Nancy C. Elder, MD, MSPH

Every primary care clinician in the United States knows the frustration of lost charts, misplaced reports, and messages from patients that should have been answered yesterday. These are some of the common frustrations and failures in day-to-day clinical practice. Many clinicians also know the guilt, shame, and self-doubt that occur when patients suffer a serious complication or die due to a mistake made by the clinician, health care team, or health care system. Between the common frustrations of practice and the rare patient death due to an error lies a large chasm, a rarely explored territory of relationships, causes and effects, and mitigating factors. Looking backward from a catastrophic patient outcome rarely goes beyond blaming the immediate person “at fault.” ¹ Looking forward from common charting errors rarely goes beyond a conclusion to be “more careful.”

Hospital-based research has categorized preventable adverse outcomes and some process errors associated with them,^2-4 but this has not been done in primary care.⁵ There are difficulties in studying errors in the primary care setting: care takes place in many locations; involves multiple visits; is provided in person, by phone, by mail, and even by computer; and involves interactions with many health care workers. However, it is important to study errors in primary care⁶ because it is the location of most health care visits in the United States.⁷

A classification or taxonomy of errors and preventable adverse events is an important first step in improving patient care. Prevalence and epidemiology studies, clinical and system interventions, and even individual practice group databases of errors and adverse events⁸ can more easily be developed if there is a beginning classification system. Just as clinicians use a differential diagnostic list for analyzing symptoms or a list of risk factors for assessing disease, so, too, can clinicians use a classification and listing of process errors and preventable adverse events to “diagnose” and “prevent” patient harm from medical care. Many taxonomies of medical error do exist and have been used in hospital accreditation or malpractice contexts for some time.⁹ These taxonomies have not been generally available for purposes other than their intended use, ie, to help their developers understand the data they were dealing with, and because these data do not originate from primary care practice, it remains unknown how well the taxonomies might meet the needs of family physicians and other primary care researchers.

The purpose of this study was to use published data from original research to understand and classify process errors and preventable adverse events associated with primary medical care. Through a systematic review and synthesis of the medical literature, we developed a classification of medical errors relevant to primary care.

Methods

To identify eligible published English-language original research articles, we searched MEDLINE and the Cochrane Library from 1965 through March 2001 with the MESH search term medical errors, modified by adding family practice, primary health care, physicians/family, or ambulatory care to the primary term. Published bibliographies from the National Patient Safety Foundation (NPSF) and the Institute for Healthcare Improvement (IHI) were also reviewed. The Web sites of the American Academy of Family Physicians, the American College of Physicians–American Society of Internal Medicine, the Institute of Medicine, the NPSF, and the IHI were also reviewed for unpublished reports, presentations, and leads to other sites, journals, or investigators with relevant work. Additional papers were identified from the references of the papers reviewed, from seminal papers in the field, and from discussion with others working in the field of patient safety or quality improvement in primary care.

We reviewed titles of 379 articles identified by electronic searches for inclusion. We excluded papers if they related to comparisons of different approaches to diagnosis or treatment of specific diseases, the evaluation of teaching or research tools, or exclusively to hospitalized patients. If there was uncertainty as to the appropriateness of an article, we read the abstract. We reviewed complete papers if they appeared from the title and abstract to report original research involving a broad assessment of medical errors and preventable adverse events in primary care. Data relating to topic, study quality, and research results were abstracted from identified papers. Both authors performed independent MEDLINE searches and reviewed citations in the papers. To broaden the search for potential studies, one author searched Web sites and NPSF and IHI bibliographies. Both authors agreed on the inclusion of the chosen studies, appraised them independently, and abstracted key classification components. One author (N.C.E.) initially prepared the classification system presented here; it was then reviewed by both authors and revised after their discussions.

Results

Four original research studies directly studied and described medical errors and preventable adverse events in primary care.^10-13 Three other studies peripherally addressed primary care medical errors as part of an investigation with another central focus^14-16 (Table 1).

TABLE 1
Primary care studies describing medical error

Outcome measures

Bhasale and colleagues¹⁰ and Fischer and coworkers¹³ collected patient outcome data; they specifically examined incidents that had “harmed” patients or had “potential for harm.” Ely and associates¹² also studied incidents causing patients harm by investigating possible causes of these incidents. Dovey and colleagues¹¹ reported physician-observed errors regardless of whether they were associated with an adverse event. Britten and coworkers¹⁶ analyzed misunderstandings between patients and physicians that had adverse consequences for taking medicines. Gandhi and associates¹⁴ described communication between primary care physicians and specialists. Holden and colleagues¹⁵ investigated deaths in general practices. All these studies attempted some categorization of medical errors. Bhasale and associates¹⁰ and Fischer and colleagues¹³ defined 4 incident cate gories and then assessed preventability. Dovey and coworkers¹¹ and Ely and associates¹² placed medical errors into categories, and Bhasale and colleagues¹⁰ listed a number of contributing factors. Britten and coworkers¹⁶ and Gandhi and associates¹⁴ categorized clinician communication problems. Holden and colleagues¹⁵ classified clinician actions that led to preventable deaths.

Due to the multiple methods used in the 7 studies and the descriptive nature of the studies, a standard assessment of quality and quantitative synthesis of data were not possible. Six studies used practicing community-based primary care physicians as their main study group. The study by Gandhi and coworkers, of communication between primary care physicians and specialists,¹⁴ was performed in an academic institution.

Classification system

We derived the following classification system (outlined in Tables 2 and 3) from the errors and preventable adverse events reported in these 7 studies.^10-16Table 2 defines the three main categories of preventable adverse events related by primary care physicians: diagnosis, treatment, and preventive services. These offer descriptors of what went wrong in the care of the patient but not of the level of harm. For example, a patient who was prescribed and took an incorrect drug has experienced a preventable adverse event. As a consequence, that patient may suffer no ill effects (a near miss), may die from anaphylaxis, or may experience some intermediate outcome (such as a rash).

Table 3 outlines “process errors” that clarify why something went wrong. For example, Why was the patient prescribed an incorrect drug? The answer may lie with a clinician factor (the doctor took an inadequate history), a communication factor (not dealing with a language or cultural barrier), an administrative factor (the medical chart was missing), or a blunt end factor (Medicare regulations). Often, multiple factors may be involved.

TABLE 2
Classification of preventable adverse events in primary care

TABLE 3
Classification of process errors in primary care

Discussion

The results of this literature synthesis are important for 3 main reasons. First, they offer a summary of the current state of published research. Second, by synthesizing the results of this small body of literature, we were able to develop a working classification system of preventable adverse events (what went wrong) and process errors (why did it go wrong). Third, this classification may clarify the relations between patient safety, process errors, and preventable adverse events in primary care.

