many primary care physicians in nonacademic settings lack a collegial forum for engaging the clinical uncertainties inherent in their work .
 practice inquiry  is proposed as a set of small - group , practice - based learning and improvement ( pbli ) methods designed to help clinicians better manage case - based clinical uncertainty .
clinicians meet regularly at their offices / clinics to present dilemma cases , share clinical experience , review evidence for blending with experience , and draw implications for practice improvement . from 2001 through 2005 ,
practice inquiry was introduced to sites in the san francisco bay area as a demonstration effort .
meeting rosters , case logs , a feedback survey , and meeting field notes documented implementation and provided data for a formative , qualitative evaluation .
2006 , 98 clinicians in 11 sites continue to hold regularly scheduled group meetings . of the 118 patient cases presented in the seven oldest groups , clinician 
clinician feedback and meeting transcript data provided insights into how busy practitioners shared cases , developed trust , and learned new knowledge / skills for moving forward with patients .
ongoing clinician involvement suggests that practice inquiry is a feasible , acceptable , and potentially useful set of pbli methods .
two of the practice inquiry s group learning tasks received comparatively less focus : integrating research evidence with clinical experience and tracking dilemma case outcomes .
future work should focus on reducing the methodological limitations of a demonstration effort and examining factors affecting clinician participation .
set - aside work time for clinicians , or other equally potent incentives , will be necessary for the further elaboration of these pbli methods aimed at managing uncertainty .
primary care physicians ( pcps ) in nonacademic settings have few safe and reliable forums where they can reflect and learn from the clinical dilemmas inherent in their work . with
the collaborative learning of residency training no longer available , clinicians often adopt idiosyncratic approaches when they encounter patient - care situations that cause them to question the limits of their own knowledge , what is knowable , and how to distinguish between their own knowledge limits and that of the medical canon  in short , clinical uncertainty.1 the methods pcps have traditionally relied upon to tackle uncertainty include :  curbsiding  colleagues , consulting print and electronic literature , making referrals to specialists , employing 
watchful waiting ,  and cme courses for generalized updates in knowledge and skills.24 in addition to questions about method effectiveness,57 the current era of exponential knowledge growth , expanding patient volume , competing evidence - based care agendas ( e.g. , acute , chronic , and preventive ) , and the public s expectations for health fixes have made dependence on these familiar methods more difficult.811 nonetheless , the need for managing case - based dilemmas remains critical as clinical uncertainty affects care outcomes , resource utilization , and patient and physician satisfaction.1215 although contexts for coping with uncertainty have changed , most physicians would support light s 1979 observation that  regardless how technically developed a professional field is , it will define the treatment of problematic cases as its true work.16 social constructivist learning theorists,17,18 medical educators,1921 and primary care researchers22 identify the problematic patient case as a powerful professional learning opportunity .
whether and how one decides to take on these problems in the  swampy lowlands23 of practice become , according to guest , decisions about 
deliberate practice.24 practitioners develop expertise when they move from their comfort zones to examine problems  at the upper limit of the complexity they can handle ;  they learn , and iteratively gain mastery through cycles of reflecting on practice , obtaining feedback , and adjusting performance.24,25 recent emphasis on  practice - based learning and improvement 
defined by moore and pennington as an approach for  reflection on and appraisal of one s own delivery of clinical care that results in pursuing an opportunity for improvement,26 pbli encompasses multiple methods that range from individual learning portfolios containing practice question literature searches to virtual clinician groups using interactive methods to discuss real patient cases.2729 whereas the effectiveness of many pbli methods is unknown , social interaction , a key element in some pbli approaches , appears to increase physician satisfaction with learning and improve certain practice and patient outcomes.30,31 a real - time , face - to - face , pcp small group could be an attractive pbli venue for tackling case - based dilemmas .
in addition , newer methods model the advantages of learning with and from colleagues ( e.g. , problem - based learning in medical school32 and case - based ebm skill training in resident clinics33 ) .
