Primary Care Providers' Experiences Caring for Complex Patients in Primary Care

Danielle F. Loeb; Elizabeth A. Bayliss; Carey Candrian; Frank V. deGruy; Ingrid A. Binswanger


BMC Fam Pract. 2016;17(34) 

In This Article


Complex patients, defined by the Agency for Healthcare and Quality (AHRQ) as persons with two or more chronic conditions where each condition may influence the care of the other condition, are commonly cared for in primary care.[1] Complex patients with multiple chronic conditions have increased medical costs, a higher number of preventable complications, higher rates of avoidable hospitalizations, and decreased quality of life.[2,3] In 2006, over 25 % of adult patients and 75 % of those over 65 reported having more than one chronic condition.[4] One study of 148 primary care practices found that 45 % of adult patients had two or more chronic conditions.[5] Family physicians in Wisconsin reported addressing more than four problems per visit in over half of the visits for diabetes care.[6]

Complex patients' experience well-described barriers to self-care have been well studied.[7,8] Less is know from the provider perspective. Physicians and pharmacists have highlighted a lack of time, poor communication with specialists, and fragmented care as barriers to effective care.[9] In studies focused on clinical decision-making for patients with multiple chronic conditions, a lack of time and adequate reimbursement emerged as barriers to clinical decision-making.[10,11]

Although barriers to medication prescribing and decision-making for primary care physicians (PCPs) caring for complex patients have been previously described, less is known about the potential impact and meaning for PCPs of caring for these patients on a daily basis. Developing a greater understanding of PCP experiences caring for complex patients is important because providing such care in the context of scarce time and resources may be associated with physician burnout.[12,13] Burnout in PCPs has been associated with a higher likelihood of leaving practice.[14] Among New York PCPs, participants described significant time pressures, chaotic work pace, and low level of control over their work.[15] In the United Kingdom, General Practitioners described tension between addressing their patients' agendas and meeting quality measures, which increased when treating patients with multiple chronic conditions.[10] In the 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, only 16 % of US physicians felt that the healthcare system worked well, 33 % felt the quality of care patient received in the healthcare system had gotten worse in the last 3 years, 43 % stated their job was very or extremely stressful, and 34 % were somewhat or very dissatisfied practicing medicine.[16] Thus, the increasing patient complexity in the setting of limited time and clinical support may represent an important source of career dissatisfaction and burnout for PCPs.[17]

Little is known about the strategies PCPs employ when faced with challenges providing care for complex patients. In order to better understand the day-to-day challenges of PCPs, the strategies they use to meet these challenges, and how to better support PCPs, we sought to characterize PCPs experiences with complex patients. Through open-ended interviews we explored their perceived barriers and facilitators to effective care and their strategies to address barriers.