Other published classification systems of medical errors and preventable adverse events range from sparse (3 categories with 19 root causes)¹⁷ to dense (80 categories with more than 12,000 branching trees).¹⁸They generally derive from studies of safety in non-medical industries¹⁷ or from studies emphasizing hospital care.^2,18 In a recent review of the medical literature, Wilson and Sheikh noted the lack of a typology of medical errors in primary care and reasoned that the key safety issues in primary care are in the arenas of diagnosis, prescribing, communication, and organizational change.⁵ Their conclusions are congruent with ours, and our more structured classification system contains these arenas.

The classification in Table 3 was generated from research in primary care settings by using data from practicing family physicians and general practitioners. (A more complete version of Table 3 may be found at http://www.jfponline.com.) If the classification is valid and useful, it should assist clinicians and researchers in understanding how process errors and preventable adverse events happen during the practice of primary care. Models assist us in understanding these relations. Among previously proposed models are the “Swiss Cheese”¹⁹ and the “Toxic Cascades.”²⁰ The Swiss Cheese model postulates that barriers exist to prevent adverse events, but they are like slices of Swiss cheese with many holes (or errors) in them. Adverse events happen when the holes in many layers temporarily line up. The Toxic Cascades model conceptualizes 4 levels of threats to patient safety: trickles, which leave little trace of their existence; creeks, which have potential seriousness; rivers, which are the actual errors that harm patients; and torrents, which are errors that lead to a patient’s death or serious injury. From our classification, we can define some of the holes in the Swiss Cheese and name many trickles and creeks in primary care Toxic Cascades.

However, we found a striking gap in the literature of an absence of discussion of the contribution of patient factors to medical errors, despite a logic suggesting these are important issues.^21,22 A new model of patient safety dynamics should incorporate features of these models and add patient issues. Our proposed “Hourglass” model, derived from the classification system, incorporates 4 potential components of preventable adverse events in the primary care setting: 2 relating mainly to the primary health care system (process errors and patient safety factors) and 2 relating mainly to patients (patient risk factors for adverse events and patient-controlled patient safety factors; Figure). At the top of the hourglass, patient encounters enter like pieces of sand that flow through a health care system full of process errors that happen regularly. But, as in the Swiss Cheese model, there are barriers (patient safety factors) stopping these process errors from becoming preventable adverse events. Unfortunately, these barriers sometimes allow errors to slip through and a bad outcome results. Luckily, only a small number of patient encounters likely exits the primary health care system with a preventable adverse event, as demonstrated by the narrow part of the hourglass.

Outside the doctor’s office, factors in the patient’s milieu influence the probability of a preventable adverse event occurring. We postulate an experience analogous to that within the health care system. There are more factors increasing a patient’s likelihood of suffering a preventable adverse event,²³ but there are also patient-controlled factors serving as barriers against errors and their consequences. These are not well researched²⁴ but occur, for example, when a patient receives a blue pill from the pharmacy that had been pink in the past. The patient may prevent an adverse event by not taking the pill and double-checking with the clinician and pharmacist.

The order in which various process errors and safety factors interact with each other likely varies with each encounter and episode. Interactions within the classification suggest that, for any episode of disease or preventive care, the hourglass gets shaken and turned over numerous times as the health care system and patient factors interact with each other at multiple levels.

Future research needs

The literature review that led to our classification system and the proposed model of interaction have identified specific areas for future study. These include assessing patients’ perspectives, investigating prevalence and causality, and testing interventions designed to improve patient safety. The current medical literature based primarily on physician reports describes events that are meaningful to the physician half of the dyad between patient and physician. Patients’ opinions about what constitutes error and the role of patients as active participants in error and safety are unknown,²⁴ although preliminary studies are currently underway.²⁵

No published studies to date have explored the prevalence of preventable adverse events and errors in primary care. Physician self-report biases reporting toward remembered events and errors. In addition, medical error studies to date have not directly studied causal links between errors and adverse events.^26,27 Observational and epidemiologic studies incorporating multiple methods may be necessary to ascertain and compare all components of the medical error equation: the amount of harm done, the preventable adverse events and near misses, the process errors, and the error-free functioning of the health care system. Although observational studies have assessed adverse events in a hospital setting²⁸ and described primary care practices,²⁹ they have not been used to assess preventable adverse events in the primary care setting.

This literature review and synthesis may have missed some studies that merited inclusion. Only English-language studies were included. Studies pertaining to specific diseases, diagnoses, or treatments or from non-primary care settings may have shed light on the interaction of errors, adverse events, and harm but could not have helped in defining a classification system for primary care errors. The small number of studies available and their small sample sizes also limit the depth and breadth of derived classification components.

Decreasing medical errors and increasing patient safety are important parts of quality health care.³⁰ Currently, the research agenda aiming to identify effective error reduction strategies appears to be based more on ease of study subject or accessibility of patients than on the severity or importance of the problem.³¹ By categorizing process errors and preventable adverse events and studying their relations more thoroughly and by adding the patient’s perspective, interventions can be designed that address the most common and the most serious of preventable adverse events in primary care.

Every primary care clinician in the United States knows the frustration of lost charts, misplaced reports, and messages from patients that should have been answered yesterday. These are some of the common frustrations and failures in day-to-day clinical practice. Many clinicians also know the guilt, shame, and self-doubt that occur when patients suffer a serious complication or die due to a mistake made by the clinician, health care team, or health care system. Between the common frustrations of practice and the rare patient death due to an error lies a large chasm, a rarely explored territory of relationships, causes and effects, and mitigating factors. Looking backward from a catastrophic patient outcome rarely goes beyond blaming the immediate person “at fault.” ¹ Looking forward from common charting errors rarely goes beyond a conclusion to be “more careful.”

Hospital-based research has categorized preventable adverse outcomes and some process errors associated with them,^2-4 but this has not been done in primary care.⁵ There are difficulties in studying errors in the primary care setting: care takes place in many locations; involves multiple visits; is provided in person, by phone, by mail, and even by computer; and involves interactions with many health care workers. However, it is important to study errors in primary care⁶ because it is the location of most health care visits in the United States.⁷

A classification or taxonomy of errors and preventable adverse events is an important first step in improving patient care. Prevalence and epidemiology studies, clinical and system interventions, and even individual practice group databases of errors and adverse events⁸ can more easily be developed if there is a beginning classification system. Just as clinicians use a differential diagnostic list for analyzing symptoms or a list of risk factors for assessing disease, so, too, can clinicians use a classification and listing of process errors and preventable adverse events to “diagnose” and “prevent” patient harm from medical care. Many taxonomies of medical error do exist and have been used in hospital accreditation or malpractice contexts for some time.⁹ These taxonomies have not been generally available for purposes other than their intended use, ie, to help their developers understand the data they were dealing with, and because these data do not originate from primary care practice, it remains unknown how well the taxonomies might meet the needs of family physicians and other primary care researchers.

