Time and the patient-physician relationship

How strategies for managing patient visit time affect physician job satisfaction: a qualitative analysis

BACKGROUND

There is much physician discontent regarding policies that limit time for patient visits and contribute to physician dissatisfaction with the medical profession as a whole. Yet little is known about how physician strategies for managing time limits correspond to job satisfaction.

OBJECTIVE

The goal of this study was to identify strategies physicians use for managing time with patients and the effects these strategies have on job satisfaction.

DESIGN

In-depth interviews with primary care providers in various clinical settings (academic medical centers, community-based centers, solo practices, nonacademic group practices) were audiorecorded.

PARTICIPANTS

Primary care physicians (n = 25).

APPROACH

Transcribed audiorecordings of physician interviews were coded using a modified grounded theory approach. An open coding process was used to identify major themes, subthemes, and the interrelationships among them.

RESULTS

Three main themes emerged. (1) Study physicians disregarded time limits despite the known financial consequences of doing so and justified their actions according to various ethical- and values-based frameworks. (2) Disregarding time limits had a positive impact on job satisfaction in the realm of direct patient care. (3) The existence of time limits had a negative impact on overall job satisfaction.

CONCLUSION

For the study physicians, disregarding time limits on patient visits is an adaptive short-term strategy that enhances satisfaction with direct patient care. It is unlikely that such a strategy alone will help physicians cope with their broader- and growing-dissatisfaction with the profession.

When the third degree is necessary: do pediatricians obtain enough information to detect patients at risk for HCM?

This study was designed to see if pediatricians are collecting sufficient data in family histories to be able to ascertain whether children are at risk for hypertrophic cardiomyopathy (HCM). Surveys were returned by 326 general pediatricians who were members of the Second Chapter of the American Academy of Pediatrics. The majority of pediatricians (98.2%) reported taking family histories; however, only 51.2% reported that this information was updated on a regular basis. Only 29.8% of the pediatricians reported including all five risk factors for HCM in a medical family history. Although almost all of the pediatricians reported including first-degree relatives in medical family histories, only 40.5% reported including all second-degree relatives. Female physicians were found to take more thorough medical family histories than male physicians, and foreign medical school graduates were found to take more thorough medical family histories than US medical school graduates. Additionally, graduates of foreign medical schools reported updating medical family histories more often than graduates of US medical schools. This study suggests that pediatricians might not be identifying risks pertinent to the identification of HCM.

The physical examination in cosmetic surgery: communication strategies to promote the desirability of surgery

Cosmetic surgery is a controversial medical practice that is rapidly expanding in the United States. In 2004 alone, 9.2 million procedures were performed. From breast augmentation to tummy tuck, Americans are taking surgical/medical/health risks to alter their bodily appearance. Although many scholars have criticized the practice, few have looked closely at how plastic surgeons interact with prospective surgical candidates. This essay explores videotaped data of naturally occurring interactions between plastic surgeons and patients seeking to transform their physical appearance. Drawing on action-implicative discourse analysis (Tracy, 2005), the article describes plastic surgeons' embodied and discursive activities during a typical physical examination. The core analysis shows how the patient's body and its aesthetic features can be used by plastic surgeons as interpretive resources to promote the desirability of surgery. By touching excess tissue, pinching it, moving it, or applying tools and artifacts (e.g., tape measurer) on and around the body, plastic surgeons literally bring to life patients' bodily "flaws." Through their multimodal performance, I argue, plastic surgeons mark the desirability of surgical transformation. As medicine meets consumerism, medical activities turn persuasive, incrementally constructing the patient's body as a territory of surgical need.