a pcp office could form the  learning practice  that rushmer , cervero , parboosingh , and frankford advocate for supporting clinicians over time as they create , take apart , and reassemble strategies for patients whose problems are  not in the book21,3436 and build a skills repository for uncertainty management.3739 engaging the problems of work at work allows for an explicit  integration of clinical judgment with the system dimensions of practice21 , making primary care practice both more efficient and personalized .
we wondered whether a pbli experience focused on case - based clinical uncertainty would generate interest and commitment from pcps in the bay area of san francisco and designed  practice inquiry ( pi )  as a set of methods to pilot in the office / clinic setting . in this study
practice inquiry practice inquiry ( pi ) is a set of methods that structure how pcps could collaborate over time in learning from their patients case - based clinical uncertainties .
they have been derived from the workplace focus of uk gps practice meetings,40,41 the relationship - centered emphasis of balint groups,42 and the  ebm - based / reality - based  direction of the canadian pcps small learning groups.43 the pi group consists of clinician colleagues , each with a patient panel , who work at the same practice site .
group members engage one another through flexible application of a dilemma case guide or a practice panel reflection guide .
these guides suggest steps for identifying dilemma cases , exploring causes and consequences of uncertainty , searching for evidence , speculating about intervention options , and articulating new steps for moving forward with patients ( see fig .  1 online ) .
clinician group members or an invited , external member facilitates by guiding discussion , supporting searches for and appraisals of evidence , and coordinating meeting logistics . 

practice recruitment between fall 2001 and spring 2005 , 30 physician practice leaders , known to the authors , were approached about holding initial pi meetings at their sites .
seventeen expressed interest ; 13 cited limited time and satisfaction with current cme as reasons for declining .
of the 17 interested practices , 10 held initial pi meetings to introduce methods , and 7 continue to meet regularly ( phase-1 groups , 65 clinicians ) . the remaining 3 discontinued meeting in early 2002 .
telephone interviews with these groups physician contacts regarding reasons for discontinuation cited lack of committed leadership and need for other types of clinical support .
four of the seven remaining interested practices began meeting in 2006 ( phase-2 groups , 38 clinicians ) , and three have yet to initiate meetings ( see fig .  2 for recruitment detail ) . 

data collection and analysis with phase-1 clinicians consent , data from four sources were collected from fall 2002 through summer 2005 .
these included : ( 1 ) pi meeting rosters with the date , location , attendance , and meeting length for each pi meeting ; ( 2 ) dilemma case logs containing descriptions of case - based clinical uncertainties ( coded by facilitators as predominately a diagnostic , therapeutic , relationship , or negative outcome , with validation by presenters at subsequent meetings ) , pertinent case data ( e.g. , patient age and current medications ) , and plans for follow - up ( e.g. , review specific literature ) ; ( 3 ) formative feedback surveys , mailed in fall 2003 to all clinicians participating in active groups ( see table  1 . ) , which asked : what have you liked about practice meetings ?
( survey responses , identifiable only by group , were transcribed and analyzed by each author , as well as a psychologist educator and a family physician educator , expert in qualitative data analysis , using a first - stage  in vivo  coding approach).44 the authors met , discussed their coding schemas , compared approaches , selected one schema , and recoded sufficiently to generate agreed - upon themes .
