• Ekaterina Anderson, Amanda K Solch, B Graeme Fincke, Mark Meterko, Jolie B Wormwood, and Varsha G Vimalananda.
• Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA. ekaterina.anderson@va.gov.
• J Gen Intern Med. 2020 Nov 1; 35 (11): 321832263218-3226.

BackgroundClinician well-being is a major priority for healthcare organizations. However, the impact of workplace environment on clinicians' well-being is poorly understood. Integrated health systems are a particularly relevant type of practice environment to focus on, given the increasing rates of practice consolidation and integration.ObjectiveTo improve understanding of the concerns of primary care clinicians (PCCs) practicing in an integrated health system.DesignWe analyzed free-text comment box responses offered on a national survey about care coordination by 555 PCCs in the Veterans Health Administration, one of the largest integrated health systems in the USA.ParticipantsA total of 555 PCCs who left free-text comments on a national survey of care coordination in the VHA (30% out of 1862 eligible respondents). Demographics and coordination scale scores were similar between respondents who left comments vs. those who did not.ApproachThe data were coded and analyzed in line with the grounded theory approach. Key themes were identified by team consensus and illustrative quotations were chosen to illustrate each theme.Key ResultsVHA PCCs described some pressures shared across practice environments, such as prohibitive administrative burden, but also reported several concerns particular to integrated settings, including "dumping" by specialists and moral distress related to a concern for patients. Frustrations due to several aspects of responsibility around referrals may be unique to integrated health systems with salaried clinicians and/or where specialists have the ability to reject referrals.ConclusionPCCs in integrated health systems feel many of the same pressures as their counterparts in non-integrated settings, but they are also confronted with unique stressors related to these systems' organizational features that restrict clinicians' autonomy. An understanding of these concerns can guide efforts to improve the well-being of PCCs in existing integrated health systems, as well as in practices on their way to integration.

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