A Clinical Communication Strategy to Enhance Effectiveness and CAHPS Scores: The ALERT Model

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a national annual report that surveys patients and rates health plans on a variety of metrics, including claims processing, customer service, office staff helpfulness, and ability to get needed care. Although physicians may feel they have no immediate control over many aspects of this questionnaire, there is an important area of the survey where they do have direct control: "how well the doctor communicates."It is well established that effective physician-patient communication has beneficial effects not only on physician and patient satisfaction but also on adherence to medical advice, diagnostic accuracy, and malpractice risk. The creators of the CAHPS survey developed and incorporated four questions seeking to ascertain the patient's impression of the physician's communication skills. These questions assess how well the physician listened carefully to the patient, how often the physician explained things understandably, how often the physician showed respect for what the patient said, and how often the physician spent enough time with the patient.Many excellent clinical communication models exist that touch on aspects of the CAHPS topics, but it behooves physicians to be mindful of the exact survey questions. The ALERT model of communication was developed to facilitate physicians' recall of these measures. By incorporating key verbal and nonverbal communication skills, clinicians can address and improve their scores on this important area of the CAHPS survey.

Do longer consultations improve the management of psychological problems in general practice? A systematic literature review

BACKGROUND

Psychological problems present a huge burden of illness in our community and GPs are the main providers of care. There is evidence that longer consultations in general practice are associated with improved quality of care; but this needs to be balanced against the fact that doctor time is a limited resource and longer consultations may lead to reduced access to health care. The aim of this research was to conduct a systematic literature review to determine whether management of psychological problems in general practice is associated with an increased consultation length and to explore whether longer consultations are associated with better health outcomes for patients with psychological problems.

METHODS

A search was conducted on Medline (Ovid) databases up to 7 June 2006. The following search terms, were used:general practice or primary health care (free text) or family practice (MeSH)AND consultation length or duration (free text) or time factors (MeSH)AND depression or psychological problems or depressed (free text).A similar search was done in Web of Science, Pubmed, Google Scholar, and Cochrane Library and no other papers were found. Studies were included if they contained data comparing consultation length and management or detection of psychological problems in a general practice or primary health care setting. The studies were read and categories developed to enable systematic data extraction and synthesis.

RESULTS

29 papers met the inclusion criteria. Consultations with a recorded diagnosis of a psychological problem were reported to be longer than those with no recorded psychological diagnosis. It is not clear if this is related to the extra time or the consultation style. GPs reported that time pressure is a major barrier to treating depression. There was some evidence that increased consultation length is associated with more accurate diagnosis of psychological problems.

CONCLUSION

Further research is needed to elucidate the factors in longer consultations that are associated with greater detection of psychological problems, and to determine the association between the detection of psychological problems and the attitude, gender, age or training of the GP and the age, gender and socioeconomic status of the patient. These are important considerations if general practice is to deal more effectively with people with psychological problems.

Voluntary physician switching by human immunodeficiency virus-infected individuals: a national study of patient, physician, and organizational factors

OBJECTIVE

We sought to assess which patient, physician, and organizational factors are related to voluntary physician switching among human immunodeficiency virus (HIV)-infected patients.

DESIGN

We analyzed the results from a 3-wave survey of patients conducted by the HIV Cost and Services Utilization Study (HCSUS), a longitudinal study of a nationally representative sample of noninstitutionalized HIV-infected individuals receiving care in the contiguous United States. Physicians providing care and care site directors were surveyed once. Relationships of interpersonal aspects of care, access and continuity, technical quality of care, and physician and site characteristics to voluntary switching were analyzed using multilevel logistic regression models that nested repeated observations within patients, patients within clinicians, and clinicians within region.

RESULTS

Approximately 15% of patients voluntarily changed their usual clinicians during the 2-year study period. In a multivariate model, lower voluntary switching was predicted by patient trust (odds ratio [OR]=0.74; 95% confidence interval [95% CI]=0.61-0.90), physician antiretroviral knowledge (OR=0.26; 95% CI 0.13-0.53), moderate (rather than low or high) HIV patient volume at a care site (OR=0.09; 95% CI=0.03-0.31), and Ryan White Care Act funding (OR=0.27, 95% CI=0.14-0.52).

CONCLUSIONS

Patients with chronic illnesses may use several markers of specialization and technical quality to make decisions about their care. These results challenge the notion that patients cannot assess the quality of care they receive.

Connoisseurs of care? Unannounced standardized patients' ratings of physicians

BACKGROUND

Patient satisfaction surveys can be informative, but bias and poor response rates may limit their utility as stable measures of physician performance. Using unannounced standardized patients (SPs) may overcome some of these limitations because their experience and training make them able judges of physician behavior.