ls recoded all data , refined themes , and circulated them for final approval ; ( 4 ) handwritten field notes describing group discussions transcribed for 64 of the 137 pi meetings : 42 were facilitated or observed and transcribed by ls and 22 by lm . of those transcripts judged to be most complete ,
table  1description of phase-1 practice inquiry groups by key characteristicsgrouplocation / sitefirst meeting date ; pre pi , case - based cme?clinicians membership ; specialty , mean attendancemeeting time , frequency , lengthfacilitatorgroup 1*san francisco , caoctober 20025 fpadmin  time , 1  h , every other monthrotated among group memberscounty - funded community health centerno4group 2*san francisco , cadecember 20023 gim , 3 fpadmin  time 1 , 1/2  h , every other monthls ( author)county - funded community health centerno5group 3oakland , caapril 20036 fp , 7 gim , 3 med subspecialistslunch , 1  h , twice monthlylm ( author , physician group member)hmo medical center ( department of medicine)no7group 4oakland , cajuly 200411 fp , 8 gim , 4 ped , 1 np , 1 palunch , 1/2  h , weeklyphysician group memberfederally funded community health center1/2  h , weekly no case log10group 5richmond , cafebruary 20058fp , 2 npafter work , 1 1/2  h , every other monthlscounty - funded community health centerno7group 6san francisco , camarch 20059 fpbefore clinic +  admin time  , monthlylsuniversity faculty practiceno6group 7san francisco , cajune 20055 fp , 1 gim , 1 npadmin time 
, 1  h , every other monthlscounty - funded community health centerno5*these groups stopped meeting for 18 and 9  months , respectively , because of budget cuts ; each resumed meeting in 2005.fp = family practitioner , gim = general internal medicine , ped = pediatrician , np = nurse practitioner , pa = physician assistant description of phase-1 practice inquiry groups by key characteristics * these groups stopped meeting for 18 and 9  months , respectively , because of budget cuts ; each resumed meeting in 2005 .
fp = family practitioner , gim = general internal medicine , ped = pediatrician , np = nurse practitioner , pa = physician assistant
meetings and attendance the seven phase-1 groups met for periods of 7  months to 3  years as a result of different start dates within the 20022005 data collection period ( see table  1 ) . attendance and
group size remained stable over 137 pi meetings despite one- to three - member turnover mostly from job change . for five- to six - member groups ,
all clinicians working that day attended meetings . for nine - plus - member groups ,
three to six clinicians attended regularly , with an additional three to six attending on a less regular basis . beginning in 2005
authors ls and lm facilitated four groups and one group , respectively ; clinician members facilitated two groups .
clinical dilemma cases across the seven phase-1 groups , we documented 118 dilemma cases discussed in the 64 meetings analyzed .
eighty - five of the cases were presented as individual case dilemmas , and 33 were generated in 10 practice panel reflections ; six of the seven groups completed at least one reflection . of the total dilemma cases ,
patient relationship , 26% as treatment , 25% as diagnosis , and 10% as negative outcome dilemmas ( see table  2 for representative dilemmas ) .
recurring treatment dilemmas included decision - making about incidental findings , morbid obesity , developmental disabilities coupled with chronic illness , and nonmalignant chronic pain with / without substance abuse . 

table  2representative case dilemmas presented at practice inquiry meetings , phase-1 groupscase dilemmapatient  clinician relationship#1this patient , also a friend , wants me to continue being his pcp after being diagnosed with prostate ca ( at earlier social gathering , he asked me about difference in testicular size , and i told him not to worry).#2i do nt know how to work with angry , defeated patient who has fired previous physician , expects same - hour return phone calls , and berates me for lack of improvement in symptoms lacking organic basis.treatment#1i am seeing a 53-year - old female with chronic hep b , htn , dm , elevated ldl , and slightly elevated lfts .
should i start her on statins?#2i do nt know how to proceed with a morbidly obese , developmentally delayed woman of 43 with sleep apnea and presumed right - sided heart failure with pulmonary htn , who now wants bariatric surgery.diagnosis#1this is a 68-year - old female with a history of chemotherapy for lymphoma .
she has new symptoms of a  hot feeling in her body  ; she is afebrile with normal labs .
how should i approach her workup?#2does this 30 year - old asian female have pcos and how can i help her become pregnant?negative outcomes#1i am hurt and confused regarding what i found out accidentally about a patient .
a physician friend in private practice is now seeing my patient ; patient left me because i did not prescribe a statin ; she blames not being on statin for her subsequent tia .
how could i have worked differently with this patient?#2i have male patient in late 1960s with presumptive diagnosis of temporal arteritis ; on low - dose steroids for several years ; was admitted to the hospital with altered mental status , nausea , vomiting , high white count and sed rate ; biopsied for temporal arteritis  negative ; treated with abx .
my realization : missed increasing dementia over time since family members brought him in and answered my questions.a third of individual case discussions produced literature searches done by group members or the facilitator .
