1. Practice Inquiry A Strong and Flexible Foundation for the Medical Home Kimberly Duir MD, Contra Costa Regional Med Center Lucia Sommers DrPH, UCSF Nancy Morioka Douglas MD MPH, Stanford University

2. Overview Introductions Brief description of Practice Inquiry and potential role in the medical home. Participate in Practice Inquiry Group Debrief Consider opportunities and challenges for implementation at home institution

3. History of Practice Inquiry Dr. Lucia Sommers began these groups for primary care clinicians in 2002 Original intent was epidemiologic and focused on clinical decision making. “What kinds of cases are primary care MD’s stumped by?” Now shown to be helpful to clinicians in practice and residents in training.

4. Definition of Practice Inquiry A facilitated small group process using group members’ most complex patients as content for practice based learning/improvement.

5. How is it Different? Unlike most CME and QI it is inherently relevant. Unlike Balint, it may include discussion of diagnostic, therapeutic, prognostic concerns, as well as doctor/patient relational concerns. Unlike much QA/QI, clinicians experience it as helpful and supportive.

6. How is it Different? Provides a supportive setting for sharing clinical uncertainty. Logging presented cases allows us to track individual outcomes Analyzing log data allows us to document need for targeted local CME and/or new directions for primary care research.

7. Why should it be built into the Medical Home? As more simple functions are shunted to other team members, the proportion of complex patients for MD’s will increase. The complexity and uncertainty of primary care practice is already burning out clinicians and scaring away medical students. If we don’t create structural supports for primary care clinicians and residents, there may be nobody at the medical home when patients come knocking.

8. Why should it be built into the Medical Home? Provides a structure for lifelong practice learning in a peer learning community. Converts our most challenging patients into opportunities for creativity and iterative learning Lessons learned benefit the entire practice. The best outcomes for patients are achieved when doctors are given the time to talk and think together.

9. What are the essentials of Practice Inquiry? Clinician identifies a case that creates “uncertainty” Structure discussion with agenda that centers on the five inputs to clinical judgement. The clinician whose case is being presented, “runs” the session by asking colleagues for help with the case.

10. What are the essentials of Practice Inquiry? Blending the five inputs, the group crafts options for intervention for that patient. Clinician provides the group with follow up on results of the intervention at the next session.

11. Inputs to Clinical Judgement Clinical experience Evidence Clinician context Patient Context Clinician patient relationship

12. Role of the facilitator Protect the presenter and the process. Probe for all the inputs to clinical judgement. Make sure that the group develops an intervention that feels good to the presenter before the session ends. Maintain the case log, track follow up of cases, and reflect with the group on case log contents.

13. Let’s Do It! Group of primary care clinicians with active patient panels (no more than 12) Each think of a patient you saw last week that you “brought home” and write a brief descriptive phrase on a card. Group of observers While the clinicians are coming up with cases, review the observer tasks.

14. Debrief How did it feel for the presenter? How is uncertainty normalized and used to stimulate creativity? What tactics did the facilitator use to help the group blend the inputs to clinical judgement and craft an intervention?

15. Debrief Were there examples of : Identifying nature of uncertainty Sharing relevant clinical experiences Acknowledging knowledge/skill gaps Probing for role of clinical literature Checking back with presenter for their “take” on the process Helping presenter to crystallize ideas on how to move forward with case. Speculating on role of “relationship” in the case

16. Taking It Home What ways could you imagine adapting this to your setting? How does this work reinforce the foundational medical home principles for staff and learners? How can PI strengthen the role of the personal physician, team practice, whole person orientation, quality and safety, coordination of care? (review contents of take home packet)