The purpose of this study was to use published data from original research to understand and classify process errors and preventable adverse events associated with primary medical care. Through a systematic review and synthesis of the medical literature, we developed a classification of medical errors relevant to primary care.

Methods

To identify eligible published English-language original research articles, we searched MEDLINE and the Cochrane Library from 1965 through March 2001 with the MESH search term medical errors, modified by adding family practice, primary health care, physicians/family, or ambulatory care to the primary term. Published bibliographies from the National Patient Safety Foundation (NPSF) and the Institute for Healthcare Improvement (IHI) were also reviewed. The Web sites of the American Academy of Family Physicians, the American College of Physicians–American Society of Internal Medicine, the Institute of Medicine, the NPSF, and the IHI were also reviewed for unpublished reports, presentations, and leads to other sites, journals, or investigators with relevant work. Additional papers were identified from the references of the papers reviewed, from seminal papers in the field, and from discussion with others working in the field of patient safety or quality improvement in primary care.

We reviewed titles of 379 articles identified by electronic searches for inclusion. We excluded papers if they related to comparisons of different approaches to diagnosis or treatment of specific diseases, the evaluation of teaching or research tools, or exclusively to hospitalized patients. If there was uncertainty as to the appropriateness of an article, we read the abstract. We reviewed complete papers if they appeared from the title and abstract to report original research involving a broad assessment of medical errors and preventable adverse events in primary care. Data relating to topic, study quality, and research results were abstracted from identified papers. Both authors performed independent MEDLINE searches and reviewed citations in the papers. To broaden the search for potential studies, one author searched Web sites and NPSF and IHI bibliographies. Both authors agreed on the inclusion of the chosen studies, appraised them independently, and abstracted key classification components. One author (N.C.E.) initially prepared the classification system presented here; it was then reviewed by both authors and revised after their discussions.

Results

Four original research studies directly studied and described medical errors and preventable adverse events in primary care.^10-13 Three other studies peripherally addressed primary care medical errors as part of an investigation with another central focus^14-16 (Table 1).

TABLE 1
Primary care studies describing medical error

Outcome measures

Bhasale and colleagues¹⁰ and Fischer and coworkers¹³ collected patient outcome data; they specifically examined incidents that had “harmed” patients or had “potential for harm.” Ely and associates¹² also studied incidents causing patients harm by investigating possible causes of these incidents. Dovey and colleagues¹¹ reported physician-observed errors regardless of whether they were associated with an adverse event. Britten and coworkers¹⁶ analyzed misunderstandings between patients and physicians that had adverse consequences for taking medicines. Gandhi and associates¹⁴ described communication between primary care physicians and specialists. Holden and colleagues¹⁵ investigated deaths in general practices. All these studies attempted some categorization of medical errors. Bhasale and associates¹⁰ and Fischer and colleagues¹³ defined 4 incident cate gories and then assessed preventability. Dovey and coworkers¹¹ and Ely and associates¹² placed medical errors into categories, and Bhasale and colleagues¹⁰ listed a number of contributing factors. Britten and coworkers¹⁶ and Gandhi and associates¹⁴ categorized clinician communication problems. Holden and colleagues¹⁵ classified clinician actions that led to preventable deaths.

Due to the multiple methods used in the 7 studies and the descriptive nature of the studies, a standard assessment of quality and quantitative synthesis of data were not possible. Six studies used practicing community-based primary care physicians as their main study group. The study by Gandhi and coworkers, of communication between primary care physicians and specialists,¹⁴ was performed in an academic institution.

Classification system

We derived the following classification system (outlined in Tables 2 and 3) from the errors and preventable adverse events reported in these 7 studies.^10-16Table 2 defines the three main categories of preventable adverse events related by primary care physicians: diagnosis, treatment, and preventive services. These offer descriptors of what went wrong in the care of the patient but not of the level of harm. For example, a patient who was prescribed and took an incorrect drug has experienced a preventable adverse event. As a consequence, that patient may suffer no ill effects (a near miss), may die from anaphylaxis, or may experience some intermediate outcome (such as a rash).

Table 3 outlines “process errors” that clarify why something went wrong. For example, Why was the patient prescribed an incorrect drug? The answer may lie with a clinician factor (the doctor took an inadequate history), a communication factor (not dealing with a language or cultural barrier), an administrative factor (the medical chart was missing), or a blunt end factor (Medicare regulations). Often, multiple factors may be involved.

TABLE 2
Classification of preventable adverse events in primary care

TABLE 3
Classification of process errors in primary care

Discussion

The results of this literature synthesis are important for 3 main reasons. First, they offer a summary of the current state of published research. Second, by synthesizing the results of this small body of literature, we were able to develop a working classification system of preventable adverse events (what went wrong) and process errors (why did it go wrong). Third, this classification may clarify the relations between patient safety, process errors, and preventable adverse events in primary care.

Other published classification systems of medical errors and preventable adverse events range from sparse (3 categories with 19 root causes)¹⁷ to dense (80 categories with more than 12,000 branching trees).¹⁸They generally derive from studies of safety in non-medical industries¹⁷ or from studies emphasizing hospital care.^2,18 In a recent review of the medical literature, Wilson and Sheikh noted the lack of a typology of medical errors in primary care and reasoned that the key safety issues in primary care are in the arenas of diagnosis, prescribing, communication, and organizational change.⁵ Their conclusions are congruent with ours, and our more structured classification system contains these arenas.

The classification in Table 3 was generated from research in primary care settings by using data from practicing family physicians and general practitioners. (A more complete version of Table 3 may be found at http://www.jfponline.com.) If the classification is valid and useful, it should assist clinicians and researchers in understanding how process errors and preventable adverse events happen during the practice of primary care. Models assist us in understanding these relations. Among previously proposed models are the “Swiss Cheese”¹⁹ and the “Toxic Cascades.”²⁰ The Swiss Cheese model postulates that barriers exist to prevent adverse events, but they are like slices of Swiss cheese with many holes (or errors) in them. Adverse events happen when the holes in many layers temporarily line up. The Toxic Cascades model conceptualizes 4 levels of threats to patient safety: trickles, which leave little trace of their existence; creeks, which have potential seriousness; rivers, which are the actual errors that harm patients; and torrents, which are errors that lead to a patient’s death or serious injury. From our classification, we can define some of the holes in the Swiss Cheese and name many trickles and creeks in primary care Toxic Cascades.

