Screenshot taken from a video explaining the ESCALATES project
“Shedding light on the work that people do not often see and therefore take for granted.”
Professor and Vice Chair of Research in the Department of Family Medicine at Oregon Health & Science University (OHSU) in Portland, Oregon. Implementation scientist and an expert in qualitative and mixed methods research.
My research examines the interpersonal and organizational aspects of health care delivery with a particular focus on primary and behavioral health care. I enjoy examining and understanding how to address the challenges that emerge when implementing innovations and quality improvements in primary care practices, and my research highlights the often-invisible work and value of primary care clinical teams. One of my current projects is to study the staffing configurations of advanced primary care practices (professionals, roles, functions) in the United States (U.S.). I am honored to be a National Academy Medicine member, and I currently serve on the National Academy of Science Engineering and Medicine Standing Committee for Primary Care, which is an advisory committee to the federal government on primary care.
For fun, I mom, a wife, a Portland Timbers fan, a foodie, and dog-lover who endeavors to be a decent recreational tennis player.
Watch the video of the interview below or on Youtube or, listen to the podcast on Spotify and all the major platforms
“… I became really interested in this idea that the way people interact with each other. The way we communicate, is a path through which we collaboratively construct our social reality.”
When I first asked you to talk to us you said, “But, I’m not a doctor”. So let’s take you back to the beginning, what did you study as an undergraduate?
Deborah Cohen: I actually started out in pre-med and, in the United States, the gateway to being a pre-med undergraduate is chemistry. And, I actually did fairly well in the class and I think I surprised the lab professor when I did really well in the Final. But, it just wasn’t for me. It was much more cut throat. It didn’t have the kind of the collegial vibe that I was looking for. I was young and I ended up taking some communication classes that I really liked. I ended up taking a bachelor’s degree, a master’s, and a PhD in interpersonal and organizational communication. So, I am a doctor. But as my kids like to point out, not the real kind.
DMacA: Tell us how your career in communication developed.
DC: As an undergrad, I think a light bulb went on around research. Communication is a broad field; there’s mass communication, where people study how the media affects people, and there’s interpersonal communication about how two people communicate with each other. But, the thing that really drove me was an interest in research. At the time, I graduated as an undergrad in 1990, women were protesting for the right for choice and the school I went to was in Pennsylvania which is still a state that has both conservative and liberal leanings. And, the thing that got me going was a research study to understand how the local, state, and national media were portraying the abortion debate. I was very fortunate to have some professors that helped me to see that there was more research I could do if that was my interest. They helped me to apply to a master’s program at the Annenberg School for Communication at the University of Pennsylvania and there I became interested in health, and in women’s health, but there wasn’t really anyone on the faculty that could help me with that. So, my thesis is in a completely different subject. However, I became really interested in this idea that the way people interact with each other, the way we communicate, is a path through which we collaboratively construct our social reality. I took a couple years off after that and then ended up going back to Rutgers University to do a PhD. They had more folks studying interpersonal communication in health care and I was really fortunate to get trained by some incredible people, to learn how to study both conversation in more detail than most people would ever want to study it, and also to understand the kinds of communication that happens in organizations. And I blended those two in a way that I never anticipated.
“… internal motivation, external motivation, resources or capacity for change… We could see how facilitators and other folks in the clinic came together to shape those four areas and how that could lead to improvements in cancer preventive care or couldn’t. And that was the beginning of a career.”
Link to the Centre for Primary Care Research and Innovation.
DMacA: So, tell us about that research in the early days that fired your imagination.
