Powerlessness, control, and complexity: the experience of family physicians in a group model HMO.

BACKGROUND I wanted to explore family physicians' perceptions of working in a group model health maintenance organization participating in ongoing quality improvement initiatives. METHODS I undertook a qualitative study using semistructured interviews with 24 family physicians in which there was specific inquiry about informants' perceptions of organizational and team functionality. RESULTS Three main themes emerged from the data: lack of control, strategies for coping, and valuing the practice of primary care. More than one half of the physicians interviewed expressed a sense of powerlessness to change or control their working environment. Some physicians managed to retain a sense of control or at least to mitigate the impact of their powerlessness by employing a range of different strategies for coping. Maintaining a sense of specialist skill in the complex art of family practice was important to many of the physicians interviewed. This sense of specialization across the broad and varied canvas of family practice was not always attainable, however. CONCLUSIONS Retaining the family physician's enthusiasm means both acknowledging what is difficult about family practice and considering how the experience of being a family physician can be improved. To achieve these ends probably means not only finding ways of restoring to family physicians a sense of professional autonomy and control over their immediate working environment but also assigning greater value to the skills in managing clinical and organizational complexity that are particular to family practice.