However, we found a striking gap in the literature of an absence of discussion of the contribution of patient factors to medical errors, despite a logic suggesting these are important issues.^21,22 A new model of patient safety dynamics should incorporate features of these models and add patient issues. Our proposed “Hourglass” model, derived from the classification system, incorporates 4 potential components of preventable adverse events in the primary care setting: 2 relating mainly to the primary health care system (process errors and patient safety factors) and 2 relating mainly to patients (patient risk factors for adverse events and patient-controlled patient safety factors; Figure). At the top of the hourglass, patient encounters enter like pieces of sand that flow through a health care system full of process errors that happen regularly. But, as in the Swiss Cheese model, there are barriers (patient safety factors) stopping these process errors from becoming preventable adverse events. Unfortunately, these barriers sometimes allow errors to slip through and a bad outcome results. Luckily, only a small number of patient encounters likely exits the primary health care system with a preventable adverse event, as demonstrated by the narrow part of the hourglass.

Outside the doctor’s office, factors in the patient’s milieu influence the probability of a preventable adverse event occurring. We postulate an experience analogous to that within the health care system. There are more factors increasing a patient’s likelihood of suffering a preventable adverse event,²³ but there are also patient-controlled factors serving as barriers against errors and their consequences. These are not well researched²⁴ but occur, for example, when a patient receives a blue pill from the pharmacy that had been pink in the past. The patient may prevent an adverse event by not taking the pill and double-checking with the clinician and pharmacist.

The order in which various process errors and safety factors interact with each other likely varies with each encounter and episode. Interactions within the classification suggest that, for any episode of disease or preventive care, the hourglass gets shaken and turned over numerous times as the health care system and patient factors interact with each other at multiple levels.

Future research needs

The literature review that led to our classification system and the proposed model of interaction have identified specific areas for future study. These include assessing patients’ perspectives, investigating prevalence and causality, and testing interventions designed to improve patient safety. The current medical literature based primarily on physician reports describes events that are meaningful to the physician half of the dyad between patient and physician. Patients’ opinions about what constitutes error and the role of patients as active participants in error and safety are unknown,²⁴ although preliminary studies are currently underway.²⁵

No published studies to date have explored the prevalence of preventable adverse events and errors in primary care. Physician self-report biases reporting toward remembered events and errors. In addition, medical error studies to date have not directly studied causal links between errors and adverse events.^26,27 Observational and epidemiologic studies incorporating multiple methods may be necessary to ascertain and compare all components of the medical error equation: the amount of harm done, the preventable adverse events and near misses, the process errors, and the error-free functioning of the health care system. Although observational studies have assessed adverse events in a hospital setting²⁸ and described primary care practices,²⁹ they have not been used to assess preventable adverse events in the primary care setting.

This literature review and synthesis may have missed some studies that merited inclusion. Only English-language studies were included. Studies pertaining to specific diseases, diagnoses, or treatments or from non-primary care settings may have shed light on the interaction of errors, adverse events, and harm but could not have helped in defining a classification system for primary care errors. The small number of studies available and their small sample sizes also limit the depth and breadth of derived classification components.

Decreasing medical errors and increasing patient safety are important parts of quality health care.³⁰ Currently, the research agenda aiming to identify effective error reduction strategies appears to be based more on ease of study subject or accessibility of patients than on the severity or importance of the problem.³¹ By categorizing process errors and preventable adverse events and studying their relations more thoroughly and by adding the patient’s perspective, interventions can be designed that address the most common and the most serious of preventable adverse events in primary care.

Every primary care clinician in the United States knows the frustration of lost charts, misplaced reports, and messages from patients that should have been answered yesterday. These are some of the common frustrations and failures in day-to-day clinical practice. Many clinicians also know the guilt, shame, and self-doubt that occur when patients suffer a serious complication or die due to a mistake made by the clinician, health care team, or health care system. Between the common frustrations of practice and the rare patient death due to an error lies a large chasm, a rarely explored territory of relationships, causes and effects, and mitigating factors. Looking backward from a catastrophic patient outcome rarely goes beyond blaming the immediate person “at fault.” ¹ Looking forward from common charting errors rarely goes beyond a conclusion to be “more careful.”

Hospital-based research has categorized preventable adverse outcomes and some process errors associated with them,^2-4 but this has not been done in primary care.⁵ There are difficulties in studying errors in the primary care setting: care takes place in many locations; involves multiple visits; is provided in person, by phone, by mail, and even by computer; and involves interactions with many health care workers. However, it is important to study errors in primary care⁶ because it is the location of most health care visits in the United States.⁷

A classification or taxonomy of errors and preventable adverse events is an important first step in improving patient care. Prevalence and epidemiology studies, clinical and system interventions, and even individual practice group databases of errors and adverse events⁸ can more easily be developed if there is a beginning classification system. Just as clinicians use a differential diagnostic list for analyzing symptoms or a list of risk factors for assessing disease, so, too, can clinicians use a classification and listing of process errors and preventable adverse events to “diagnose” and “prevent” patient harm from medical care. Many taxonomies of medical error do exist and have been used in hospital accreditation or malpractice contexts for some time.⁹ These taxonomies have not been generally available for purposes other than their intended use, ie, to help their developers understand the data they were dealing with, and because these data do not originate from primary care practice, it remains unknown how well the taxonomies might meet the needs of family physicians and other primary care researchers.

The purpose of this study was to use published data from original research to understand and classify process errors and preventable adverse events associated with primary medical care. Through a systematic review and synthesis of the medical literature, we developed a classification of medical errors relevant to primary care.

Methods

To identify eligible published English-language original research articles, we searched MEDLINE and the Cochrane Library from 1965 through March 2001 with the MESH search term medical errors, modified by adding family practice, primary health care, physicians/family, or ambulatory care to the primary term. Published bibliographies from the National Patient Safety Foundation (NPSF) and the Institute for Healthcare Improvement (IHI) were also reviewed. The Web sites of the American Academy of Family Physicians, the American College of Physicians–American Society of Internal Medicine, the Institute of Medicine, the NPSF, and the IHI were also reviewed for unpublished reports, presentations, and leads to other sites, journals, or investigators with relevant work. Additional papers were identified from the references of the papers reviewed, from seminal papers in the field, and from discussion with others working in the field of patient safety or quality improvement in primary care.

We reviewed titles of 379 articles identified by electronic searches for inclusion. We excluded papers if they related to comparisons of different approaches to diagnosis or treatment of specific diseases, the evaluation of teaching or research tools, or exclusively to hospitalized patients. If there was uncertainty as to the appropriateness of an article, we read the abstract. We reviewed complete papers if they appeared from the title and abstract to report original research involving a broad assessment of medical errors and preventable adverse events in primary care. Data relating to topic, study quality, and research results were abstracted from identified papers. Both authors performed independent MEDLINE searches and reviewed citations in the papers. To broaden the search for potential studies, one author searched Web sites and NPSF and IHI bibliographies. Both authors agreed on the inclusion of the chosen studies, appraised them independently, and abstracted key classification components. One author (N.C.E.) initially prepared the classification system presented here; it was then reviewed by both authors and revised after their discussions.

