In these Japanese primary care settings, all three types of expert GPs, namely all-rounder GPs, GPs with special interests, and expert generalists, were found to face more or less multifocal levels of complex problems in the context of individual patients, healthcare professionals, organizations, and communities. In the system, we focused on GPs’ interactions among individuals. Among examples, GPs shared information with other healthcare professionals about complex patients with multiple chronic conditions, etc. On the other hand, some organizations have trouble with sharing clinical information with healthcare professionals and management of healthcare organizations due to sectionalism, etc. Some communities have concerns about the optimal use of community resources and interprofessional collaboration strategies beyond their facilities. In such contexts, the final findings revealed that four types of patterned GP interaction promoted a reduction in these complexities within whole networks as well as within the necessary parts of the network, namely:
1. GPs shared the whole picture of patients with complex problems and address their problems multi-directionally.
2. GPs built horizontal, trusting relationships with other healthcare professionals and stakeholders to share information and thereby reduce the degree of complexity of problems.
3. GPs changed the learning climate while committing to their own growth based on societal needs by reflecting on their own position and working as a role model for other professionals through daily interpersonal facilitation.
4. GPs shared community vision with multi-professionals as a driving force for organizational change.
1. GPs share the picture of patients with complex problems as a whole being and address their problems multi-directionally
GPs perceived the individual patient as a whole being and recognized the interrelationships of health risk factors with patient issues such as polypharmacy with multiple chronic conditions. GPs have willingly tried to incorporate multi-dimensional perspectives on the complexity, which enabled healthcare professionals to reconsider their roles.
“I get the impression that GPs have a broad perspective (on their patients). The GPs have a broad view (of the patient), and also looks at the future and the background. Even a single record is different. In the emergency room, they tend to just describe the symptoms, but they also describe where the patient is coming from and his or her family.” (nurse in Hospital C)
The specialist said, “It takes multiple perspectives on the patient, which makes subsequent diagnosis and treatment easier. It would have been very difficult without them. (fieldnote in Hospital C).
Additionally, by involving other healthcare professionals and being involved, GPs reduced not only the complexity of multimorbidity care, but also social, economic, and mental difficulties by internalizing the bio-psycho-social approach.
“Administration staff sometimes accept patients with intractable and multiple diseases to our hospital. In these cases, we introduce GPs to them.” (nurse in Hospital C)
“I think GPs always talk with patients about their economic and physical conditions.” (MSWs in Hospitals A, C and F)
Similar thoughts were expressed by nurses and social workers, as follows: “To be honest, we are specialists who support patients’ QOL and post-discharge lives rather than the disease, but the GPs are equally concerned about the psychosocial issues of their patients, so that's really, in a good way, something we shouldn't lose. “(field note in hospital F)
Thus, GPs shared in the care of individual patients as a whole being and addressed their problems multi-directionally through multi-dimensional perspectives with multi-professionals. As a result, healthcare professionals improved their understanding of the prioritization of disseminated issues and were able to advance their provision of care in a stable manner. Through GPs’ interactions, the sharing of the picture of patients with complex problems triggered interconnections with the other healthcare professionals’ view as part of the network.
2. GPs build a horizontal, trusting relationship with other healthcare professionals and stakeholders and thereby reduce the degree of complexity of problems.
GPs helped multi-healthcare professionals understand complex information while working with a sense of reciprocity, which means that they helped and complemented the activities of other healthcare professionals voluntarily and horizontally, instead of in a hierarchical, top-down relationship with them.
“Now, each GP has a conference once a week with physicians in charge, nurses, MSWs, nutritionists, therapists, and pharmacists to discuss whether any current patients can be discharged. This is a very beneficial conference for healthcare professionals in our department as it allows them to understand medical information in summary form.” (nurses in Hospital C)
“We are frankly working with the GPs to come up with solutions to the complex information surrounding our patients. If this is the only conclusion we can reach now, we can agree. We will then feel reassured, and be able to say, "Well, we'll just have to wait and see.” (pharmacist in Hospital F)
The GPs carefully exchanged complicated internal and external information regarding their own departments and organizations, and reduced the degree of complexity of information to meet the activities of their departments, organization and community.
