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


In this study, we used in-depth semi-structured interviews to understand PCP experiences treating complex patients in primary care settings. PCPs described: 1) strong desires to provide optimal care for complex patients with multidimensional needs, 2) significant barriers to optimal care delivery at a local and system level, and 3) reliance on professional values and individual care strategies to overcome these barriers.

PCPs described optimal care for their complex patients in terms of actions they could take that would help their patients' overall health and quality of life. Specifically, they focused on coordinating care among specialists, preventing hospitalizations, and building patient trust. This description of optimal care aligns with recommendations for a shift from problem-oriented care to goal-oriented care.[28,29] Goal-oriented care focuses on patient-defined goals rather than disease-specific guidelines. This shift has been supported by research that highlights potential negative consequences of following guideline-concordant care for multiple different concomitant diseases in the same patient.[30]

Within their local institutions, PCPs reported that insufficient clinical support, challenges communicating with specialists, and productivity pressures interfered with their care of complex patients. These findings are consistent with past qualitative research on prescribing and decision-making for complex patients.[9–11] Further, the time pressures and lack of clinical support raise a risk of burnout in these providers. In the Minimizing Error, Maximizing Outcome (MEMO) study, adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave.[15]

PCPs relied on professional values and personal strategies to navigate local institutional and healthcare system barriers to provide optimal care to their complex patients. This emphasis on professionalism, specifically self-sacrifice, and self-reflection by PCPs in this study is consistent with core values of professionalism articulated by physician professional organizations. Professionalism has been identified as one of six Core Competencies for internal medicine residents.[31] American and European Internal Medicine boards and societies[32] have identified 1) the primacy of patient welfare; 2) patient autonomy; and 3) social justice as three principles of professionalism. While reliance on professionalism and self-sacrifice is consistent with core competencies, it may not overcome the system barriers preventing optimal care. Further, since professionalism often was described as working longer hours and sacrificing PCP's personal needs, these strategies may contribute to PCP burnout.

Participants endorsed changes consistent with team-based care models to help them effectively manage complex patients. Team-based interventions[33,34] based on the Chronic Care Model[35] have been developed for managing high-risk[36] patients with chronic diseases in the primary care setting. Transitioning to team-based models may address some of the barriers to optimal care identified by PCPs in our study. Among VA primary care personnel, those working in clinics that were appropriately staffed, emphasized participatory decision making, and had an increased proportion of time team members spend working to the top of their competency level reported lower rates of burnout.[37] Working in a tight team structure and greater perceptions of team culture have been associated with less clinician exhaustion.[38]