OBJECTIVES

We sought to understand the reliability of unannounced SPs in rating primary care physicians when covertly presenting as real patients.

STUDY DESIGN

Data from 2 studies (Patient Centered Communication [PCC]; Social Influences in Practice [SIP]) were included. For the PCC study, 5 SPs made 192 visits to 96 physicians; for the SIP study, 18 SPs made 292 visits to 146 physicians. SPs visits to physicians were randomized, thus avoiding mutual selection bias. Each SP rated 16 to 38 physicians on interpersonal skills (autonomy support: PCC, SIP), technical skills (information gathering: SIP-only), and overall satisfaction (SIP-only). We evaluated SP evaluation consistency (physician vs. total variance rho), and SPs' overall satisfaction with specific dimensions of physician performance.

RESULTS

Scale reliability varied from 0.71 to 0.92. Physician rhos (95% confidence intervals) for autonomy support were 0.40 (0.22-0.58; PCC) and 0.30 (0.14-0.45; SIP); information gathering rho was 0.46 (0.33-0.59; SIP). Overall SP satisfaction rho was 0.47 (0.34-0.60; SIP). SPs varied significantly in adjusted overall satisfaction levels, but not other dimensions.

CONCLUSIONS

These analyses provide some evidence that medical connoisseurship can be learned. When adequately sampled by trained SPs, some physician skills can be reliably measured in community practice settings.

Exploring and validating patient concerns: relation to prescribing for depression

PURPOSE

This study examined moderating effects of physician communication behaviors on relationships between patient requests for antidepressant medications and subsequent prescribing.

METHODS

We conducted a secondary analysis of a randomized trial. Primary care physicians (N = 152) each had 1 or 2 unannounced visits from standardized patients portraying the role of major depression or adjustment disorder. Each standardized patient made brand-specific, general, or no requests for antidepressants. We coded covert visit audio recordings for physicians' exploration and validation of patient concerns (EVC). Effects of communication on prescribing (the main outcome) were evaluated using logistic regression analysis, accounting for clustering and for site, physician, and visit characteristics, and stratified by request type and standardized patient role.

RESULTS

In the absence of requests, high-EVC visits were associated with higher rates of prescribing of antidepressants for major depression. In low-EVC visits, prescribing was driven by patient requests (adjusted odds ratio [AOR] for request vs no request = 43.54, 95% confidence interval [CI], 1.69-1,120.87; P < or = .005), not clinical indications (AOR for depression vs adjustment disorder = 1.82; 95% CI, 0.33-9.89; P = NS). In contrast, in high-EVC visits, prescribing was driven equally by requests (AOR = 4.02; 95% CI, 1.67-9.68; P < or = .005) and clinical indications (AOR = 4.70; 95% CI, 2.18-10.16; P < or = .005). More thorough history taking of depression symptoms did not mediate these results.

CONCLUSIONS

Quality of care for depression is improved when patients participate more actively in the encounter and when physicians explore and validate patient concerns. Communication interventions to improve quality of care should target both physician and patient communication behaviors. Cognitive mechanisms that link patient requests and EVC to quality of care warrant further study.

Facilitating narrative medical discussions of type 1 diabetes with computer visualizations and photography

OBJECTIVE

Patient-centered approaches to medicine suggest the need for physicians to become more aware of concerns and needs expressed in patient narratives. However, patients and physicians have different goals and discourse styles during consultations. We attempt to bridge these differences by providing patients with ways to collect, visualize, and describe behavioral and biomedical data.

METHODS

We describe an intervention where individuals with type 1 diabetes photograph health-related behaviors. These images and blood glucose records are displayed in computer visualizations and used during patient-physician interviews.

RESULTS

Qualitative analyses of interview data with patients who photographed their lives suggest the range of difficulties associated with diabetes self-management. The visualizations helped them articulate concerns about stress, peer relations, and unhealthy routines.

CONCLUSION

Interventions that combine biomedical and biopsychosocial data during patient-physician consultations may be beneficial for patients, helping them reflect on correlations between behaviors and health. Physicians are provided with contextual evidence to better understand patient issues around diabetes management.