DC: My first job after my PhD was as a research analyst in a department of family medicine at the University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School, which is now Rutgers University. I was hired by Ben Crabtree, who is a very well-known qualitative researcher in the field. He needed someone to analyze a mountain’s worth of data that he and Kurt Stange had collected. And, I loved it. They had collected observations and interviews in about 17 primary care practices across the country with a focus on prevention and their field researchers observed 1600 encounters across those practices. There were field notes so they weren’t data that I’d been necessarily trained to analyze, but it all came together. I’d been trained to be a good analyst and so we looked at a bunch of things. In that initial study, one of the topics that emerged as really interesting, was the way that some physicians were able to use an acute care visit to create a window of opportunity to talk about smoking cessation. And, we were able to publish some work on that topic. That led to a second study that was led by Kurt Stange which was one of the first implementation science studies, I think, in this country. I could be wrong about that but it was a very early implementation science study, and it was before folks called it implementation science. He had conducted a study called Step Up, where he offered practice support to primary care clinics, specifically a practice facilitator, who worked with the clinics to help them improve their cancer preventive care. That trial was very successful and he got a continuing grant from the National Institute of Health, National Cancer Institute, to look at why some practices has improved over the study’s 24-month time and why some didn’t. And, that’s where I came in. I led the analysis of the data they had collected with a small team. Kurt had the quantitative data and I had access to their qualitative data. That analysis led to the development of a model that we still use today, called the practice change model. It identified four simple areas and the interdependencies between those areas that seemed to explain why some practices made improvements and others didn’t. And these were internal motivation, external motivation, resources or capacity for change, and how the group was able to see what their opportunities for change were. We could see how facilitators and other folks in the clinic came together to shape those four areas and how that could lead to improvements in cancer preventive care or couldn’t. And that was the beginning of a career.
A department dinner at the meeting of the North American Primary Care Research Group. NAPCRG
“The idea is that the way people interact and communicate really are the building blocks of social life and that you can see the actions and work people do by taking a close look at the way they talk with each other.”
DMacA: Let’s go back a little bit because I’m really interested in interpersonal communication because that’s so much a part of the consultation in family medicine. Tell us about your studies in that area.
DC: I was trained as a conversation analyst and although I was in a communication department, my dissertation advisor, was also in the communication department, had been trained in conversation analysis. That is a sociological discipline that falls under the field of ethnomethodology. The idea is that the way people interact and communicate really are the building blocks of social life and that you can see the actions and work people do by taking a close look at the way they talk with each other. There’s been a lot of incredible work done on how people do greetings, how doctor’s visits are opened, and how the way a doctor’s visit is opened can shape how it ends and whether or not something might come up as they are head out of the visit. If you open a visit with, for example, a sort of- what’s going on, how can I help you today- a broad question that surfaces all the patient’s concerns, the research shows you are less likely to have somebody say, as they’re walking out the door “ hey, by the way, I’m having chest pains” During my PhD I was interested in the communication of social support, and my dissertation focused on support group interaction.
There had been some things written at that point that had suggested that being a supportive person means being a good listener and I was curious about that. Maybe it was my own cultural background or my own experiences, but I wasn’t sure that was absolutely accurate. I got permission to audio record three support groups. These were psychologist led support groups for women who were experiencing infertility. And, audio recordings were the best I could do. I recorded their first, the middle, and the last meeting. But I never analyzed their middle and last meeting because their first meeting was so interesting. This meeting focused almost entirely with each of them telling what I called an injury story. It was a story about how someone, who was often very close to them, had said something insensitive and hurtful to them about their infertility. What I found interesting about these stories was how interactive they were. The teller told the story in such a way that by the time she got to the punch line, the people who were listening were able to show that they knew what was coming- oh boy, here it comes – that kind of response, before she told the punch line. I thought that they had this unique way of showing empathy that was not one directional, it was much more interactive. That was the bottom line of my dissertation.
That was the beginning of an interest in health communication and health care. It’s challenging to study that kind of interaction in health care but occasionally, I get the opportunity to study interpersonal communication closely in health care settings. Even if I am not audio- or video-recording communication in health care settings, this perspective has influenced my approach. When I am a field researcher, and to the extent that we can, we do a lot of observation and those are definitely the kinds of things I to pay attention to.
DMacA: I can see how that triggered a career as that’s absolutely fascinating. So tell us about how your career then progressed after that.
