title: 'It just has to click': Internists' views of: what constitutes productive interactions with chronically ill patients.
abstract: According to the Chronic Care Model, productive interactions are crucial to patient outcomes. Despite productive interactions being at the heart of the Model, however, it is unclear what constitutes such an interaction. The aim of this study was to gain a better understanding of physician views of productive interactions with the chronically ill.
  
  
  
  We conducted a qualitative study and interviewed 20 internists working in an academic hospital. The data were analyzed using a constructivist approach of grounded theory. To categorize the data, a coding process within which a code list was developed and tested with two other coders was conducted.
  
  
  
  The participants engaged in goal-directed reasoning when reflecting on productive interactions. This resulted in the identification of four goal orientations: (a) health outcome; (b) satisfaction; (c) medical process; and (d) collaboration. Collaboration appeared to be conditional for reaching medical process goals and ultimately health outcome and satisfaction goals. Achieving rapport with the patient ('clicking,' in the term of the participants) was found to be a key condition that catalyzed collaboration goals. Clicking appeared to be seen as a somewhat unpredictable phenomenon that might or might not emerge, which one had to accept and work with. Goal orientations were found to be related to the specific medical context (i.e., a participant's subspecialty and the nature of a patient's complaint).
  
  
  
  The participants viewed a productive interaction as essentially goal-directed, catalyzed by the two parties clicking, and dependent on the nature of a patient's complaint. Using the findings, we developed a conceptual process model with the four goal orientations as wheels and with clicking in the center as a flywheel. Because clicking was viewed as important, but somewhat unpredictable, teaching physicians how to click, while taking account of the medical context, may warrant greater attention.
authors.affiliation: Division of Chronic and Vascular Disease, University of Groningen, University Medical Centre, Hanzeplein 1, 9751 RB, Groningen, The Netherlands. n.m.h.kromme@umcg.nl.
authors.forename: N M H
authors.initials: NMH
authors.lastname: Kromme
authors.affiliation: Faculty of Economics and Business, Centre of Expertise Healthwise, University of Groningen, University Medical Centre Groningen, Nettelbosje 2, 9747 AE, Groningen, The Netherlands.
authors.forename: C T B
authors.initials: CTB
authors.lastname: Ahaus
authors.affiliation: Department of Internal Medicine, University of Groningen, University Medical Centre Groningen, 9751 RB, Groningen, The Netherlands.
authors.forename: R O B
authors.initials: ROB
authors.lastname: Gans
authors.affiliation: Wenckebach Institute, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9751 RB, Groningen, The Netherlands.
authors.forename: H B M
authors.initials: HBM
authors.lastname: van de Wiel
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002908:Chronic Disease; D005260:Female; D006801:Humans; D007396:Internship and Residency; D008297:Male; D010817:Physician-Patient Relations; D010820:Physicians; D036301:Qualitative Research
keywords: Chronic Care Model; Goal orientations; Medical context; Productive patient–physician interaction; Rapport; Subspecialty