Researching Organizational Structures of Primary Care

March 30, 2023

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

How does a clinician’s stress affect patient care? How can we alleviate the crisis of physician burnout? What was COVID-19’s impact on the field of primary care?

  Erin Sullivan_SquareErin E. Sullivan, Ph.D.

Erin E. Sullivan, Ph.D., is an Associate Professor of Healthcare Management at the Sawyer School of Business at Suffolk University and holds a part-time faculty appointment in the Department of Global Health and Social Medicine at the HMS Center for Primary Care. With a focus on the organizational structures and processes related to primary care in the U.S., Sullivan’s research sets out to provide answers to some of the field’s most pressing questions.

Sullivan has published more than 25 peer-reviewed research articles in the past five years. Her research papers have been cited in top health care journals such as The New England Journal of Medicine, Health Affairs, JAMA Internal Medicine, Social Science & Medicine, BMC Health Services Research, and Academic Medicine. Her goal is to continue to conduct exciting research in this area to help raise the status and importance of primary care in the U.S. health system. We sat down with Sullivan to learn more about her work.

Why have you chosen to focus your career on organizational structures of primary care?

Wow, this is a good question! I think I ended up here through a rather circuitous path. I’m a management scientist by training with a focus on qualitative research. My first stop after graduate school was research in global health, and I was able to learn about and understand different models of health care delivery across the globe. After four years, I wanted to spend more time focusing on our heterogenous health care system and the many models of care delivery in the U.S. I like studying how models of care work and this usually involves organizational structures, processes, technology, and humans. Primary care is often seen as the foundation of health care, but, according to a May 2021 National Academies of Sciences, Engineering, and Medicine report, it is a discipline that is very much in danger. By researching primary care organizational structures and processes, I hope we can find more sustainable ways to deliver care and strengthen this foundational piece of our health system.

What has been the most surprising finding from your research?

Recently, I have had access to some very large and impressive qualitative data sets that were collected during the COVID-19 pandemic. The data show a lot of anger and hostility towards health care leaders and administrators from clinicians. Their frustration stemmed from the lack of transparency in communications and decision-making during the pandemic, as well as the perception that leaders’ and administrators’ decisions were primarily driven by money as opposed to what was best for patients. This caught my attention for two reasons. First and foremost, because I do not have the data from leaders and administrators to see their perspectives, including their challenges and frustrations. Secondly, I’ve taught leadership and management classes for physicians and now I teach health care administration students. The underlying tensions that exist between these two groups are always discussed in these courses. Clinicians and administration have very different backgrounds and training which contributes to this tension. My sense is the division between these groups, who really need to work together for the good of patients, is an existing issue that was magnified by COVID—like so many other issues in health care.

Can you tell us a little bit about your research that investigates the relationship between diagnosis, work conditions, and responses to work conditions (including stress and burnout)?

This was an interesting project with a great team. I got to really focus on the qualitative methodology of comparing clinical notes (from electronic medical records) and transcripts of encounters (what was actually said between the physician and patient) to figure out how to systematically assess and analyze them. The pandemic short-circuited our data collection, so we didn’t get to do this project at the scale we initially planned, but one of the findings from our dataset that I think is worthy of future exploration is that physicians who reported high stress or levels of burnout were less likely to record psychosocial information about the patient in the notes and encounters, while low-stress physicians recorded psychosocial information consistently in 67 percent of encounters.

You found that some of the primary care physicians who participated in leadership development programs were hesitant to assume leadership roles. What was their hesitation and why is it important to ensure PCPs are in leadership positions?

PCPs have been hesitant to take on leadership roles for a few specific reasons.

They went into medicine to be doctors and they specifically chose primary care in order to have relationships with patients. Being a leader takes valuable time away from patient care.

Leadership roles are not resourced or compensated in the same way as clinical time. Many PCPs in our study mentioned that being a leader made it harder for them to have the time to meet their productivity goals, which adversely impacts their income.

PCPs also enjoy the relationships with their peers and do not want to move into roles where they have to manage and navigate conflict with this particular group. So, really, they viewed leadership roles as having many disincentives.

Why is this important? Well, PCPs are the generalists of our health system. They take care of the whole patient, not just one system or disease area, and as such, need to have a seat at the table. I think given the post-pandemic state of primary care, we need them at the table more than ever to be sure primary care has a role to play and that systems find better ways of supporting patients and PCPs. What happens if primary care disappears? I don’t think we want to find out, and having strong PCP leaders and advocates in places where decisions are made is important for providers and patients.

Your research shows that to have exemplary primary care, there needs to be an organizational culture characterized by 1) trusting, long-term relationships; and 2) power, responsibility, and authority redistribution. What steps can organizations take to move toward that culture?

I finished this research well in advance of the pandemic, before the ‘Great Resignation’ and all the talk about the importance of organizational culture, toxic cultures, and quiet quitting. I think the findings now are probably even more relevant than they were five years ago. Looking at some of the qualitative data from COVID, health care workers will attribute trust within their organization to transparent communication, leaders showing up on the frontlines to talk to those delivering care, and the organization providing various supports such as childcare or flexible work schedules. In terms of the distribution of power, responsibility, and authority, the finding from our research that continues to stand out to me is that in organizations where this was the case, employees felt like they had the ability to take risks, try things, fail quickly, and then try again or make a new plan. This seems relevant now given the current state of health care and how in need we are of new ideas and innovations to address some of our system-level challenges.

What is the path forward for primary care? How do we overcome burnout and physician shortages?

If I bring my management lens to the data that I have, the job of primary care, as currently designed, is untenable. The payment structure is wrong, the workload is overwhelming, more patients are living with complex conditions, and longer appointments are needed to adequately care for patients. The job needs to be redesigned or we will continue to struggle with recruiting enough clinicians to practice primary care, and we will lose people currently practicing to other opportunities. No one wants to be on an exhausting hamster wheel every day when they walk into the office.

What research are you working on now or are most excited about conducting in the future?

Just about all my research projects excite me right now, and there are many of them! Going back to my earlier comments about the tension between physicians and leaders and administrators during the pandemic, I want to better understand the challenges and frustrations of the leaders and administrators. Anecdotally, there has been a lot of turnover in this leader/administrator group since COVID arrived, and I have designed a study to learn more about that and if they, too, are burned out. I’m also still mining some of the larger qualitative data sets from COVID for insights, and just finished a manuscript on what contributed to health care workers feeling valued (or not) during the pandemic. I think there will be some follow-on analyses to the feeling valued work that looks at the data based on gender or specialty since we just started to uncover some interesting patterns as we looked across the entire data set.


**Feature photo obtained with a standard license on Shutterstock.


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