Results

Four original research studies directly studied and described medical errors and preventable adverse events in primary care.^10-13 Three other studies peripherally addressed primary care medical errors as part of an investigation with another central focus^14-16 (Table 1).

TABLE 1
Primary care studies describing medical error

Outcome measures

Bhasale and colleagues¹⁰ and Fischer and coworkers¹³ collected patient outcome data; they specifically examined incidents that had “harmed” patients or had “potential for harm.” Ely and associates¹² also studied incidents causing patients harm by investigating possible causes of these incidents. Dovey and colleagues¹¹ reported physician-observed errors regardless of whether they were associated with an adverse event. Britten and coworkers¹⁶ analyzed misunderstandings between patients and physicians that had adverse consequences for taking medicines. Gandhi and associates¹⁴ described communication between primary care physicians and specialists. Holden and colleagues¹⁵ investigated deaths in general practices. All these studies attempted some categorization of medical errors. Bhasale and associates¹⁰ and Fischer and colleagues¹³ defined 4 incident cate gories and then assessed preventability. Dovey and coworkers¹¹ and Ely and associates¹² placed medical errors into categories, and Bhasale and colleagues¹⁰ listed a number of contributing factors. Britten and coworkers¹⁶ and Gandhi and associates¹⁴ categorized clinician communication problems. Holden and colleagues¹⁵ classified clinician actions that led to preventable deaths.

Due to the multiple methods used in the 7 studies and the descriptive nature of the studies, a standard assessment of quality and quantitative synthesis of data were not possible. Six studies used practicing community-based primary care physicians as their main study group. The study by Gandhi and coworkers, of communication between primary care physicians and specialists,¹⁴ was performed in an academic institution.

Classification system

We derived the following classification system (outlined in Tables 2 and 3) from the errors and preventable adverse events reported in these 7 studies.^10-16Table 2 defines the three main categories of preventable adverse events related by primary care physicians: diagnosis, treatment, and preventive services. These offer descriptors of what went wrong in the care of the patient but not of the level of harm. For example, a patient who was prescribed and took an incorrect drug has experienced a preventable adverse event. As a consequence, that patient may suffer no ill effects (a near miss), may die from anaphylaxis, or may experience some intermediate outcome (such as a rash).

Table 3 outlines “process errors” that clarify why something went wrong. For example, Why was the patient prescribed an incorrect drug? The answer may lie with a clinician factor (the doctor took an inadequate history), a communication factor (not dealing with a language or cultural barrier), an administrative factor (the medical chart was missing), or a blunt end factor (Medicare regulations). Often, multiple factors may be involved.

TABLE 2
Classification of preventable adverse events in primary care

TABLE 3
Classification of process errors in primary care

Discussion

The results of this literature synthesis are important for 3 main reasons. First, they offer a summary of the current state of published research. Second, by synthesizing the results of this small body of literature, we were able to develop a working classification system of preventable adverse events (what went wrong) and process errors (why did it go wrong). Third, this classification may clarify the relations between patient safety, process errors, and preventable adverse events in primary care.

Other published classification systems of medical errors and preventable adverse events range from sparse (3 categories with 19 root causes)¹⁷ to dense (80 categories with more than 12,000 branching trees).¹⁸They generally derive from studies of safety in non-medical industries¹⁷ or from studies emphasizing hospital care.^2,18 In a recent review of the medical literature, Wilson and Sheikh noted the lack of a typology of medical errors in primary care and reasoned that the key safety issues in primary care are in the arenas of diagnosis, prescribing, communication, and organizational change.⁵ Their conclusions are congruent with ours, and our more structured classification system contains these arenas.

The classification in Table 3 was generated from research in primary care settings by using data from practicing family physicians and general practitioners. (A more complete version of Table 3 may be found at http://www.jfponline.com.) If the classification is valid and useful, it should assist clinicians and researchers in understanding how process errors and preventable adverse events happen during the practice of primary care. Models assist us in understanding these relations. Among previously proposed models are the “Swiss Cheese”¹⁹ and the “Toxic Cascades.”²⁰ The Swiss Cheese model postulates that barriers exist to prevent adverse events, but they are like slices of Swiss cheese with many holes (or errors) in them. Adverse events happen when the holes in many layers temporarily line up. The Toxic Cascades model conceptualizes 4 levels of threats to patient safety: trickles, which leave little trace of their existence; creeks, which have potential seriousness; rivers, which are the actual errors that harm patients; and torrents, which are errors that lead to a patient’s death or serious injury. From our classification, we can define some of the holes in the Swiss Cheese and name many trickles and creeks in primary care Toxic Cascades.

However, we found a striking gap in the literature of an absence of discussion of the contribution of patient factors to medical errors, despite a logic suggesting these are important issues.^21,22 A new model of patient safety dynamics should incorporate features of these models and add patient issues. Our proposed “Hourglass” model, derived from the classification system, incorporates 4 potential components of preventable adverse events in the primary care setting: 2 relating mainly to the primary health care system (process errors and patient safety factors) and 2 relating mainly to patients (patient risk factors for adverse events and patient-controlled patient safety factors; Figure). At the top of the hourglass, patient encounters enter like pieces of sand that flow through a health care system full of process errors that happen regularly. But, as in the Swiss Cheese model, there are barriers (patient safety factors) stopping these process errors from becoming preventable adverse events. Unfortunately, these barriers sometimes allow errors to slip through and a bad outcome results. Luckily, only a small number of patient encounters likely exits the primary health care system with a preventable adverse event, as demonstrated by the narrow part of the hourglass.

Outside the doctor’s office, factors in the patient’s milieu influence the probability of a preventable adverse event occurring. We postulate an experience analogous to that within the health care system. There are more factors increasing a patient’s likelihood of suffering a preventable adverse event,²³ but there are also patient-controlled factors serving as barriers against errors and their consequences. These are not well researched²⁴ but occur, for example, when a patient receives a blue pill from the pharmacy that had been pink in the past. The patient may prevent an adverse event by not taking the pill and double-checking with the clinician and pharmacist.

The order in which various process errors and safety factors interact with each other likely varies with each encounter and episode. Interactions within the classification suggest that, for any episode of disease or preventive care, the hourglass gets shaken and turned over numerous times as the health care system and patient factors interact with each other at multiple levels.