PRACTICE IMPLICATIONS

We suggest that this and similar interventions could be used as an occasional diagnostic to help patients articulate stories of their health-related practices. Annotated archives of photographs and glucose data may also be useful tools for sharing diabetes experiences with newly diagnosed patients.

The clinical context and patient participation in post-diagnostic consultations

OBJECTIVE

Although patient participation is an important feature of patient-centered health care, few studies have examined how the clinical context affects patient involvement in medical encounters. This investigation examined the way patients communicate with physicians in two diverse post-diagnostic settings, post-angiogram consultations and initial lung cancer visits.

METHODS

From transcripts and audiorecordings of post-angiogram consultations (n=88) and initial lung cancer visits (n=62) within a VA hospital in the United States, three measures of patient participation were coded--number of active participation behaviors (questions, acts of assertiveness, and expressions of concern), proportion of patients' utterances in the form of active participation, and conversational involvement (ratio of patient utterances to physician plus patient utterances). Mixed linear regression procedures assessed the independent effects of the clinical setting, physicians' facilitative communication (partnership-building and supportive talk), and patients' age, education, and ethnicity on patient participation.

RESULTS

Not only was their less talk in the post-angiogram consultations compared with the lung cancer visits, heart patients also were less conversationally involved (accounted for 25% of the talk) than were lung cancer patients (45% of the talk) and their doctors used proportionally less facilitative talk than did the lung cancer physicians. In both settings, patients were more conversationally engaged when proportionally more of the physicians' talk was facilitative.

CONCLUSIONS

The clinical context has a profound effect on patient participation. However, within individual settings, physicians can increase patient involvement by using partnering and supportive communication.

PRACTICE IMPLICATIONS

Clinicians and administrators should assess clinical practices that restrict patient involvement in ways that could affect quality of decision-making.

Chest pain: communication of symptoms and history in a London emergency department

OBJECTIVE

To describe patient-provider interactions for patients in an emergency department with possible acute coronary syndrome (ACS) and to generate hypotheses about how communication might contribute to sociocultural disparities in cardiac care.

METHODS

Qualitative analysis of observational data. Seventy-four consecutive patients presenting between 8 a.m. and 10 p.m. over a 4-month period.

RESULTS

Participants were aged 40-85 years; 58% were male; 67% were white, 18% Afro-Caribbean, and 15% South East Asian. Observations revealed significant obstacles to communication for the majority of patients. The three most prominent impediments to effective communication were: the use of leading questions to define chest pain, patient-provider conflict as a result of, and contributor to, poor communication, and frank miscommunication due to language barriers and translational difficulties.

CONCLUSION

This study documents aspects of the communication process that compromise the quality of the medical history obtained in emergency department patients with suspected ACS. Accurate diagnosis relies on an interaction that weaves both the patient's and the physician's perspective into a shared understanding of events that comprise a patient's history. When diagnostic short cuts are taken to overcome educational, cultural, or language barriers in the medical interview, they may contribute to health care disparities.

PRACTICE IMPLICATIONS

Physicians should take a more attentive and careful approach to patient interviewing than was observed here and should be aware of the ways in which they shape the interview through their questions and focus. Good communication skills can be effectively taught at all levels of training and practice.

Doctor-patient communications in the Aboriginal community: towards the development of educational programs

OBJECTIVE

Aboriginal people in Canada have poorer health than the rest of the population. Reasons for health disparities are many and include problems in communication between doctor and patient. The objective of this study was to understand doctor-patient communication in Aboriginal communities in order to design educational interventions for medical students based on the needs and experiences of patients.

METHODS

Experiences of good and poor communication were studied by semi-structured interviews or focus groups with 22 Aboriginal community members, 2 community health representatives and 2 Aboriginal trainee physicians. Transcribed data were coded and subjected to thematic analysis.

RESULTS

Positive and negative experiences of communicating with physicians fell into three broad and interrelated themes: their histories as First Nations citizens; the extent to which the physician was trusted; time in the medical interview.

CONCLUSION

Aboriginal peoples' history affects their communication with physicians; barriers may be overcome when patients feel they have a voice and the time for it to be heard.