systematic reviews and metaanalyses were the most frequent literature formats provided . approximately one in five cases was discussed in subsequent meetings as  follow - up  ; follow - up consisted of 2- to 4-min reports of patient status , literature usefulness , new questions , and/or implications for other patients .
representative case dilemmas presented at practice inquiry meetings , phase-1 groups clinician feedback seventeen of the 23 physicians who returned questionnaires produced 92 comments .
three categories accounted for the majority of comments : the value of  being with colleagues  ( 55% ) , group process / meeting logistics suggestions ( 27% ) , and  the role of time(16% ) .  being with colleagues  was further analyzed to yield four subthemes : ( 1 ) gaining renewal through reflection , ( 2 ) obtaining others perspectives , ( 3 ) developing collegial trust , and ( 4 ) learning specific information / skills ( see table  3 for representative responses ) .
over half of the respondents commented on time issues related to participation ; a third saw time constraints as deterring attendance . 

table  3phase-1 groups feedback survey responses by coding group ( n  =  92)coding groupsn ( % comments)representative commentsbeing with colleagues51 ( 55% )  gaining renewal through reflection15(g2 , 2 ) * although it was hard to break away from all our work responsibilities , the meetings have forced me to take protected time away from the daily grind to be more thoughtful ... (g3 , 2 ) i like the idea of reflecting on what we do rather than the daily do , do , do . in addition , to reflect on how what we do affects the patient  physician relationship . 
obtaining colleagues perspectives14(g2 , 4 ) fresh eyes and ideas on old cases means new ideas ...
(g3 , 3 ) exposure to a variety of physician / patient encounters and expectations  developing trust as a group12(g2 , 3 ) i learned about my colleagues .
i was surprised by some of what was shared in terms of questions they had 
i would have thought that i was the only one.(g3 , 8) helps develop a feeling of connectedness to peers , which balances out the isolation of clinical practice  learning new information / skills10(g1 , 3 ) learning efficient ways to deal with complicated but frequently occurring issues(g2 , 5 ) making sure that my knowledge level is not falling too far behind!group process / meeting logistics24 ( 27% ) more research time12(g1 , 2 ) set aside time to research clinical questions more case follow - up4(g3 , 2 ) follow - up cases previously discussed in a more  formal  way  misc8(g2 , 5 ) cme would make this more worth my time.(g1 , 1 ) case presentation format all over the maprole of time15 ( 16% ) create set - aside time9(g2 , 3 ) meetings come out of clinical time instead of paperwork times . 
time is a problem.6(g3 , 7 ) want to continue but time is always a problem  not codable in above categories2 ( 2%)(g3 , 2 ) i want to continue.*g2 , 2 = survey respondent # 2 in group 2 phase-1 groups feedback survey responses by coding group ( n  =  92 ) * g2 , 2 = survey respondent # 2 in group 2 clinician group discussion analysis of the 15 pi meeting transcripts yielded four themes : acknowledging uncertainty , receiving validation , generating speculations , and envisioning practice change . in describing dilemmas
, clinicians seemed to be willing to reveal knowledge gaps , cognitive biases , and unrealistic expectations : 
what should have told me it was temporal arteritis ?   when my gut says cancer , i get a bone marrow biopsy . 
 if i had been more aggressive with his cocaine addiction , would this have prevented his hospitalization ?  these disclosures appeared to elicit validation from colleagues :  amazing you got as far as you did ... you got the tox screen !  
patients choose you but you ca nt choose them !   why in 15  min should we take on more risks ?  such interchanges stimulated speculative thinking as well as metastrategies :  seems like you could create small successes to build on ... like saying ,  wow , you took your hiv meds for 4  days !  
when i have a patient like this , i schedule a special appointment to do a family tree ... then , it all becomes obvious .
 clues that case presenters were thinking aloud , reframing assumptions , and imagining opportunities for change came through statements such as : 
you re suggesting she s not as worried about herself as i am and , if that s denial , maybe that s okay .   i may not be taking this patient s depression as seriously as i should . 
