Physician practice change I: a critical review and description of an Integrated Systems Model

Abstract

The long lag time between medical discovery and when Americans benefit from that discovery has a huge cost in terms of morbidity and mortality. Medicine needs more effective methods for moving discovery to practice. In this article, the authors first offer a critical review of the models of structure and change process gleaned from the physician change literature. Next, they describe the Integrated Systems Model (ISM) that they derive from this review. The ISM has four major components: superstructure, change motivators, change process, and functional interactions. The ISM considers the physician practice to operate as a complex adaptive system requiring diversion of resources from reserves to make a change. In the ISM, resource return is a function of improved quality of care and reimbursement for services. Changes decreasing the resources of the system (parasitic) will be harder to make than those that increase resources (symbiotic) because of resistance to resource loss. The authors extend the ISM to the individual level and describe the need to consider whether individuals within the practice have sufficient reserves to fulfill their part in making the change. Any given change is generally competing with other changes for adoption. Finally, the authors consider the strengths and weaknesses of their model, concluding that by keeping patient welfare, quality care, and finances in the forefront, the ISM provides a more complete picture of forces affecting medical practice change.