PRACTICE IMPLICATIONS

Physicians can improve communication with Aboriginal patients by learning about their history, building trust and giving time.

Making communication research matter: what do patients notice, what do patients want, and what do patients need?

OBJECTIVE

To explore limitations of current communication theory by considering different perspectives of researchers, clinicians, patients and teachers of communication.

METHOD

Theory development based on limitations of the current communication research literature due to inconsistencies between patient reports and observed communication behavior.

RESULTS

While researchers focus on the mechanics and techniques of communication, patients seek relationships in which they experience trust, the right amount of autonomy, caring, and expertise. Patients', physicians', and communication experts' perspectives do not always define the same problems and often point to different solutions.

CONCLUSIONS

In addition to studying clinician behaviors and patient perceptions of care, communication research should focus on five additional factors: what patients notice, want and need, and how their perspectives differ from those of physicians and researchers; the context, including illness severity and type and family influences; how complex health systems facilitate and impede communication; patients' influences on physician communication behavior; and habits of mind that promote attentive care.

Tailoring communication in cancer genetic counseling through individual video-supported feedback: a controlled pretest-posttest design

OBJECTIVES

To assess the influence of a 1-day individual video-feedback training for cancer genetic counselors on the interaction during initial visits. Feedback was intended to help counselors make counselees' needs more explicit and increase counselors' sensitivity to these.

METHODS

In total 158 counselees, mainly referred for breast or colon cancer and visiting 1 of 10 counselors, received a pre- and post-visit questionnaire assessing needs (fulfillment). Visits were videotaped, counselor eye gaze was assessed, and verbal communication was analyzed by Roter Interaction Analysis System (RIAS) adapted to the genetic setting. Halfway the study, five counselors were trained.

RESULTS

Trained counselors provided more psychosocial information, and with trained counselors emotional consequences of DNA-testing was more often discussed. Counselees seen by a trained counselor considered their need for explanations on (emotional) consequences of counseling as better fulfilled. Unexpectedly, counselees' contribution to the interaction was smaller with trained counselors.

CONCLUSION

Feedback appeared to result in greater emphasis on psychosocial issues, without lengthening the visit. However, counselors did not become more verbally supportive in other ways than by providing information.

PRACTICE IMPLICATIONS

A 1 day individual training appears effective to some extend; increased opportunities for watching and practicing behavioral alternatives and arranging consolidating sessions may improve training results.

Physicians' responses to patients' medically unexplained symptoms

OBJECTIVE

To understand how physicians communicate may contribute to the mistrust and poor clinical outcomes observed in patients who present with medically unexplained symptoms (MUS).

METHODS

After providing informed consent, 100 primary care physicians in greater Rochester, New York, were visited by two unannounced covert standardized patients (actors, or SPs) portraying two chest pain roles: classic symptoms of gastroesophageal reflux disease (GERD) with nausea and insomnia (the GERD role) and poorly characterized chest pain with fatigue and dizziness (the MUS role). The visits were surreptitiously audiorecorded and analyzed using the Measure of Patient-Centered Communication (MPCC), which scores physicians on their exploration of the patients' experience of illness (component 1) and psychosocial context (component 2), and their attempts to find common ground on diagnosis and treatment (component 3).

RESULTS

In multivariate analyses, MUS visits yielded significantly lower scores on MPCC component 1 (p = .01). Subanalysis of component 1 scores showed that patients' symptoms were not explored as fully and that validation was less likely to be used in response to patient concerns in the MUS than in the GERD visits. Component 2 and component 3 were unchanged.

CONCLUSION

Physicians' inquiry into and validation of symptoms in patients with MUS was less common compared with more medically straightforward patient presentations. Further research should study the relationship between communication variables and poor clinical outcomes, misunderstandings, mutual distrust, and inappropriate healthcare utilization in this population, and test interventions to address this problem.

Helping patients improve their health-related behaviors: what system changes do we need?