DC: I finished my PhD around the time I was 28, and shortly thereafter I had two little kids. So, for a while, and I tell this to a lot of folks that I mentor, it was really quite perfect for me to be a research analyst. I did not work full time. I worked 80% time. And, that was a good fit for me and my family. About four years into that I realized that I was doing faculty level work and I was working full time, and the folks around me were very nice about getting me on to more of a faculty track. Around the same time, Ben Crabtree had an opportunity to evaluate a national program that was being funded by the Robert Wood Johnson Foundation, called ‘Prescription for Health’. The National program Office was being led by Larry Green, who was in the Department of Family Medicine at the University of Colorado. And the way these programs work is that the Robert Wood Johnson Foundation sets up a National Program Office and they also set up an evaluation of that program. Laura Levitan, who I and others considered to be one of the nation’s top evaluation sciences was at the Robert Wood Johnson Foundation. She was meeting with Ben about evaluating that national program. Prescription for Health was focused on integrating prevention, with a focus on diet, physical activity, smoking and alcohol use, into primary care and it had two rounds of funding. The first round was sort of a -let a thousand flowers bloom- kind of phase, where the program office funded 22 grantees. Grantees implemented innovations in their own regions through practice based research networks to try to improve those targets. I worked with Ben on this evaluation and we used qualitative and quantitative data to understand each of the 22 projects. With the second round, the Principal Investigator role transitioned to me and the focus shifted slightly. So, instead of having 22 sites, there were eight and these eight sites were truly trying to have an impact and working with many more practices. We were monitoring the reach and effectiveness of their programs, and how well they were implementing the changes that they planned. Despite having a shared goal of and similar targets for practice change, the grantees were all doing slightly different things and we were pulling those threads together to make sense of what we were seeing, using quantitative data to understand what they did and robust qualitative data to understand how they did it. We were interacting with each of the teams through an online diary, we were doing some site visits, we were conducting some interviews, and I mention this program because it kicked off an unexpected thread of my career, which is developing evaluations for these multi-site demonstrations that have a shared target but provide the freedom for each of the sites to innovate.
So, what followed Prescription for Health? There was then a program in Colorado called Advancing Care Together, where Larry Green asked us to evaluate a program in that same state that involved 11 sites integrating behavioural health and primary care, where we did something similar. We evaluated the outcomes of these programs and interacted with them in real time to share the data and learn with them as we went along. Then we pulled together the qualitative and quantitative findings. And, subsequent to that, we applied for and were selected to be the national evaluator for an Agency for Healthcare Research and Quality program (AHRQ) called ‘EvidenceNOW’, which involved 1700 practices in 12 states that focused on improving cardiovascular preventive care in primary care settings. We used a very similar approach to understanding, tracking effectiveness, tracking implementation, and then really trying to partner with each of the sites to understand, using qualitative methods, what happened on the ground and why.
“I view EvidenceNOW as one of the largest studies to-date that studies the implementation and impact of a primary care health care extension.”
“I view EvidenceNOW as one of the largest studies to-date that studies the implementation and impact of a primary care health care extension.”
DMacA: EvidenceNOW was a landmark study that really hit the headlines.
DC: It was a big one. It hit the grey hair headlines too. I think!
DMacA: This then moves on to – ‘ESCALATES?’
DC: Yes. The name of our grant was Evaluating System Change to Advance Learning and Take Evidence to Scale or simply ESCALATES. The Agency for Health Care Research and Quality had a vision for building infrastructure in the United States for supporting primary care. They’ve had a 20 plus year trajectory of supporting practice-based research networks and they really wanted to establish infrastructure across the states and study it in what we have come to call, a primary care health care extension. I view EvidenceNOW as one of the largest studies to-date that studies the implementation and impact of a primary care health care extension. The idea of the primary care extension or health care extension, emerges from the idea of an agricultural extension in the United States. In the early 1900s, the United States government established the agricultural extension in the US. And what they did was that they provided funding to each of the land grant universities in each state- every state has a state university that is considered a land grant university. They provided them with funds to establish teams that, while they wouldn’t do farming for farmers, they would do education and outreach and the relationship building to support better farming practice. And it transformed farming in the United States. Some for good, some for bad, like all things, but it really transformed farming practices through education, through outreach and through research. And the primary care extension or the health care extension is the exact same principle for health care and for primary care, which is to build infrastructure that supports research, outreach, and quality improvement in primary care. And that idea was built into the Affordable Care Act, but it wasn’t funded by Congress. And AHRQ picked that up. And that is what EvidenceNOW does.
