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Routine, ceremony, or drama: an exploratory field study of the primary care clinical encounter.

BACKGROUND
Practicing family physicians often find family systems theory and the biopsychosocial model attractive, but have difficulties applying them in a busy office practice.


METHODS
Two family physicians in a four-person group practice were identified as "exemplars" at managing daily office practice. A collaborative, qualitative methodology was used to explore their strategy. A series of semistructured key informant interviews with the two physicians and the head nurse identified themes later clarified using ethnoscience interviewing techniques. The resultant clinical encounter typology and decision-making taxonomy were evaluated using participant observation and key informant review. The final results were compared with the literature on physician-patient relationships.


RESULTS
Three clinical encounter types were identified. "Routines" were simple, single, and brief visits in which a contractual style and the biomedical model were used. "Ceremonies" were linked rituals that invoked a covenantal style. "Dramas" were a series of visits concerning situations of conflict and emotion and included psychosocial problems. The family was often convened for dramas. Determination of the presenting concern, the trigger for coming, the patient request, the illness prototype, and the type of communication allowed recognition of the clinical encounter type.


CONCLUSIONS
Identifying a clinical encounter as a routine, ceremony, or drama may help family physicians integrate family systems concepts into their busy office practices. These findings have numerous implications for future research, clinical practice, and teaching.