A large gap separates actual clinical outcomes of patients with chronic disease from optimal outcomes. This gap may be attributable to physician problems (physicians unaware of practice guidelines), patient problems (patients who choose not to follow medical advice) or system problems (physicians lack time to assist patients in managing their chronic condition). A goal for chronic illness care is to assist people with chronic conditions to become informed, activated patients. Patients who are informed and activated (activated = participating in health-related decisions) have better health-related behaviors and clinical outcomes. Primary care is often conducted within a 15-minute, multi-agenda visit between physician and patient. Such a structure has led to (1) patients being inadequately informed about their chronic conditions and (2) patients being passive recipients of medical advice rather than active participants in medical decisions. The result has been poorly informed, passive patients. This situation constitutes a system problem. Three redesign elements have the potential to address this system problem: (1) Pre-activating patients prior to the clinical visit appears to encourage more active patients and--in one study--improved clinical outcomes. (2) Planned visits, with a care manager spending time with patients, individually or in groups, providing education and medical management, have been shown to improve clinical outcomes. (3) Regular sustained follow-up, by face-to-face visits, telephone, or electronic means, is associated with healthier behaviors. Not all patients receiving disease management through redesigned primary care will adopt healthier behaviors because many factors outside the medical care system influence personal choices. However, until the medical care system regularly offers adequate information and encourages collaborative decision-making, it is improper to place the responsibility for unhealthy behaviors onto patients.

General practitioners' and family physicians' negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review

OBJECTIVE

To estimate the proportion of general practitioners (GPs) and family physicians (FPs) with negative beliefs and attitudes towards discussing smoking cessation with patients.

METHODS

A systematic review.

STUDY SELECTION

All studies published in English, in peer-reviewed journals, which allowed the extraction of the proportion of GPs and FPs with negative beliefs and attitudes towards discussing smoking cessation.

DATA SYNTHESIS

Negative beliefs and attitudes were extracted and categorised. Proportions were synthesized giving greater weight to those obtained from studies with larger samples. Those assessed in two or more studies are reported.

RESULTS

Across 19 studies, eight negative beliefs and attitudes were identified. While the majority of GPs and FPs do not have negative beliefs and attitudes towards discussing smoking with their patients, a sizeable minority do. The most common negative beliefs were that such discussions were too time-consuming (weighted proportion: 42%) and were ineffective (38%). Just over a quarter (22%) of physicians reported lacking confidence in their ability to discuss smoking with their patients, 18% felt such discussions were unpleasant, 16% lacked confidence in their knowledge, and relatively few considered discussing smoking outside of their professional duty (5%), or that this intruded upon patients' privacy (5%), or that such discussion were inappropriate (3%).

CONCLUSIONS

In addition to providing skills training, interventions designed to increase the implementation of smoking cessation interventions by primary care physicians may be more effective if they address a range of commonly held negative beliefs and attitudes towards discussing smoking cessation. These include beliefs and values that influence primary care physicians' judgements about whether discussing smoking is an effective use of their time.

Measuring patient-centered communication in Patient–Physician consultations: Theoretical and practical issues

The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.

Patient-centered communication and diagnostic testing

PURPOSE

Although patient-centered communication is associated with improved health and patient trust, information about the impact of patient-centered communication on health care costs is limited. We studied the relationship between patient-centered communication and diagnostic testing expenditures.

METHODS

We undertook an observational cross-sectional study using covert standardized patient visits to study physician interaction style and its relationship to diagnostic testing costs. Participants were 100 primary care physicians in the Rochester, NY, area participating in a large managed care organization (MCO). Audio recordings of 2 standardized patient encounters for each physician were rated using the Measure of Patient-Centered Communication (MPCC). Standardized diagnostic testing and other expenditures, adjusted for patient demographics and case-mix, were derived from the MCO claims database. Analyses were adjusted for demographics and standardized patient detection.

RESULTS

Compared with other physicians, those who had MPCC scores in the lowest tercile had greater standardized diagnostic testing expenditures (11.0% higher, 95% confidence interval [CI], 4.5%-17.8%) and greater total standardized expenditures (3.5% higher, 95% CI, 1.0%-6.1%). Whereas lower MPCC scores were associated with shorter visits, adjustment for visit length and standardized patient detection did not affect the relationship with expenditures. Total (testing, ambulatory and hospital care) expenditures were also greater for physicians who had lower MPCC scores, an effect primarily associated with the effect on testing expenditures.