“Working with GPs has opened my eyes to the outside world as well. We have many opportunities to exchange information about management systems at other facilities with GPs”. (nurse in Hospital I)
“We established a relationship with a community newspaper company to deliver meaningful medical information to lay people. We then started publishing easy-to-understand information on important subjects in family medicine for lay people, which was very well understood by patients. For example, I wrote about advanced care planning. After that, some patients started to tell me that they wanted to reflect on their own end of life. Recently, the company has increased the number of opportunities for us to publish articles about medical information”. (GP in Clinic H)
Thus, the findings revealed that these patterned interactions between GPs and other healthcare professionals and/or community stakeholders established horizontal and trusting relationships which were interconnected with a reduction in the degree of complexity of information to meet particular contexts as part of the network.
3. GPs change the learning climate while committing to their own growth based on societal needs through reflecting on their own positions and acting as role models for other professionals through daily interpersonal facilitation.
GPs reflected on their own position in the organization and local community, and expanded their own duties or created innovative work behaviors based on societal needs.
“We had not previously established a home care system. We therefore developed home visiting nursing-care and rehabilitation programs, because such systems were necessary in our local community. We achieved interprofessional collaboration through the development of these systems.” (GP in Clinic B)
The GPs took time to gain an understanding of common background matters and to strengthen human networks with care managers and other professionals under the concept of the "community hospital," which provides comprehensive and continuous care in the community. (Fieldnote in Hospital I)
Additionally, GPs acted as role models and aided the other healthcare professionals in reflecting on their work, which tended to be focused around procedures and efficiency of care.
“We have been learning about how to collect the family history and background of patients - which is part of our responsibilities - through study meetings with our GPs.” (nurse at an HCU in Hospital C).
In evening conferences, a GP was asking questions in an attempt to broaden healthcare professionals’ perspectives and made statements that caused the healthcare professionals to reflect. Another GP allowed the healthcare professionals to speak freely. GPs, by adopting different patterns of respectful attitude - as appropriate for the character of the particular healthcare professional they were dealing with - used bottom-up communication strategies so that all individuals could think about the patient’s ‘best life’. (fieldnote at Clinic D)
In this way, the GPs gradually changed the learning climate in the department.
Thus, GPs undertook both self-improvement and improvement of other healthcare professionals through interpersonal facilitation based on the local context. The patterned interactions between GPs and other healthcare professionals and/or organizations empowered them to commit to their growth. Through this process, the individuals reflected on their own positions and were motivated to learn what was necessary to care for their patients.
4. GPs shared community vision with multi-professionals as a driving force for organizational change
GPs routinely came across opportunities to remind other healthcare professionals and staff of their goals, and stimulated their morale and motivation.
GPs held routine meetings with healthcare professionals every morning and once a week in the evening, which had the effect of increasing staff morale. (fieldnote at Clinic C)
“We conduct daily visiting rounds with our GPs, which facilitates patient transfer or discharge from hospital. Although it is not easy to achieve our goal, we learn a lot from the GPs’ viewpoint during these rounds.” (nurse working in the local community network section of Hospital C, who lead the rounds in the ward)
Similar data were extracted from Hospitals A, F, G, and I.
GPs also played the role of authority, leader, and collaborating motivator in efforts to change the system of their organization or institution.
When they contacted other facilities to transfer their own patients, they noted, “We, as team members, carry out our mission by getting advice from GPs. Hospitalization systems have improved year by year because we changed our system to meet requests from other medical institutions while receiving advice and authorization from GPs.” (fieldnote at Hospital C)
Similar data were extracted from Hospitals A, F, G, and I.
In this way, GPs emphasized community values as a means of inspiring healthcare professionals and staff to reflect on their behavior in the service of patients, facilities, and their local community and to achieve sustainable local community development. At the same time, they accepted the efforts of others, shared their goals, and worked together with them to achieve the goals. GPs served as role models for healthcare professionals. As such, from the patterned interactions between GPs and/or other healthcare professionals and/or organization and/or community emerged a shared vision as a driving force for organizational change. These interrelations systematized their healthcare and welfare community networks.