Its target was cardiovascular preventive care focusing on the ABCs of cardiovascular prevention, aspirin, blood pressure control, cholesterol management, and smoking / tobacco cessation. And, through a grant mechanism, the Agency for Healthcare Research and Quality identified seven grantees that were tasked with working in their own state or contiguous states, like clusters of states, to recruit over 200 primary care practices, ideally focused on practices that didn’t have their own internal quality improvement support, to both do outreach and support to those practices, and to study the impact of that. As part of that program, they funded an independent evaluation, which we called ‘ESCALATES’. The idea was that our work was meant to escalate or elevate theirs, not to get in the way of their work. And so, we designed a very comprehensive mixed methods evaluation that looked at the effectiveness of each of these regional programs. We examined their implementation and the part of implementation that we could track quantitatively most closely was the dose and intensity of practice facilitation support that they delivered because they all had that component and then looked at what was going on in each of their contexts. So, we made visits to their state. We understood their partners. We were very much in constant connection with each of them, very intentionally not to replace what they were going to find in their studies, but to try to add another higher-level layer to that. I think we were able to show what an investment in a primary care extension can produce. Some states have had investment in their extension for over a decade, our work showed how those states were able to leverage and accelerate and help practices that would not have had support without them and have an impact on their patients. It was a huge initiative and effort. There were 1700 practices involved with the potential to really touch over 8 million patients through their primary care office.
“And I feel like I’m trying to make the most of it because a person doesn’t get these kinds of opportunities to make a difference all that often.”
The National Academy of Medicine – links to publications and public events by the Standing Committee on Primary Care
DMacA: It really is a remarkable piece of work. And when you say it touched 8 million patients, that tells us how big a study that was. And, all that work, to use another meaning of the word ‘escalate’ brought you on as an elected member of the National Academy of Medicine.
DC: I had not really thought about those things at the time. I think I was most worried that I wanted to do a good job, given how important I felt the work was. I didn’t even think The National Academy of Medicine was even within the realm of possibility for me. But that is true. I have to acknowledge that it is nice to be valued.
I’ve had a lot of good fortune in my career and one is that I currently have a chair, Jen DeVoe who has really dedicated herself to uplifting and supporting faculty in our department. That is certainly part of it but that isn’t all of it. I do feel that it’s nice to have other folks in your discipline or field who appreciate the work that you do. And so that was a really nice part of the National Academy of Medicine. Perhaps the more important part of it is that folks who are NAM members can decide to do something with that or not. It is a completely volunteer operation, and often you are volunteering to do a lot of work. I had the honour of serving on a committee that wrote a report on Achieving Whole Health with a focus on the VA.
And, that was a couple of years of work which was not led by me, fortunately, because the folks that lead those are essentially writing books, and carry a lot of extra work. But I was able to contribute to a couple of the chapters somewhat significantly. And I do think that understanding how to accomplish whole health care for folks in the United States, including veterans, is really important and particularly timely right now. To accomplish that for veterans in the US requires having a more holistic and comprehensive system for everyone, because a lot of veterans don’t necessarily go to the VA for all their health care. I also had had the opportunity to serve, and continue to serve, on a standing committee for primary care. A few years ago, during the Biden-Harris administration, there was a push to try to set up an office for primary care in the United States. That is kind of interesting because HRSA (Health Services Resource Administration) oversees our community health centers and Federally Qualified Health Centers (FQHCs), but there really isn’t anyone in the government that is looking out for all primary care, making sure we’ve got enough doctors to serve our population. Milbank has funded a primary care scorecard, and we can see that we are losing workforce in primary care, but there wasn’t anyone in the government that was truly watching and trying to remedy that. And there was a push from some exceptional primary care leaders to establish an advisory council to this office. The office never came to pass for probably political-ish reasons. But the National Academy of Medicine, with funding from a range of different external funders, put together a standing committee to advise and answer the federal government’s questions about primary care and I am just delighted to be able to serve on that committee. It is led by Mary Wakefield and Lauren Hughes, and we have just done a tremendous amount of really good work to uplift some important messages around how primary care is valued in the United States. Value, not exclusively in terms of its monetary valuation, but in terms of the importance of maintaining the primary care workforce in the United States. We’ve brought panels together for the public that talk about training the next generation of clinicians for the primary care workforce. And we are now working on another brief report that will look at workforce more specifically. So, the National Academy of Medicine is what you make of it. And I feel like I’m trying to make the most of it because a person doesn’t get these kinds of opportunities to make a difference all that often.
DMacA: And family medicine is very lucky to have you there flying the flag. It’s been fascinating to talk about your career. Thank you very much for sharing so much of your time with us today. It’s been fabulous.
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