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DELPHI ROUND PURPOSE PROCEDURES Round 1 posted for12 days (86% response) Identify and describe rewards and challenges Participants were asked to do the following -
Complete a demographic questionnaire:
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Describe significant rewards and challenges they have experienced in practice
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Include reasons for their choices
Round 2 posted for37 days (96% response) Clarify rewards and challenges and identify any new rewards or challenges 34 themes from round 1 were posted for review. Participants were asked to do the following: -
Rate how well the theme rejected their comments(1—not at all, 4—very well) and comment
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Rate themes’ importance and effect on family medicine(1—not at all, 5—very important) and provide reasons for ratings
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Review themes rated as important for “breadth and completeness” and “clarify”
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Reject on the breadth and completeness of rewards and challenges as described and add any others and rate them
Round 3 posted for 12 days (89% response) Develop consensus on key rewards and challenges and obtain feedback 53 themes from round 2 were posted for review (divided into rewards and challenges). Participants were asked to do the following -
Select up to 10 key rewards and challenges each:
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Provide comments and feedback
Round 4 posted for 17 days (89% response) Validate and clarify key rewards and challenges identified, develop a priority list of rewards and challenges, explore Potential solutions including the role organizations could play, determine whether other rewards or challenges should be considered, and obtain feedback Rewards and challenges chosen were posted along with the results of previous rounds. Participants were asked to do the following: -
Rate how well the list represents the key rewards and challenges(1—not at all, 5—very well)
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Clarify whether “maintaining and acquiring skills and knowledge” represents 2 separate issues or the same issue
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Clarify whether “medicolegal issues, paperwork, and motor vehicle accidents” could be included with “paperwork, telephone calls, and forms”
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Comment on proposed list and add any items that should be included
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Select the 5 most important rewards and challenges and rank them on a scale of 1 to 5 relative to each other. Repeat this process to identify the least important items
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Rate the need to address challenges (1—no need, 5—very strong need).
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Reject on the key rewards and challenges and provide salient and concrete suggestions on the precise way specific organizations could assist
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Provide any other ideas, comments, feedback, or suggestions
Round 5 posted for 27 days (86% response) Obtain further clarification determine whether new, challenges identified in round 4 should be included, and obtain feedback Summarized results from round 4 were posted, including 3 new potential challenges with descriptions of what could be done to address each challenge. Participants were asked to do the following: -
Clarify the wording of “rewards of maintaining and acquiring skills and knowledge” and “medicolegal issues, insurance paperwork, and motor vehicle accidents”
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Comment on and rate the need to address the new challenge(1—no need, 5—very strong need)
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Decide whether the new challenge should be a key challenge
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Provide ideas on solutions and the role key organizations could play
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Answer the questionnaire soliciting feedback
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- Table 2
Overview of ranking (highest to lowest): In Delphi round 4, 8 rewards and 6 challenges were ranked according to their level of importance relative to each other on a scale of 1 to 5 (1—least important, 5—most important)
REWARDS AND CHALLENGES MEAN RANKING (N = 24*) REWARDS Diversity and comprehensive care 4.0 (n = 20) Preventive care 3.8 (n = 4) Relationships with patients and their families 3.5 (n = 17) Being an immersed witness to the human condition 3.3 (n = 8) Continuity of care and ongoing feedback 2.9 (n = 8) Control, flexibility, and security 2.7 (n = 11) Maintaining and acquiring skills and knowledge 2.0 (n = 2) Teaching, sharing knowledge and experience, and mentoring 1.8 (n = 6) CHALLENGES Medicolegal issues, paperwork, and motor vehicle accidents 4.0 (n = 1) Workload and time pressure, meeting demands 2.6 (n = 17) Maintaining and acquiring skills and knowledge 2.2 (n = 5) Paperwork, telephone calls, and forms 2.2 (n = 6) Availability of specialists, procedures, tests, and other resources 2.0 (n = 5) Patients’ expectations 1.9 (n = 8) -
↵* 24 of the 25 round-4 respondents completed this part of the survey. On the most important rankings, 23 of the 24 ranked 3 and 2 on the most important items; all 24 responded to the rest of the rankings.