in this first pi demonstration , as of summer 2006 , 11 groups , composed of 98 clinicians , continue to meet on a regular basis . in the seven phase-1 groups ,
participants willingly presented individual dilemmas , validated each other s concerns , shared uncertainty management strategies , and responded positively to new clinical perspectives . despite pcps  beleaguered status  in turbulent times,45
these findings suggest the feasibility , acceptability , and potential usefulness of these pbli methods . to address pi s usefulness for practice improvement will require more focused modeling and assessment .
analyses of meeting logs and feedback suggest that participants lacked sufficient opportunities to collaborate in searching for and appraising research evidence , and then blending it with clinical experience to apply to case dilemmas .
ebm enthusiasts advocate these skills but provide little guidance for their development.46,47 additionally , limited case follow - up may have truncated the iterative process of integrating feedback and new evidence into changing practice . to better support pcps in managing uncertainty , more meeting time should be spent on the deliberate practice of blending evidence with experience ( e.g. , per - case , focused analysis of guideline / relevance48 ) and using case follow - up insights to 
reconstruct practice20 for the individual patient while appreciating implications for the clinic / office as a whole .
future work must address methodological limitations that threatened this demonstration effort s external and internal validity .
these include a convenience sample from one geographic area lacking private practice pcps , moderate clinician response to a cross - sectional feedback survey sent to three groups meeting in 2003 , and qualitative analyses performed on a small meeting transcript sample and an incomplete dilemma case sample .
in addition , limited data collection for achieving theoretical saturation and overlapping datasets hampering data triangulation remain as challenges .
further pi development , undertaken with rigorously designed , coordinated qualitative and quantitative methods,49 should examine how contextual variables ( e.g. , group facilitation ) impact case discussion , development of uncertainty management skills , and clinician work - life satisfaction .
future pi development should not be predicated on the assumption that phase 1 and two groups will continue to thrive , and recruitment of new , heterogeneous groups representing different geographic areas will proceed unabated .
feedback suggests that holding meetings during personal / administrative may be suboptimal and result in even longer workdays .
would the 13 clinician leaders who originally rejected pi have reacted positively if compensated , set - aside time or credits toward board recertification were linked to participation?5053 because compensating attendance without evidence of impact would be ill - advised , primary care leadership should advocate for studies that examine diverse incentive structures for involvement in pbli efforts focused on clinical uncertainty and how that involvement affects practice and patient care .
 problemmany primary care physicians in nonacademic settings lack a collegial forum for engaging the clinical uncertainties inherent in their work.program descriptionpractice inquiry  is proposed as a set of small - group , practice - based learning and improvement ( pbli ) methods designed to help clinicians better manage case - based clinical uncertainty . 
 clinicians meet regularly at their offices / clinics to present dilemma cases , share clinical experience , review evidence for blending with experience , and draw implications for practice improvement . from 2001 through 2005 , 
 practice inquiry was introduced to sites in the san francisco bay area as a demonstration effort . 
 meeting rosters , case logs , a feedback survey , and meeting field notes documented implementation and provided data for a formative , qualitative evaluation.program evaluationof the 30 sites approached , 14 held introductory meetings . 
 as of summer 2006 , 98 clinicians in 11 sites continue to hold regularly scheduled group meetings . of the 118 patient cases presented in the seven oldest groups , clinician  patient relationship and treatment dilemmas were most common . 
 clinician feedback and meeting transcript data provided insights into how busy practitioners shared cases , developed trust , and learned new knowledge / skills for moving forward with patients.discussionongoing clinician involvement suggests that practice inquiry is a feasible , acceptable , and potentially useful set of pbli methods . 
 two of the practice inquiry s group learning tasks received comparatively less focus : integrating research evidence with clinical experience and tracking dilemma case outcomes . 
 future work should focus on reducing the methodological limitations of a demonstration effort and examining factors affecting clinician participation . 
 set - aside work time for clinicians , or other equally potent incentives , will be necessary for the further elaboration of these pbli methods aimed at managing uncertainty . 