'It just has to click':Internists' views of: what constitutes productive interactions with chronically ill patients

Background: According to the Chronic Care Model, productive interactions are crucial to patient outcomes. Despite productive interactions being at the heart of the Model, however, it is unclear what constitutes such an interaction. The aim of this study was to gain a better understanding of physician views of productive interactions with the chronically ill. Method: We conducted a qualitative study and interviewed 20 internists working in an academic hospital. The data were analyzed using a constructivist approach of grounded theory. To categorize the data, a coding process within which a code list was developed and tested with two other coders was conducted. Results: The participants engaged in goal-directed reasoning when reflecting on productive interactions. This resulted in the identification of four goal orientations: (a) health outcome; (b) satisfaction; (c) medical process; and (d) collaboration. Collaboration appeared to be conditional for reaching medical process goals and ultimately health outcome and satisfaction goals. Achieving rapport with the patient ('clicking,' in the term of the participants) was found to be a key condition that catalyzed collaboration goals. Clicking appeared to be seen as a somewhat unpredictable phenomenon that might or might not emerge, which one had to accept and work with. Goal orientations were found to be related to the specific medical context (i.e., a participant's subspecialty and the nature of a patient's complaint). Conclusions: The participants viewed a productive interaction as essentially goal-directed, catalyzed by the two parties clicking, and dependent on the nature of a patient's complaint. Using the findings, we developed a conceptual process model with the four goal orientations as wheels and with clicking in the center as a flywheel. Because clicking was viewed as important, but somewhat unpredictable, teaching physicians how to click, while taking account of the medical context, may warrant greater attention

Internists’ dilemmas in their interactions with chronically ill patients; A comparison of their interaction strategies and dilemmas in two different medical contexts.

Background Internists appear to define productive interactions, key concept of the Chronic Care Model, as goal-directed, catalyzed by achieving rapport, and depending on the medical context: i.e. medically explained symptoms (MES) or medically unexplained symptoms (MUS). Objective To explore internists’ interaction strategy discourses in the context of MES and MUS. Methods We interviewed twenty internists working in a Dutch academic hospital, identified relevant text fragments in the interview transcripts and analyzed the data based on a discourse analysis approach. Results We identified four interaction strategy discourses: relating, structuring, exploring, and influencing. Each was characterized by a dilemma: relating by ‘creating nearness versus keeping distance’; structuring by ‘giving space versus taking control’; exploring by ‘asking for physical versus psychosocial causes’; and influencing by ‘taking responsibility versus accepting a patient’s choice. The balance sought in these dilemmas depended on whether the patient’s symptoms were medically explained or unexplained (MES or MUS). Towards MUS the internists tended to maintain greater distance, take more control, ask more cautiously questions related to psychosocial causes, and take less responsibility for shared decision making. Discussion and conclusions Adopting a basic distinction between MES and MUS, the internists in our study appeared to seek a different balance in each of four rather fundamental clinical dilemmas. Balancing these dilemmas seemed more difficult regarding MUS where the internists seemed more distancing and controlling, and tended to