1. A typology of primary care physician styles in diabetes care
Jesse C. Crosson, Chien-Wen Tseng, Julie A. Schmittdiel, Kingsley Onyemere,
Sonja Ross, Bix Swain, Michelle Heisler, Gabrielle J. Davis, Monica Girotra, Norman Lasser
Introduction
Control of cardiovascular disease (CVD) risk factors, blood glucose, blood pressure and lipids, among patients with diabetes has been shown to reduce the incidence of morbidity and mortality in this population. Predictors of poor risk factor control include clinical inertia, or the failure to intensify treatment appropriately, and patient non-adherence to prescribed therapies. Previous research has found that patients of physicians with more participatory decision making styles have better diabetes-related processes of care but do not have better risk factor control.
A new typology of physician styles is needed to explore the predictors of poor CVD risk factor control.
Results
During analysis two dimensions of physician style emerged: outcome expectations and patient-centeredness.
Conclusions
Physician resignation when handling this complex clinical issue was common in these interviews indicating many of these primary care physicians had a good appreciation of patient barriers but had lost faith in their ability to facilitate good CVD risk factor control.
Although either resignation or judgmental approaches are unlikely to lead to improved outcomes, the relationship between the styles identified here and CVD risk factor control remains to be explored.
Resigned:
“I have a patient (who) … knows she’s not eating the right way and she says … ‘that’s all … I can afford, and I know its cheap and filling and that’s it. I know I’m not doing well but what else can I do.’ And I’m like ‘sure, I know.’ No matter how much I can provide her with, the changes … are not going to happen, because of the financial barrier.”
“I lecture them, and I give them a chance, but if you’re coming late to your appointments an hour and a half or even on different days … then I can’t do anything.”
Collaborative:
“All you can do is support, and maintain trust and credibility. … the right thing is to just be there. I think sometimes a lot of physicians get very, very frustrated by it, including myself, and it’s like “oh what’s the purpose?” and then you say that, and then you lose trust. The patient loses trust in you, I should say, like you don’t care anymore about them. … no one is going to care about them if you don’t.”
Directive:
“I just sent him a letter, and said, this is the kind of thing that happens when your diabetes is out of control. … every time I see him I keep hammering.”
Judgmental:
“… the woman he lives with is kind of in a similar intelligence level … and I don’t think is helpful in regards to changing dietary habits. … He’s just a stubborn, little old fat man.”
Higher expectations
Next Steps
Develop quantitative measures to explore the relationship between physician style and CVD risk factor control in a larger sample with patient outcome data.
Lower expectations
Methods
In-depth interviews with 34 primary care physicians in four states.
Figure 2. Classification of physician styles
Figure 2 shows the relationship between the two dimensions of physician style and the typical styles defined by the interaction of these.
Physicians with higher expectations (the “collaborative” or “directive” styles) tended to report that patients could achieve good control regardless of the barriers that they faced while those with lower expectations (“resigned” or “judgmental”) saw barriers as more insurmountable.
Physicians who were more patient centered (the “collaborative” or “resigned” styles) tended to identify success or failure in achieving good outcomes with patient attributes or actions while those with a more physician centered view (“directive” or “judgmental”) tended to emphasize the importance of following instructions from the physician.
Acknowledgments
This research is supported by a grant from the Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Diseases (U58/CCU223529)
Figure 1. Interview subjects in each state
Author affiliations
UMDNJ-New Jersey Medial School & UMDNJ-Robert Wood Johnson Medical School, Departments of Family Medicine: JCC
University of Hawaii, Department of Family Medicine & Pacific Health Research Institute: CWT.
Kaiser Permanente Division of Research: JAS, BS.
University of Michigan: KO, MH.
UMDNJ-Center for Continuing and Outreach Education: SR, GD.
UMDNJ-New Jersey Medical School, Department of Medicine: NL.
Interview transcripts were coded and analyzed using ATLAS.ti. We used a template organizing style for coding allowing for emergent themes. The initial template focused on physician-reported barriers and facilitators to good CVD risk factor control.