Future research needs

The literature review that led to our classification system and the proposed model of interaction have identified specific areas for future study. These include assessing patients’ perspectives, investigating prevalence and causality, and testing interventions designed to improve patient safety. The current medical literature based primarily on physician reports describes events that are meaningful to the physician half of the dyad between patient and physician. Patients’ opinions about what constitutes error and the role of patients as active participants in error and safety are unknown,²⁴ although preliminary studies are currently underway.²⁵

No published studies to date have explored the prevalence of preventable adverse events and errors in primary care. Physician self-report biases reporting toward remembered events and errors. In addition, medical error studies to date have not directly studied causal links between errors and adverse events.^26,27 Observational and epidemiologic studies incorporating multiple methods may be necessary to ascertain and compare all components of the medical error equation: the amount of harm done, the preventable adverse events and near misses, the process errors, and the error-free functioning of the health care system. Although observational studies have assessed adverse events in a hospital setting²⁸ and described primary care practices,²⁹ they have not been used to assess preventable adverse events in the primary care setting.

This literature review and synthesis may have missed some studies that merited inclusion. Only English-language studies were included. Studies pertaining to specific diseases, diagnoses, or treatments or from non-primary care settings may have shed light on the interaction of errors, adverse events, and harm but could not have helped in defining a classification system for primary care errors. The small number of studies available and their small sample sizes also limit the depth and breadth of derived classification components.

Decreasing medical errors and increasing patient safety are important parts of quality health care.³⁰ Currently, the research agenda aiming to identify effective error reduction strategies appears to be based more on ease of study subject or accessibility of patients than on the severity or importance of the problem.³¹ By categorizing process errors and preventable adverse events and studying their relations more thoroughly and by adding the patient’s perspective, interventions can be designed that address the most common and the most serious of preventable adverse events in primary care.

Every family physician knows the frustration of seeing patients with diabetes who never seem to be able to control their blood sugar level. Since the prevalence of diabetes mellitus in the United States has tripled in the past 30 years to 6% of our population,¹ the care of these patients is a large part of the family physician’s workload. In this issue of the Journal, Freeman and Loewe² have researched the family physician’s understanding of patients who have diabetes. The authors used qualitative research techniques to explore in detail how providers at an urban family practice residency program feel about caring for people with diabetes. Almost all the issues the providers felt were important were classified under the themes of control and frustration; that is, the inability of providers and patients to communicate effectively about control often led to frustration.

As discussed by Freeman and Loewe, control has a variety of meanings in the context of diabetes management: metabolic control; control of diet, exercise, or other lifestyle decisions; control of medical decisions; and so forth. All levels of control interact with and affect one another. Physicians, especially those still in training, struggle with patients when confronted with these issues of control-sometimes overtly, sometimes covertly. Physicians would like to see themselves as air traffic controllers with many patients hovering around the control tower (ie, clinic or office) doing exactly what they are told to do. But in the real world, social and cultural pressures are much more complicated. It is the wise and experienced physician who understands that ultimate control lies with the patient and that genetic, social, cultural, and environmental influences may affect lifestyle decisions more than encouragements about blood sugar control.

Complicated medical problems are rarely dealt with effectively when only addressed within the physician-patient relationship. Although some health problems have routinely been thought of as public health issues (eg, infectious diseases and tobacco use), other diseases such as coronary artery disease, stroke, and diabetes are only now being looked at as such.¹ Social, cultural, and environmental influences are often far stronger than the physician-patient relationship. Yet as Freeman and Loewe point out, these nondrug issues are rarely taught and are usually learned experientially. We suggest that the failure of physicians to address diabetes as a public health issue is a major gap in medical education and practice and is a primary cause of the frustration felt by physicians caring for patients with the disease.

The current environment

Diabetes continues to strike individuals of all ages, and even children are developing type 2 diabetes at a remarkably increasing rate.³ As Hill and Peters⁴ report, “Our current environment is characterized by an essentially unlimited supply of convenient, relatively inexpensive, highly palatable, energy-dense foods, coupled with a lifestyle requiring only low levels of physical activity for substinence.” Media pressures aimed at young Americans stress watching television and playing video games while consuming junk food, soft drinks, and eventually beer and cigarettes. A sedentary lifestyle and poor dietary choices are increasingly tied to obesity, which can lead to diabetes in those genetically inclined. Grocery and convenience stores have aisles lined with foods high in fat, calories, and taste, and low in nutrition. Children no longer clamber for their first bicycle as much as they want their first Nintendo. A physician’s message of “lose weight and exercise more” can barely be heard over the conflicting messages from television, print advertisements, movies, schools, and peers. Our office patient education will not easily reverse the attitudes and habits resulting from years of influence from these environmental pressures.

Physicians see patients within the physician’s environment, surrounded by others of their own social class (other physicians and nurses). Rarely does a physician know the patient’s reading ability when handing out a pamphlet. When recommending a low-fat, low-calorie diet, does the physician know how the patient gets to the grocery store? Is it by car, by foot, or by bus with 3 transfers? Is the neighborhood safe enough for the patient to walk 20 minutes every day as recommended by the physician? What is the patient’s cultural or ethnic group, and how do these influences affect his or her view of diabetes? When physicians made house calls, the visit took place in the patient’s environment surrounded by others of the patient’s social class and culture. Although this was not the most time-efficient way for the physician to conduct a routine visit, the amount of information learned about the patient was invaluable for effective communication between the patient and the physician.⁵

Both literally and metaphorically, the abandonment of house calls during the past century has led to a change in the physician’s perception of his or her patients. Placed within a 15-minute visit in a sterile examination room environment, physicians justifiably complain of having no time to deal with cultural differences, media influences, educational problems, social difficulties, and the spiritual crises of their patients with diabetes.⁶ Is it any wonder that physicians are more comfortable talking about controlling hemoglobin A1c than barriers to healthy eating? And yet, the outcomes hoped for by physicians (ie, better metabolic control, fewer long-term complications, less death and disability, and happier patients) do not occur as often as the physicians would like, and frustration ensues.

Share the community

Freeman and Loewe recommend that providers, “open themselves to learning the beliefs and attitudes of their patients with diabetes.” We would take this recommendation even further. Physicians also need to approach diabetes both as a public health problem and as an individual patient problem. They need to get involved in the community of the patient and have the patient join them in the community of medicine. Within the 15-minute office visit, physicians can begin to address the social, cultural, and environmental issues of patients’ lives. Kleinman⁷ suggests asking patients to define and discuss not just the disease but also their illness and their desired care. Understanding the role diabetes plays in the patient’s life and being willing to compromise one’s own control is often necessary for establishing a working partnership.

Physicians should make a home visit to patients with diabetes to better understand the cultural and social contexts of their lives. Every visit would not have to be in the patient’s home, but just think what a physician could find out in 30 or 45 minutes of seeing how a patient lives. It could save hours of interviewing time during the next few months and years.