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- Table 3
Ranking of the need to address challenges:Mean scores as identified in Delphi rounds 4* and 5† (1—no need to address, 5—strong need to address)
KEY CHALLENGES MEAN SCORE (RANGE, MEDIAN SCORE) Workload and time pressures, meeting demands 4.48* (3–5, 5) Need to promote the rewards identified to those who might consider family practice as a profession 4.44* (3–5, 5) Overhead and income inequities 4.27† (2–5, 5) Getting respect from specialists 4.22† (2–5, 5) Need to ensure that the rewards identified are not adversely affected by primary care reform 4.0* (1–5, 5) Availability of specialists, procedures, tests, and other resources 3.88* (2–5, 4) Running a practice—a small business 3.87† (2–5, 4) Paperwork, telephone calls, and forms 3.72* (2–5, 4) Maintaining and acquiring skills and knowledge 3.67* (1–5, 4) Patients’ expectations 3.63* (2–5, 3.5) Medicolegal issues, insurance paperwork, and motor vehicle accidents 3.48* (1–5, 3) - Table 4
Rewards and challenges of family practice: Number of participants ranking rewards and challenges in Delphi rounds 3* and 5.†
REWARDS IN ORDER OF RANK AND CHALLENGES IN ORDER OF THE NEED TO ADDRESS THEM NO. OF PARTICIPANTS RANKING THEM ILLUSTRATIVE QUOTES REWARDS Diversity and comprehensive care (reflects the variety,breadth, and diversity of practice; a complex set of skills;specific technical skills; etc) 22/25* Broad range of knowledge; never boring; difficulty and complexity; one physician who can look at all aspects; patient assessed as a whole person Preventive care 13/25* Early, when it is relatively easy to educate patients, to effect change, and to focus on wellness; satisfying and fun; our most important role; integral to family medicine Relationships with patients and their families 22/25* Advocates, highly privileged position; personal ... intense relationship; experienced birth, severe illness, or death in the family; long-term relationships— generations; emphasized more in recruiting efforts; most significant reason for continuing Being an immersed witness to the human condition 11/25* Learn from observing; we grow from interacting; witness to the powerful moments of life; the church has the sacraments, [but] we usually are involved at some stage in the actual physical expression of them Continuity of care and ongoing feedback 17/25* Following patients; knowing they benefited; encouragement personally and professionally; enduring feeling ... done some good; I know my patients, ... a good thing for everybody Control, flexibility, and security 19/25* Flexibility in this occupation; being able to exert significant control over my client load, work hours, work style, and setting; type of medicine; ability to learn new skills Maintaining skills and knowledge 13/25* Stimulation and satisfaction; learn something new each day; modern technology; maintain an advanced skill, eg, endoscopy; constructive feedback from colleagues(family physicians, nurses, consultants); key to becoming an excellent clinician Teaching, sharing knowledge and experience, and mentoring 13/25* Bringing someone to valuing appropriately their skill and place … is of great benefit; there are things we can teach that are not teachable in the classroom CHALLENGES Workload and time pressures, meeting demands 19/25* Never enough time to do anything well; meeting patient needs and demands; single largest frustration; feeling rushed; affected my family life to its detriment Need to promote the rewards identified to those who might consider family practice as a profession Overhead and income Inequities 17/21† Family practice ... poorly paid relative to other specialties; affects our ability to take the time for paperwork [or] for extra training and with our patients; need to see enough patients to make the office ... cost-effective; cost of providing primary care is largely borne by family physicians, ourselves Getting respect from specialists 17/21† [Specialists] do not understand our role; [do not accept] telephone appointments and[offoad] work onto our staff, undermining our credibility with our patients; negative comments about our specialty to residents and medical students reject a lack of respect; in the past [we had] more opportunities to meet and work together Need to ensure that the rewards are not adversely affected by primary care reform Availability of specialists, procedures, tests, and other Resources 12/25* Much time is spent either trying to access resources or patching up the cracks in the system; sometimes dangerous as we try to manage our patients in need; feeling powerless in the face of unacceptable delay; increases the “burnout factor” CHALLENGES Running a practice—a small business 14/23† Part... is overhead expenses, but running a practice is so much more: staffing, supplies, computer systems management, health information act; running one’s practice efficiently (time and cost) and safely is a major challenge Paperwork, telephone calls, and forms 18/25* Bureaucracy intrudes on my ability to provide good patient care; hours of work to take home; biggest downsides to family medicine; other reports fall in our laps from specialists Maintaining and acquiring skills and knowledge 14/25* Expanding body of knowledge is daunting; frustrating to see colleagues ... not in keeping with the need to remain current; negative incentives and barriers; difficult in a rural practice ... low volumes; ever-changing goals and standards of care Medicolegal issues, insurance paperwork, and motor vehicle accidents 13/25* Done in non-patient-care time; assist a process that inherently delays recovery of health; wasting good clinical time
