Of 23 participating physicians, most were MDs (n = 21) in hospital-affiliated clinics (n = 14). Interviews were conducted with physicians across all regions of the VHA. Demographics of the participants are in Table 1. Emergent themes for factors affecting decision-making for complex patients with multimorbidity are described below; Table 2 provides additional representative quotes.
Factors affecting decision making: Major themes
Theme #1: Care planning for complex patients is collaborative in primary care.
Many physicians described working in teams to decide on or carry out recommendations for their complex patients. In response to high volumes of care needs, they described dividing up tasks among available team members and using their team to extend follow-through for ongoing needs. Physicians also described relying on collateral input from their team to care plan.
“Usually I would talk to my nurse. She seems to have a lot more ideas. If we can’t get anywhere, we will talk to social work” (P01).
Specific areas of care for complex patients, however, were felt to fall outside the scope of primary care. Mental health was felt by some physicians to be a particularly siloed domain, and others felt that there were some care needs which were the responsibility of specialists.
“I just found a psychiatrist and invited them to please help me, because I really think this is your job” (P13).
Theme #2. Patient access to resources impacts care plans.
Physicians considered potential limitations on patient access to care when deciding care plans, including resources, matching needs with available options, and travel time burden on patients with multimorbidity.
“We have no lab, we have no x-ray, we have no nothing. It's just me in a room, that's it” (P12).
“When the traffic is good, and it [the drive] could be even up to two hours. So I've been trying to get him imaging outside [the clinic]” (P15).
Many physicians considered time tradeoffs in prioritizing issues to address at visits. They recognized that the number of issues per encounter was limited by time, and not addressing some needs would mean bringing patients back to clinic more often. Some responded either by opting to extend visits or setting patient expectations. Several also described how more frequent visits weren’t always permissible in the VHA.
“Let's face it: you get the first two or three [issues] and make sure there's nothing acute going on otherwise and then see him back in a month or two to catch the rest of it” (P21).
“I really feel that the more complex patients, we need to be able to see them more often” (P23).
Some physicians discussed proactive outreach to deal with the volume of care needs and for keeping ahead of needs of patients. One described this process (referencing the Care Assessment Need score, a VHA risk score predicting adverse outcomes of utilization or mortality):(27)
“About every quarter, my nurse […], just pulls the CAN score list and anybody with an elevated CAN score she just cold calls him” (P03).
Finally, some physicians decided their care plans more reactively, in response to their perception of a patient’s goals as beneficial to health, likelihood of follow-up, or (in)ability to carry out plans.
“If patients are wishing to, say continue tobacco use, I'm certainly less likely to try to give them quicker refills on some of their inhaler medication” (P16).
Theme #3. Organizational structures provide boundaries.
Several physicians felt care decisions were dictated by system features or idiosyncrasies. This included physicians trying to match decisions to the visit format (e.g., in-person or telehealth), and being aware of VHA performance metrics.
“My plan is to do everything I can at one visit that requires me to examine them” (P01). “Most of the time with this patient, their priorities and my priorities and the quality metrics of the watchdogs are all going to match” (P23).
A few physicians noted how decisions were affected by the (lack of) availability of information about a patient. Some felt this stemmed from COVID-19 restrictions on bringing patients into the office, while others described how complex patients refused or were unable to make needed disclosures under some circumstances.
“By telephone, with all this going on, especially right now, it's a lot easier for them to say nothing's wrong, and you're just going, ‘Oh, I don't know if I believe you or not’” (P23).
Theme #4. Decisions are tailored to individual patients.
Physicians considered unique patient characteristics and their interactions when care planning. Many talked about how the severity of the patient’s health or acuity of care needs dictated decisions, feeling the need to account for changes in the patient’s health status, and acknowledged an awareness of interactions between health and the patient’s psychosocial context.
“What's going to kill him the quickest. What, if this went wrong, would lead to the most imminent demise. And that was the prioritization” (P16).
“I'll start by asking them how they're doing, if anything has recently changed, if there's any new stressors in their lives that would potentially interfere with their ability to effectively manage their medicine” (P11).
Besides acuity, most physicians articulated that they prioritized among care needs based on concrete or observable data from complex patients, such as age, finances, mental health, decision-making capacity, labs, or vital signs.
“I always look to see if they have had recent lab[s] and I look for lab abnormalities, as I'm kind of talking with them, I look at their vital signs and if they've kept a chart for me, that's good, and I look at that. […] I look at all the data that's available” (P21).
A few physicians, however, felt there was no to generalize how they made decisions for complex patients.
“When you asked me what sets the agenda, the answer is it's this deeply matrixed thing” (P07).
Theme #5. An underlying style or habit guides decisions.
Clinician style impacts care decisions. For example, some alluded to wanting to ‘do no harm’ or minimize unnecessary care for vulnerable patients.
“Trying to determine the most innocuous care plan that takes into consideration his additional comorbidities” (P24).
“Polypharmacy is a big problem… I was like, wow, is there a way that we can consolidate, or does he really need this?” (P13).
Some physicians relied on systematic approaches in care planning for complex patients, such as a habit of always arranging follow-up appointments for continuity or pre-visit preparation for efficient interactions. Several described the role of documentation, noting how their care decisions were guided by past records and using the health record to communicate plans to other team members.
“The first thing I do is I have very good notes, so [the care team] can rely on those. And they're also organized in a way that you can exactly tell what I'm thinking about” (P21).
Theme #6. Care planning for an overarching goal for care.