Physicians should become involved in the community. Preventive health efforts are needed in every social group. Talk to kids in schools; review the school cafeteria menu; lead efforts to remove the soda and candy machines in the high school. Affect public policy with letters, telephone calls, and information. Lobby for having bike paths put into the community to encourage regular biking or walking to work. Be a role model not just in the office, but in your neighborhood as well.⁶

Freeman and Loewe provide a realistic picture of how physicians, especially those in training, think and feel about caring for patients with diabetes. It is not always a pretty picture, but it is one we need to see clearly if we are to improve our care of these patients. The authors performed this study by immersing themselves in the environment of their participants, talking to the care providers, and observing them in the clinical setting. This is how qualitative research helps to answer questions that cannot be addressed in a structured controlled clinical trial. The analogy is obvious. If we want to get a realistic view of patients with diabetes, we need to see them in their environment and their homes. We need to ask the hard questions as well as the easy ones. We need to take the time to listen as they explain their culture. We may not always see what we want to see as physicians, but this will allow us to help patients take back control of their lives and achieve their own goals.

Every family physician knows the frustration of seeing patients with diabetes who never seem to be able to control their blood sugar level. Since the prevalence of diabetes mellitus in the United States has tripled in the past 30 years to 6% of our population,¹ the care of these patients is a large part of the family physician’s workload. In this issue of the Journal, Freeman and Loewe² have researched the family physician’s understanding of patients who have diabetes. The authors used qualitative research techniques to explore in detail how providers at an urban family practice residency program feel about caring for people with diabetes. Almost all the issues the providers felt were important were classified under the themes of control and frustration; that is, the inability of providers and patients to communicate effectively about control often led to frustration.

As discussed by Freeman and Loewe, control has a variety of meanings in the context of diabetes management: metabolic control; control of diet, exercise, or other lifestyle decisions; control of medical decisions; and so forth. All levels of control interact with and affect one another. Physicians, especially those still in training, struggle with patients when confronted with these issues of control-sometimes overtly, sometimes covertly. Physicians would like to see themselves as air traffic controllers with many patients hovering around the control tower (ie, clinic or office) doing exactly what they are told to do. But in the real world, social and cultural pressures are much more complicated. It is the wise and experienced physician who understands that ultimate control lies with the patient and that genetic, social, cultural, and environmental influences may affect lifestyle decisions more than encouragements about blood sugar control.

Complicated medical problems are rarely dealt with effectively when only addressed within the physician-patient relationship. Although some health problems have routinely been thought of as public health issues (eg, infectious diseases and tobacco use), other diseases such as coronary artery disease, stroke, and diabetes are only now being looked at as such.¹ Social, cultural, and environmental influences are often far stronger than the physician-patient relationship. Yet as Freeman and Loewe point out, these nondrug issues are rarely taught and are usually learned experientially. We suggest that the failure of physicians to address diabetes as a public health issue is a major gap in medical education and practice and is a primary cause of the frustration felt by physicians caring for patients with the disease.

The current environment

Diabetes continues to strike individuals of all ages, and even children are developing type 2 diabetes at a remarkably increasing rate.³ As Hill and Peters⁴ report, “Our current environment is characterized by an essentially unlimited supply of convenient, relatively inexpensive, highly palatable, energy-dense foods, coupled with a lifestyle requiring only low levels of physical activity for substinence.” Media pressures aimed at young Americans stress watching television and playing video games while consuming junk food, soft drinks, and eventually beer and cigarettes. A sedentary lifestyle and poor dietary choices are increasingly tied to obesity, which can lead to diabetes in those genetically inclined. Grocery and convenience stores have aisles lined with foods high in fat, calories, and taste, and low in nutrition. Children no longer clamber for their first bicycle as much as they want their first Nintendo. A physician’s message of “lose weight and exercise more” can barely be heard over the conflicting messages from television, print advertisements, movies, schools, and peers. Our office patient education will not easily reverse the attitudes and habits resulting from years of influence from these environmental pressures.

Physicians see patients within the physician’s environment, surrounded by others of their own social class (other physicians and nurses). Rarely does a physician know the patient’s reading ability when handing out a pamphlet. When recommending a low-fat, low-calorie diet, does the physician know how the patient gets to the grocery store? Is it by car, by foot, or by bus with 3 transfers? Is the neighborhood safe enough for the patient to walk 20 minutes every day as recommended by the physician? What is the patient’s cultural or ethnic group, and how do these influences affect his or her view of diabetes? When physicians made house calls, the visit took place in the patient’s environment surrounded by others of the patient’s social class and culture. Although this was not the most time-efficient way for the physician to conduct a routine visit, the amount of information learned about the patient was invaluable for effective communication between the patient and the physician.⁵

Both literally and metaphorically, the abandonment of house calls during the past century has led to a change in the physician’s perception of his or her patients. Placed within a 15-minute visit in a sterile examination room environment, physicians justifiably complain of having no time to deal with cultural differences, media influences, educational problems, social difficulties, and the spiritual crises of their patients with diabetes.⁶ Is it any wonder that physicians are more comfortable talking about controlling hemoglobin A1c than barriers to healthy eating? And yet, the outcomes hoped for by physicians (ie, better metabolic control, fewer long-term complications, less death and disability, and happier patients) do not occur as often as the physicians would like, and frustration ensues.

Share the community

Freeman and Loewe recommend that providers, “open themselves to learning the beliefs and attitudes of their patients with diabetes.” We would take this recommendation even further. Physicians also need to approach diabetes both as a public health problem and as an individual patient problem. They need to get involved in the community of the patient and have the patient join them in the community of medicine. Within the 15-minute office visit, physicians can begin to address the social, cultural, and environmental issues of patients’ lives. Kleinman⁷ suggests asking patients to define and discuss not just the disease but also their illness and their desired care. Understanding the role diabetes plays in the patient’s life and being willing to compromise one’s own control is often necessary for establishing a working partnership.

Physicians should make a home visit to patients with diabetes to better understand the cultural and social contexts of their lives. Every visit would not have to be in the patient’s home, but just think what a physician could find out in 30 or 45 minutes of seeing how a patient lives. It could save hours of interviewing time during the next few months and years.