CONCLUSIONS

Patient-centered communication is associated with fewer diagnostic testing expenditures but also with increased visit length. Because costs and visit length may affect physicians' and health systems' willingness to endorse and practice a patient-centered approach, these results should be confirmed in future randomized trials.

The effect of physician solicitation approaches on ability to identify patient concerns

CONTEXT

Studies showing that physicians often interrupt the patient's opening statement assume that this compromises data collection.

OBJECTIVE

To explore the association between such interruptions and physician accuracy in identifying patient concerns.

DESIGN

This study replicates the Beckman-Frankel methodology and adds exit interviews to assess physician understanding. The authors audiotaped a convenience sample of 70 encounters and surveyed both parties following the visit.

SETTING

A community-based ambulatory clinic.

PARTICIPANTS

Internal medicine residents (77%) and attending physicians and their adult, English-speaking patients who were primarily low income and ethnic minority.

OUTCOME MEASURE

The Index of Understanding measures patient-physician problem list concordance. It is the percentage of patient problems, obtained on exit, that the physician correctly identifies.

RESULTS

In 26% of the visits, patients were allowed to complete their agenda without interruption; in 37% the physicians interrupted; and in 37% no inquiry about agenda was made in the first 5 minutes. Neither physician experience nor their assessment of time pressure or medical difficulty was associated with these rates. Exit interviews showed no significant difference in Index of Understanding between those involving completion of agenda (84.6%) and those involving patient interruption (82.4%) (P=.83). But when the physician did not solicit an agenda, the concordance was 59.2%, significantly lower than either the completion (P=.014) or the interruption group (P=.013).

CONCLUSION

Interruption as defined by Beckman-Frankel does not curtail ability to identify patient concerns, but failure to ask for the patient's agenda associates with a 24% reduction in physician understanding.

Managed care, physician job satisfaction, and the quality of primary care

OBJECTIVE

To determine the associations between managed care, physician job satisfaction, and the quality of primary care, and to determine whether physician job satisfaction is associated with health outcomes among primary care patients with pain and depressive symptoms.

DESIGN

Prospective cohort study.

SETTING

Offices of 261 primary physicians in private practice in Seattle.

PATIENTS

We screened 17,187 patients in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms; 2,004 patients completed a 6-month follow-up survey.

MEASUREMENTS AND RESULTS

For each patient, managed care was measured by the intensity of managed care controls in the patient's primary care office, physician financial incentives, and whether the physician read or used back pain and depression guidelines. Physician job satisfaction at baseline was measured through a 6-item scale. Quality of primary care at follow-up was measured by patient rating of care provided by the primary physician, patient trust and confidence in primary physician, quality-of-care index, and continuity of primary physician. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days. Pain and depression patients of physicians with greater job satisfaction had greater trust and confidence in their primary physicians. Pain patients of more satisfied physicians also were less likely to change physicians in the follow-up period. Depression patients of more satisfied physicians had higher ratings of the care provided by their physicians. These associations remained after controlling statistically for managed care. Physician job satisfaction was not associated with health outcomes.

CONCLUSIONS

For primary care patients with pain or depressive symptoms, primary physician job satisfaction is associated with some measures of patient-rated quality of care but not health outcomes.

Predicting reports of unmet expectations among rheumatology patients

OBJECTIVE

Approximately 25% of patients report unmet expectations after their doctor visits. In a longitudinal study of rheumatology patients, we examined whether changes in health status could predict unmet expectations.

METHODS

Arthritis patients (n = 177) responded to 2 surveys (baseline and 6-month followup). Both surveys contained questions on health status (functional status, pain, helplessness, psychological status) and visit duration. The followup survey contained questions on postvisit unmet expectations. Factors associated with unmet expectations were determined.

RESULTS

Fifty-eight patients (33%) reported unmet expectations, most often for information (47%) and new medications (31%). Unmet expectations were more common among patients with greater baseline helplessness (odds ratio [OR] 1.9, 95% confidence interval [95% CI] 1.0-3.6) and short doctor visits at followup (OR 5.6, 95% CI 2.4-13.1). Unmet expectations were less common among those experiencing a decline in pain (OR 0.3, 95% CI 0.1-0.9).