Most physicians felt that maintaining the stability or status-quo of complex patients dictated decisions. Safety was also described as a major goal.
“First priority is clinical stability. That’s very important of course. Things that may tip the patient into less clinical stability” (P17).
Care decisions often prioritized the priorities and concerns of complex patients, frequently focusing on symptoms or function.
“He has chronic back and leg pain that we discuss pretty much every time I see him, because that's one of his primary concerns” (P12).
Many discussed deliberately balancing their own and the patient’s goals, and some recognized that family, caregiver, or other healthcare staff goals were influential. Some physicians also described how they tried to obtain goal alignment before being able to advance care plans.
“My usual way of prioritizing is to find out what the most important thing to the patient is, but for him, both the patient and the spouse, and go through their list of priorities and then try to hit my priorities” (P19).
“I may have an agenda, but if my agenda doesn't match up with my patient's agenda, then we may not make any progress” (P19).
Theme #7. Decisions are affected by dynamic patient relationships.
Physicians considered their relationship with complex patients and tried to achieve trust and gain treatment buy-in from patients.
“You have to make your patients feel like you care about them. You should care about them, but you also have to convey that to them, that you do care and their needs and their concerns and what's important to them, it's also important to you” (P19).
“When I first met her, it was just laying down the groundwork and essentially I attempted to build a rapport and lay out what the issues are and asked her to consider how we could hopefully come to some communal ground” (P08).
A few physicians described how they emotionally reacted to some complex patients or had self-imposed boundaries that influenced their decisions.
“He's a lovely man and it's great to hang out with him and enjoy the experience of meeting with him, but also try and make sure that he really does understand what you are suggesting, and want to make the kinds of changes you're talking about” (P07).
Physicians also reflected on how decision-making may have evolved in response to prior patient behavior.
“I used to automatically refill his medication just to make sure he had them, and then I realized that didn't let me assess what he was actually taking, so I stopped doing that” (P14).
Table 2. Representative Quotes of Themes and Subthemes
Key take-away
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Key Quote
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Team collaborates on workload and provides collateral
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"You have to feel it out at first, just be cautious, and as the clinical situation develops, then you just get a good sense of what's going on. That's what I did in that scenario, just bring in multiple players and... you can see them in the home, the social workers getting the social aspect of it, and then you just really go with your gut feeling." (P03)
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Primary care has a defined scope
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“Specialty care needs to take care of the consults. Stop putting patients on primary care all the time and follow up on that.” (P04)
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Theme #2. Patient access to resources constrains care plans.
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Time tradeoffs are inherent
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"Either you address the main concern […] and have them come back later. Or, if you can address everything in one visit, then you're bringing [them] back less times." (P04)
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Resource availability
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“Some of these patients, they come from really far away and we don't have an MRI and CT where we're at, we’re like a peripheral site. I wanted some imaging of his back, [but] it means driving down even further.” (P15)
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Theme #3. Organizational structures provide boundaries.
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Tasks pair to visit modality
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“We need to be able to maybe see the complex ones more often so that we can uncomplex them. Once they're stabilized, twice a year is fine, but a lot of these, you’ve got to be seen a lot more often – and a lot of it needs to be face to face; it's not going to work by phone.” (P23)
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Organizational peculiarities
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“Sometimes patients get mixed messages, they get a different message from me and a different message from [...] their civilian provider.” (P19)
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Theme #4. Decisions are tailored to individual patients.
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Severity of concern/health
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"I first prioritize what the veteran’s goal of the visit is, but I also look at what would be most threatening, in terms of their long-term health. If the issue at that time is that the COPD or asthma is uncontrolled, and they’re wheezing and short of breath, I’d be more likely to address that." (P00)
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Response to observable data
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“You prioritize with your vitals – if […] his blood pressure is extremely high, got to really address that; if his sugars are really extremely high. I actually usually do address both of those.” (P13)
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Decisions are unique
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"For some people their struggle is […] clinical. For other people their struggling is social. For other people it's economic. For other people it's mental health." (P17)
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Theme #5. An underlying style or habit guides decisions.
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Physicians have a style or preferred approach
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"Part of my job is to be the coach and encourager and know that this is a lifelong process. You've got to make small changes that are permanent, but you can't try and make everything change all at once" (P11)
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Documentation is bidirectional with care decisions
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"If you have time to prep, that's always a good thing, because you can either go over the home monitoring stuff or like I said, go back to your previous notes: “OK, I know I needed to ask about this, because I made a note about it in my last note.”" (P06)
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Theme #6. Care planning for an overarching goal for care.
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Stability or status-quo
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“I ask him: ‘Are you status-quo today or is there something different going on?’ And then I look to these others [to] make sure that's stable.” (P21)
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Patient goals, acute needs take priority
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“Whatever the patient feels to be the absolute necessary to address, but there are times we start examining them and other things take over because they absolutely need to be addressed. [. Then anything else like chronic disease that needs to be addressed.” (P01)
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Theme #7. Decisions are affected by dynamic patient relationships.
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Advance trust and buy-in
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"She wanted to stop smoking, lose weight, use CPAP, because she had sleep apnea, and eat better. Those are big, and so I had to get her to see how her current lifestyle was preventing her from being able to do that, so therefore I got more buy-in." (P08)
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Physician internal state
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"I explained that that was my reason for not saying that he was legally blind, but he wanted me to change the form anyways [...]. I don't know if that affected care; it affected me as a provider – I felt like it was another layer of drama and frustration in trying to provide care for him." (P09)
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