The future of family practice lies in developing medical homes for our patients, offering comprehensive family practice services while meeting population and public health needs. This patient-centred approach addresses continuity of care through coordinating all medical services a patient receives in the community.1 Most provinces have practice structures designed for community-focused health care (Ontario’s family health teams,2,3 Alberta’s primary care networks, Quebec’s family medicine groups, etc). Yet several factors hinder physicians’ familiarity with patients’ communities, inhibiting their input in the design and planning of medical homes.
Physicians focus on their own patients, who might come from multiple neighbourhoods. Busy schedules limit physicians’ participation in community activities. Clinicians no longer regularly take part in hospital rounds, diminishing contact with other physicians and conversations about common issues in practice. The growth in urban centres limits opportunities for the casual encounters of smaller centres. And within this vicious cycle there is a dwindling sense of community that hinders physician involvement. Becoming more engaged with the patient-centred practice of medicine is a professional imperative.4
Engagement, defined as “an energetic state of involvement with personally fulfilling activities that enhance one’s sense of professional efficacy,”5 is essential to job satisfaction.6 An engaged physician is more attentive to patients, enabling a higher level of care. Physician engagement benefits health care organizations, as these individuals develop into leaders who
assume responsibility to set direction for positive change in health and wellness in the health system, to exercise that responsibility in a caring and compassionate fashion, and to influence others to work together to achieve those changes.7
More important, engagement benefits the physicians themselves by preventing burnout, the chronic sense of exhaustion and detachment that is sadly common among primary care physicians.5
Typically, physicians are highly engaged at the outset of their careers. Physician education and training centre on the knowledge and clinical skills necessary for individual patient care but lack a focus on the other competencies of successful medical practitioners.4 Although regulated and guided by professional colleges, physicians are autonomous. As they develop the competencies essential to practise, physicians identify themes in the health of their patients. Their interest in population health grows and is enhanced by positive experiences of interprofessional collaboration.
Spheres of interest
Maintaining engagement follows a progressive pattern, evolving with the physician’s interests (Figure 1). The more basic areas must be addressed before a physician’s attention turns to the next sphere of interest.
Personal interest.
At the outset, physicians’ central concerns are themselves and the patients in their care. They identify opportunities to effectively advocate for patients. The time required for the practice of medicine grows, and physicians strive to balance their career and personal lives. Inevitably, physicians recognize gaps in their knowledge.
Education or scholar.
To fill these gaps and improve the care of their patients, physicians focus on professional development. New knowledge and insights gained through conferences or continuing professional development (CPD) programs are translated to clinical practice. A benefit of attending conferences and courses, whether in person or online, is the opportunity to discuss challenges encountered in practice with peers. Some might value these experiences so much so that they develop their own skills in educating other physicians. If an engaged physician’s frustrations in patient care remain unresolved, he or she might turn to research or contribute to the medical literature.
Quality improvement (QI).
With education, an understanding of the effects of clinic processes on patient care grows, often with recognition of how barriers to best practice can develop. Engaged physicians address these frustrations by involving others in such efforts as QI initiatives. Quality improvement requires data collection and analysis at a small level, then integrating a trial change to evaluate its effect on patient care and the organization as a whole. Results inform change in practice processes, enabling better patient outcomes. Experience in QI brings insight into multiple aspects of patient care in a physician’s particular organization and strengthens interprofessional collaboration. Participating in innovative change is itself invigorating and satisfying.7
Leadership career.
Success in improving patient care through such collaborative initiatives might inspire an interest in leading further improvements. By cultivating a more holistic approach to problem solving, physicians can take part in organizational governance. They might choose to represent colleagues and advocate for patients in broader structures, designing and planning health care in the community.
System thinking.
Exceptional individuals might take on the ultimate challenge in health care: designing and integrating health care systems on a macro level. Engagement at this level can transform the health care system.
Evolving engagement
Engagement enables physicians to build and strengthen the medical home for their patients. Through listening to patients, educating themselves to enable better care, and implementing improvements in patient-centred processes (spheres 1 to 3), physicians build the medical homes their patients want. As an engaged physician builds a leadership career (sphere 4) and adopts system thinking (sphere 5), successful innovations can be applied more widely, reinforcing medical homes throughout the health care system.
Ultimately, physicians engage through active choice, strengthened by a community orientation and social consciousness—a desire to contribute.7 Self-awareness and strong communication skills are important factors. Innovative thinkers are more likely to become leaders.7,8 Fear of failure8 and anxiety about one’s competence as a leader7 are individual barriers. Not every physician will become a leader, but health care organizations can encourage physician engagement and remove barriers to participation.
Highly bureaucratic organizations thwart physician engagement.7,8 Chronic conflict, poor communication practices, lack of consultation, and interference with the best possible care of patients are considerable barriers.7 A culture of engagement is one of open communication,7–9 trust,7,8 and respect,7 promoting collaboration and encouraging physician input and participation, particularly around patient care.7 Physicians are more engaged in organizations that systematically include physicians in decisions addressing their concerns.7,9 An organizational commitment to problem solving in teams is conducive to physician engagement. Engagement requires support, such as resources, training, and education opportunities, particularly in leadership, communication, and conflict management skills.7–9 Incentives to engage are helpful and need not be financial. It is more important that they address the physician’s primary pressures: time, administrative burden, and work-life balance.9 Simple invitations to participate and recognition build engagement.7
The structure of physician compensation can either encourage or dissuade engagement. Fee-for-service models can have a patchwork effect on patient care. A strictly capitation approach—a flat fee for each patient enrolled—does not address the complexities of practice. Neither model offers an incentive for improving patient care. Blended payment models, incorporating both capitation and fee-for-service, can encourage engagement, particularly when incentive bonuses target preventive care and chronic disease management. Engaged physicians are more skilled in patient care and more attuned to the changes they can make in practice to improve patient outcomes. Rewarding engagement will ultimately benefit the health care system.
Strategies to build physician engagement
Strategies targeting each of the 5 spheres of physician interest will strengthen physicians’ individual commitment to improving all aspects of patient care. Incentives (monetary or not), which save physicians time, spare costs to the system, and improve patient care, can engage physicians in medical home design. For physicians who are in the first sphere of personal interest, the required incentives include pay for performance, billing tips, improved referral systems, and opportunities to collaborate with other health care professionals. For those physicians who are pursuing education or adopting the scholar role (sphere 2), CPD programs that are designed for proactive change and increased collaboration are ideal. Some examples include faculty development programs, assistance with academic research, and incentives to study population health. Physicians beginning to work in QI (sphere 3) require training in these initiatives. Engagement is enhanced by providing data at the population level, sharing benchmarking targets, and receiving organizational support for decisions to make the changes in practice indicated by the QI data. As physicians move into leadership careers (sphere 4), leadership training will increase engagement, whether the training is provided by medical schools, residencies, or CPD programs, such as the Canadian College of Health Leaders LEADS program.10 System thinking physicians (sphere 5) are engaged by opportunities to collaborate with other parts of the health care system, exploring other models of care.
Physician engagement can help develop leaders, strengthen the voice of family physicians in the care of our patients and the design of medical homes, as well as improve the health of our communities.
Footnotes
Competing interests
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
Cet article se trouve aussi en français à la page 615.
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