Physicians should become involved in the community. Preventive health efforts are needed in every social group. Talk to kids in schools; review the school cafeteria menu; lead efforts to remove the soda and candy machines in the high school. Affect public policy with letters, telephone calls, and information. Lobby for having bike paths put into the community to encourage regular biking or walking to work. Be a role model not just in the office, but in your neighborhood as well.⁶

Freeman and Loewe provide a realistic picture of how physicians, especially those in training, think and feel about caring for patients with diabetes. It is not always a pretty picture, but it is one we need to see clearly if we are to improve our care of these patients. The authors performed this study by immersing themselves in the environment of their participants, talking to the care providers, and observing them in the clinical setting. This is how qualitative research helps to answer questions that cannot be addressed in a structured controlled clinical trial. The analogy is obvious. If we want to get a realistic view of patients with diabetes, we need to see them in their environment and their homes. We need to ask the hard questions as well as the easy ones. We need to take the time to listen as they explain their culture. We may not always see what we want to see as physicians, but this will allow us to help patients take back control of their lives and achieve their own goals.

Every family physician knows the frustration of seeing patients with diabetes who never seem to be able to control their blood sugar level. Since the prevalence of diabetes mellitus in the United States has tripled in the past 30 years to 6% of our population,¹ the care of these patients is a large part of the family physician’s workload. In this issue of the Journal, Freeman and Loewe² have researched the family physician’s understanding of patients who have diabetes. The authors used qualitative research techniques to explore in detail how providers at an urban family practice residency program feel about caring for people with diabetes. Almost all the issues the providers felt were important were classified under the themes of control and frustration; that is, the inability of providers and patients to communicate effectively about control often led to frustration.

As discussed by Freeman and Loewe, control has a variety of meanings in the context of diabetes management: metabolic control; control of diet, exercise, or other lifestyle decisions; control of medical decisions; and so forth. All levels of control interact with and affect one another. Physicians, especially those still in training, struggle with patients when confronted with these issues of control-sometimes overtly, sometimes covertly. Physicians would like to see themselves as air traffic controllers with many patients hovering around the control tower (ie, clinic or office) doing exactly what they are told to do. But in the real world, social and cultural pressures are much more complicated. It is the wise and experienced physician who understands that ultimate control lies with the patient and that genetic, social, cultural, and environmental influences may affect lifestyle decisions more than encouragements about blood sugar control.

Complicated medical problems are rarely dealt with effectively when only addressed within the physician-patient relationship. Although some health problems have routinely been thought of as public health issues (eg, infectious diseases and tobacco use), other diseases such as coronary artery disease, stroke, and diabetes are only now being looked at as such.¹ Social, cultural, and environmental influences are often far stronger than the physician-patient relationship. Yet as Freeman and Loewe point out, these nondrug issues are rarely taught and are usually learned experientially. We suggest that the failure of physicians to address diabetes as a public health issue is a major gap in medical education and practice and is a primary cause of the frustration felt by physicians caring for patients with the disease.

The current environment

Diabetes continues to strike individuals of all ages, and even children are developing type 2 diabetes at a remarkably increasing rate.³ As Hill and Peters⁴ report, “Our current environment is characterized by an essentially unlimited supply of convenient, relatively inexpensive, highly palatable, energy-dense foods, coupled with a lifestyle requiring only low levels of physical activity for substinence.” Media pressures aimed at young Americans stress watching television and playing video games while consuming junk food, soft drinks, and eventually beer and cigarettes. A sedentary lifestyle and poor dietary choices are increasingly tied to obesity, which can lead to diabetes in those genetically inclined. Grocery and convenience stores have aisles lined with foods high in fat, calories, and taste, and low in nutrition. Children no longer clamber for their first bicycle as much as they want their first Nintendo. A physician’s message of “lose weight and exercise more” can barely be heard over the conflicting messages from television, print advertisements, movies, schools, and peers. Our office patient education will not easily reverse the attitudes and habits resulting from years of influence from these environmental pressures.

Physicians see patients within the physician’s environment, surrounded by others of their own social class (other physicians and nurses). Rarely does a physician know the patient’s reading ability when handing out a pamphlet. When recommending a low-fat, low-calorie diet, does the physician know how the patient gets to the grocery store? Is it by car, by foot, or by bus with 3 transfers? Is the neighborhood safe enough for the patient to walk 20 minutes every day as recommended by the physician? What is the patient’s cultural or ethnic group, and how do these influences affect his or her view of diabetes? When physicians made house calls, the visit took place in the patient’s environment surrounded by others of the patient’s social class and culture. Although this was not the most time-efficient way for the physician to conduct a routine visit, the amount of information learned about the patient was invaluable for effective communication between the patient and the physician.⁵

Both literally and metaphorically, the abandonment of house calls during the past century has led to a change in the physician’s perception of his or her patients. Placed within a 15-minute visit in a sterile examination room environment, physicians justifiably complain of having no time to deal with cultural differences, media influences, educational problems, social difficulties, and the spiritual crises of their patients with diabetes.⁶ Is it any wonder that physicians are more comfortable talking about controlling hemoglobin A1c than barriers to healthy eating? And yet, the outcomes hoped for by physicians (ie, better metabolic control, fewer long-term complications, less death and disability, and happier patients) do not occur as often as the physicians would like, and frustration ensues.

Share the community

Freeman and Loewe recommend that providers, “open themselves to learning the beliefs and attitudes of their patients with diabetes.” We would take this recommendation even further. Physicians also need to approach diabetes both as a public health problem and as an individual patient problem. They need to get involved in the community of the patient and have the patient join them in the community of medicine. Within the 15-minute office visit, physicians can begin to address the social, cultural, and environmental issues of patients’ lives. Kleinman⁷ suggests asking patients to define and discuss not just the disease but also their illness and their desired care. Understanding the role diabetes plays in the patient’s life and being willing to compromise one’s own control is often necessary for establishing a working partnership.

Physicians should make a home visit to patients with diabetes to better understand the cultural and social contexts of their lives. Every visit would not have to be in the patient’s home, but just think what a physician could find out in 30 or 45 minutes of seeing how a patient lives. It could save hours of interviewing time during the next few months and years.

Physicians should become involved in the community. Preventive health efforts are needed in every social group. Talk to kids in schools; review the school cafeteria menu; lead efforts to remove the soda and candy machines in the high school. Affect public policy with letters, telephone calls, and information. Lobby for having bike paths put into the community to encourage regular biking or walking to work. Be a role model not just in the office, but in your neighborhood as well.⁶

Freeman and Loewe provide a realistic picture of how physicians, especially those in training, think and feel about caring for patients with diabetes. It is not always a pretty picture, but it is one we need to see clearly if we are to improve our care of these patients. The authors performed this study by immersing themselves in the environment of their participants, talking to the care providers, and observing them in the clinical setting. This is how qualitative research helps to answer questions that cannot be addressed in a structured controlled clinical trial. The analogy is obvious. If we want to get a realistic view of patients with diabetes, we need to see them in their environment and their homes. We need to ask the hard questions as well as the easy ones. We need to take the time to listen as they explain their culture. We may not always see what we want to see as physicians, but this will allow us to help patients take back control of their lives and achieve their own goals.