BACKGROUND This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODS We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTS Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns. CONCLUSIONS Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations.

Implementing an EMR without an understanding of the systemic effects and communication and the decision-making processes within an office practice and without methods for bringing to the surface and addressing conflicts limits the opportunities for improved care offered by EMRs. Understanding how these common issues manifest within unique practice settings can enhance the effective implementation and use of EMRs.

Background: Obesity is epidemic and leads to substantial morbidity/mortality. Effective strategies exist for managing obesity yet are rarely used by physicians. This applied evidence-based review provides a rationale for the diagnosis and treatment of obesity in adults by providing test characteristics for the body mass index (BMI) and number needed to treat (NNT) for relevant treatments. Methods: We integrated evidence supporting recommendations from scientific bodies addressing obesity in adults, including: the National Heart, Lung, and Blood Institute, the World Health Organization, the Canadian Task Force on Preventive Health Care, and the US Preventive Task Force. In addition, pertinent studies were identified from MEDLINE, Database of Abstracts of Reviews of Effectiveness, and the Cochrane Database. Results: ( 1) manage obesity as a chronic relapsing disease; ( 2) use BMI as a vital sign to screen for overweight/obese patients and to decide treatment ( positive predictive value of 97%); ( 3) modest weight loss (10%) positively affects prevention/treatment of hypertension ( NNT = 3), diabetes ( NNT = 9), and hyperlipidemia; ( 4) effective treatments exist for overweight/obese patients and a combination of diet and exercise provides the best results ( NNT = 7); ( 5) counsel patients to achieve a goal of 10% reduction in weight ( 500 to 800 kcal/day decrease to affect 1- to 2-pound loss/week); ( 6) counsel patients to exercise to achieve a goal of any increased energy expenditure. Conclusions: Weight loss has an impact on important disease states and risk factors. Effective strategies exist for the management of obesity when viewed as a chronic relapsing disease.

Objective. To describe how clinicians create opportunities to deliver preventive care in illness visits and assess the impact this has on preventive service delivery.Method. Detailed and descriptive fieldnotes were collected from 18 purposefully selected family practices, including direct observations of 53 primary care clinicians and 1620 patient encounters. Conversation analysis was used to examine the conversational techniques employed to deliver four preventive services (smoking counseling, immunization delivery, mammography, and cervical cancer screening) in illness visits. Qualitative data was coded and analyzed to assess impact on preventive service delivery rates.Results. Two methods for opportunistic preventive service delivery were observed. In the first, clinicians used the close of the medical encounter to make arrangement for follow-up preventive care. In the second approach, clinicians use a stepwise conversational device to exit talk about the patient's presenting problem and enter into relevant health habit advice. Quantitative analyses show that opportunistic methods are rarely used to deliver preventive services in illness visits. The stepwise technique was the most frequently used method. Patients treated by clinicians who used opportunistic techniques to deliver preventive care in illness visits were more likely to be up-to-date on smoking counseling and cervical cancer screening than those patients who were treated by clinicians who did not use opportunistic approaches.Conclusions. Opportunistic preventive service delivery in illness visits can be an efficient and effective way to deliver preventive care. Although infrequently used, quantitative data suggest that the use of opportunistic approaches to deliver preventive services during illness visits can enhance preventive care rates. Interventions aimed at helping clinicians develop effective strategies for offering preventive care during illness visits may be an important complement to existing mechanical interventions that might, by themselves, be insufficient to improve preventive care. (C) 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.

Background. Obesity is epidemic in the US and other industrialized countries and contributes significantly to population morbidity and mortality. Primary care physicians see a substantial portion of the obese population, yet rarely counsel patients to lose weight.Methods. Descriptive field notes of outpatient visits collected as part of a multimethod comparative case study were used to study patterns of physician-patient communication around weight control in 633 encounters in family practices in a Midwestern state.Results. Sixty-eight percent of adults and 35% of children were overweight. Excess weight was mentioned in 17% of encounters with overweight patients, while weight loss counseling occurred with 11% of overweight adults and 8% of overweight children. In weight loss counseling encounters, patients formulated weight as a problem by making it a reason for visit or explicitly or implicitly asking for help with weight loss. Clinicians did so by framing weight as a medical problem in itself or as an exacerbating factor for another medical problem.Conclusions. Strategies that increase the likelihood of patients identifying weight as a problem, or that provide clinicians with a way to "medicalize" the patient's obesity, are likely to increase the frequency of weight loss counseling in primary care visits. (C) 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.

Two voices tell the story of an evolving doctor-patient relationship. Seizures are the first indication of squamous cell lung cancer metastatic to the brain. Both doctor and patient describe the course of the illness, treatment, and remarkable recovery, each from his own perspective. The patient describes how the cancer became a creative as well as a destructive force, expressed in his painting and new approach to life. The essay concludes by discussing limitations of the biomedical model of disease in this case and the complex two-way nature of the healing relationship between doctor and patient.

The U.S. health care system serves a diverse population, often resulting in significant disparities in delivery and quality of care. Nevertheless, most quality improvement efforts fail to systematically assess diversity and associated disparities. This article describes application of the multimethod assessment process (MAP) for understanding disparities in relation to diversity, cultural competence, and quality improvement in clinical practice. MAP is an innovative quality improvement methodology that integrates quantitative and qualitative techniques and produces a system level understanding of organizations to guide quality improvement interventions. A demonstration project in a primary care practice illustrates the utility of MAP for assessing diversity.