Clinical Uncertainty in Primary Care: The challenge of collaborative engagement
Chapter 9
Practice Inquiry: Uncertainty Learning in Primary Care Practice
On-line Resource #2
The CME Programs: Practice Inquiry - Improving Clinical Judgment and Clinical Practice, at the Department
of Family & Community Medicine at University of California, San Francisco,and at Kaiser Permanente
Medical Center Oakland, California
Lucia S. Sommers, DrPH
The Practice Inquiry CME Program at UCSF based in the Department of Family and Community Medicine
began in 2005 preceded by 2 ½ years of pilot work. As of summer 2012, seven PI groups are part of the
program. Two PI groups have been meeting in Kaiser Permanente Medical Centers based in the Department of
Medicine; one group has been CME- certified since 2005 and the other group is currently applying for
accredited CME status. In the US, most states require physicians and mid-level practitioners to obtain ‘CME
credits’ in order for licensure renewal.
Practice Inquiry Groups
Group
Site
Affiliation
First
Mtg
Date
Current
Members
Meeting
Frequency/
Time
Facilitation
1. Maxine Hall Health
Center (San Francisco))
Community health center
(publicly funded)
2002
6 PCPs
1 NP
Every other month
LS
2. Asian Health Services
(Oakland)
Community health center
(publicly funded)
2004
22 PCPs
1 PA
Weekly
MD member
Private Non-profit HMO
2004
4-7 PCPs
2-3 specialists
MD member
Private, non-profit,
university sponsored
2005
6 PCPs
2 NPs
Monthly, ON HOLD
(Physician
facilitator retired)
Monthly
Community health center
(publicly funded)
2006
Every other month
LS
Private practice
2006
5 PCPs
1 NP
1 Specialist
3 PCPs
1 NP
7. Axis Health
Center
(Pleasanton)
Community health center
(publicly funded)
2009
6-8 PCPs
1 NP
8. Sutter East Bay
Foundation
(Albany)
Hospital system-owned
PCP group practice
2010
6 PCPs
2 NPs
Monthly
LS
9. Kaiser Permanente
(Richmond)
Private Non-profit HMO
2010
7-9 PCPs
3-4 specialists
Weekly
MD member
(in Northern California)
3. Kaiser Permanente
(Oakland)
4. Lakeshore
UCSF FM Faculty Practice
(San Francisco)
5. Potrero Hill Health
Center
(San Francisco)
6. Baywest
(San Francisco)
Monthly, ON HOLD
(Lost members;
new hires as of
7/12)
Monthly
PCP- primary care physician, NP- nurse practitioner, PA – physician assistant, LS- Lucia Sommers
1
LS
MD members
LS
MD member
Funding: $500 annual accreditation review fee waived by UCSF as a community service in the interest of
supporting non-commercial, practice-based CME; no fees at Kaiser Permanente
CME Program Clinician Educational Objectives:
 To share uncertainties in managing difficult/complex patients with colleagues
 To practice blending multiple clinical judgment input into strategies for engaging uncertainty
 To identify recurring uncertainties requiring clinic-wide educational/ system interventions
CME Program Group Participation Requirements:
 Minimum of 3 clinicians to count as CME credit-worthy (Category 1 CME credit)
 Facilitator present (4th group member or external person of group’s choosing)
 Case log maintained (See example case log below.)
 Participant comments via annual PI Feedback Questionnaire (See Figure 1 attached.)
UCSF CME Program (#MGR12059) Department of Family and Community Medicine
PRACTICE INQUIRY
(Name of Group) CASE LOG (November – January )
Date
#
11/18 #69
1/20
2
Clinical Uncertainty
Case Description/Issues
Feedback/Discussion
 Pt. cancelled apt with PCP
 Implications for larger practice –
should we tell patients about
potential adverse effects of certain
antibiotics (e.g., cipro) and
sterioids?
 To do lit review: frequency of
tendon rupture with levaquin &
cipro,
“I’m not sure what needs to be done Pt currently on seroquel,
 Consider getting EKG to look at QT
next.” 75yo female experiencing
clonopin, lomectil, coumdin,
interval
drug interaction between Seroquel digoxin, and flecamide. Gets
 Consider referring to new
and
her
cardiac
meds
–
SOB
and
SOB
and
tachy,
hot
and
sweaty
cardiologist.
New
tachy while walking. I need to
while walking; anxiety re
 To do lit review on how seroquel
negotiate management changes
falling. Cardioverted with no
interacts with cardiac meds
with pt’s psychiatrist and
improvement; now to receive
cardiologist to reduce symptoms
holter
“He keeps getting admitted… looks Mid 70’s male with CHF from  Common CHF dilemma
like patient and daughter have given Pakistan lives with caregiver
 Placement in B&C, nursing
daughter; HTN, DM;
home?
up trying.”
New
ambulatory , 02 dependent; 4  Ready for hospice?
admits in 4 months, non Depressed? (anti-depressants
compliant with meds, now on
were prescribed but probably
doesn’t take)
verge of being admitted again.
Follow-up #56: 39 yo female with
 At
lastdoes
visit,he
complaining
oflife?
What
want out of
many atypical problems over a lot of
referredreferral
to GI,
 abdom
Considerpain;
counseling
systems (hx of Cushings syndrome,
 negative colonoscopy.; not
pos adrenal insuffic, PCOS, and
anti-coag.
ovarian mass being worked up at
 Keeps cancelling visits at last
Old
UCSF OBGYN; post chole developed
minute and only comes when
DVT on BCP; warfarin rx failed to
in crisis
impact INRs,) struggling with the
 Consider phone call/letter to
insurance company to cover her
lay out terms of relationship
Lovenox
Follow-up #68: 25 yo male
prescribed Levaquin for bad
bronchitis (ABX allergies);
subsequently complained couldn’t
Old move shoulder; saw commercial
regarding tendon rupture caused by
Levequin
11/18
1/20
New/
Old
#72

