Case Scenario

I completed my residency two years ago. I now am a junior member of a six-physician family practice. During my residency, the faculty encouraged me to practice medicine in accordance with the New Model of family medicine introduced in the Future of Family Medicine report (e.g., electronic health records, continuous quality-improvement initiatives). My colleagues, however, completed residencies at least 15 years ago. They regularly complain about declining reimbursements, impractical time demands for preventive care and chronic disease management, and difficulties with staying current on new medical knowledge.

At recent staff meetings, I have suggested that we could improve physician morale and patient care by redesigning our practice strategies (e.g., group visits for pregnant women and those with common chronic conditions, same-day appointment scheduling, an electronic health record system). So far my colleagues have unanimously opposed these ideas. They seem to fear a possible upheaval from such a transition.

During my residency, I thought that I would work at a “model practice” that would incorporate the best innovations that family medicine has to offer. Were my high expectations unrealistic? How can I persuade my senior colleagues to embrace rather than fear these changes?

Commentary

The resistance to change described in the scenario is common in medical practice. Group practices evolve over many years, and physicians become comfortable with how their practices work. Although these routines may not be perfect, they are predictable and reliable. This may make it difficult to implement change. Acknowledging the fact that change may not be easy or painless and then focusing on the benefits of a new system may be helpful. To elicit the attention of other physicians in a practice, it is essential to adequately address their concerns. These concerns typically include loss of productivity during the transition, potential failure of new technology, and the inability to recover necessary expenditures (i.e., return on investment).

The New Model of family medicine, introduced in the Future of Family Medicine report,¹ offers physicians the opportunity to increase the efficiency and reliability of their practices and improve clinical care, patient satisfaction, and the “bottom line.” Elements of the New Model include a consistent basket of services; active management of chronic illness; easier access to medical care for patients; and information technology that supports system quality, timely patient communication, and decision making at the point of care.¹ The Future of Family Medicine project’s Task Force 6 developed a financial model for the New Model of family medicine.² The task force estimates that by implementing all of the elements of the New Model, family physicians could work the same amount of hours and increase their income by 26 percent, or they could work 12 percent fewer hours and maintain the same income.²

Family medicine residents often choose to join a practice based on location, contract perks, or familiarity with the other members of the practice. It is often difficult to understand the governance, politics, and chemistry of a practice without spending significant time there. Of course, any group relationship, no matter how good it seems initially, will reveal some interpersonal difficulties as time goes on. If the group deals with conflict openly and sensitively, the group dynamic and cohesion will strengthen.

After joining a practice, many new physicians face a dilemma: how to implement change when someone else is in charge. A few strategies may help resolve this dilemma: 1) finding one or two partners who are sympathetic to new ideas and having them help with approaching the office manager and other key staff members; 2) having those who support a suggested plan serve as the innovation team; and 3) planning and executing a project that is limited in scope, reporting (or having the office manager report, if possible) on its successes to the rest of the group, then asking permission to increase the scale of the project.

Some group practices have periodic retreats to discuss strategic planning and the future of the practice. This would be the ideal setting to verbalize new ideas. Those proposing a change should be prepared for objections and should be ready to provide facts about the project and its benefits. Depending on the group dynamic, including a facilitator in the discussion may be helpful. The facilitator can help keep the discussion positive and keep individuals from influencing the group too much.

Partners in group practices are often equal owners and want to have a say in how the practice is managed, which may create leadership issues. Even if a leader or manager is identified, he or she may have little power to make change against the will of other members of the group. In essence, if a decision is not unanimous, it is difficult to move forward. Therefore, if no progress can be made toward a practice consistent with the New Model, the physician may consider joining another practice that fits more closely with his or her principles. The physician also may consider starting his or her own practice. A new practice that has electronic health record systems, open-access scheduling, and group visits will have an advantage when recruiting new family physicians fresh from training.