 JO
Key Statistics:
 Largest number of groups in any one year: 14
 Number of groups meeting for at least 3 years: 10
 Number of groups meeting for at least 5 years: 6
 Number of groups meeting regularly for at least 18 months no longer participating: 3
Program Evaluation:
 Case Series Analysis (150 cases)
o Uncertainty type: 33% diagnostic, 25% management uncertainties, 23% diagnostic/management;
19% clinician-patient relation
o 15% - adverse outcome; 8% End-of-life
o Top 7 condition types: morbid obesity, chronic pain, use of the prostate specific antigen (PSA) test,
lipid abnormalities, and incidental findings on studies, bi-polar disorders, and patients with both
diabetes and hypertension.
(See On-Line Resource #3 “Practice Inquiry Clinical Uncertainty Taxonomy” for a description of the work
underway to categorize 350 uncertainty cases using an automated data collection and categorization tool.)

Seven- Year Trend Analysis (Data collected via annual PI Feedback Questionnaire; see Figure 1,
attached.)
Practice Inquiry Clinician Self-Report Trend Analysis
Program Years
# SF Bay Area
Groups
#Forms
distributed
Response
Rate
Overall
Value*
% Clinicians
writing case
comments **
2005-06
7
2006-07
9
2007-08
10
2008-09
6
2009-10
7
2010-11
8
2011-12
7
60
110
72
65
77
83
57
80%
71%
75%
55%
73%
68%
79%
3.9
4.0
unavailable
4.0
3.8
4.1
4.0
58%
67%
67%
57%
47%
51%
66%
*5-point Likert scale, 5 = highest value





**Examples
“Blind older female with chronic renal disease and diabetes needing to use insulin but refusing. Came here daily for
injections but can’t continue forever.. Patient refusing to self-inject; no family. Group advised to offer oral meds and
if in the end the patient refuses, then to just accept that it’s the patient’s choice”
“Elderly female with anemia - will check an additional test and then stop worrying about it”
“Long-term use of Fosamax in patients who have been on it for >5 years; I’ll repeat Dexa and consider DC-ing med”
“Patient with newly diagnosed lupus. Since patient not be able to be seen by specialist for a couple of months, what
should I be doing if the patient is not having a flare…Patient has mildly elevated ESR. Question: without symptoms,
need to lower ESR? Group thought ‘no.’“
“Patient with chronic pain, depression, poor motivation. Brought to the group – came away with different
interpretation of patient behavior – ultimately more successful management of the patient”
3