CONCLUSION

Attention to the patient's level of pain and helplessness and duration of the visit may limit reports of unmet expectations.

Job stress and job satisfaction of cancer care workers

BACKGROUND

There is an increasing demand for oncology care as a result of a number of trends. In combination with ongoing changes to the health-care system, these trends have an impact on the workplace environment of systemic therapy personnel.

METHODS

A postal survey was sent to major providers of tertiary systemic therapy services in Ontario. Included in the survey were measures of job satisfaction and stress. In order to capture in-depth data related to survey themes, focus groups were held with personnel at six major cancer treatment facilities. Content analysis identified major themes.

RESULTS

Analysis of focus group and survey studies showed that the greatest source of job satisfaction stemmed from patient care and contact. Manifestations of increasing workload emerged as major sources of job stress. Personnel were concerned as to what they saw as negative consequences of heavy workload--a perceived decrease in the quality of patient care and staff morale.

CONCLUSIONS

The findings of this research suggest that the current workplace environment is having a negative impact on the well-being of systemic therapy staff, and may have consequences in terms of quality of patient care. Personnel identified system changes that they felt would help alleviate workload and resulting stress.

Impact of interpretation method on clinic visit length

OBJECTIVE

To determine the impact of interpretation method on outpatient visit length.

DESIGN

Time-motion study.

SETTING

Hospital-based outpatient teaching clinic.

PARTICIPANTS

Patients presenting for scheduled outpatient visits.

MEASUREMENTS AND MAIN RESULTS

Over a 6-week study period, a research assistant recorded the following information for consecutive patient visits: patient age, gender and insurance type; type of interpreter used (none, hospital interpreter, telephone interpreter or patient-supplied interpreter); scheduled visit length; provider type (nurse practitioner; attending physician; resident in postgraduate year 1, 2 or 3, or medical student); provider gender; amount of time the patient spent in the examination room with the provider (provider time); and total time the patient spent in the clinic from check-in to checkout (clinic time). When compared to patients not requiring an interpreter, patients using some form of interpreter had longer mean provider times (32.4 minutes [min] vs 28.0 min, P <.001) and clinic times (93.6 min vs 82.4 min, P =.002). Compared to patients not requiring an interpreter, patients using a telephone interpreter had significantly longer mean provider times (36.3 min vs 28.0 min, P <.001) and clinic times (99.9 min vs 82.4 min, P =.02). Similarly, patients using a patient-supplied interpreter had longer mean provider times (34.4 min vs 28.0 min, P <.001) and mean clinic times (92.8 min vs 82.4 min, P =.027). In contrast, patients using a hospital interpreter did not have significantly different mean provider times (26.8 min vs 28.0 min, P =.51) or mean clinic times (91.0 min vs 82.4 min, P =.16) than patients not requiring an interpreter.

CONCLUSION

In our setting, telephone and patient-supplied interpreters were associated with longer visit times, but full-time hospital interpreters were not.

GPs' perspectives on managing time in consultations with patients suffering from depression: a qualitative study

BACKGROUND

Although there is widespread concern that general practice consultations are too short for doctors to provide a high quality of care for patients, the relationship between the length and outcome of these consultations remains unclear. Research to date has neglected the subjective experience of consultation time of both patients and GPs.

OBJECTIVES

Our aim was to investigate GP perspectives on consultation time and the management of depression in general practice.

METHOD

A qualitative interview-based study was carried out of 19 GPs from eight West Midlands general practices.

RESULTS

The GPs in this study acknowledged the pressure of work and resource constraints in general practice. However, they did not feel these prevented them from providing good support and treatment for depression. They were confident in the effectiveness of antidepressants and their own skills in providing counselling support, and were able to utilize time flexibly in responding to patients' variable needs. Depression was viewed as a relatively straightforward problem that usually could be managed within the resources available to general practice.

CONCLUSION

The doctors generally did not experience time to be a limiting factor in providing care for patients with depression. This is in contrast to the more acute sense of time pressure commonly reported by patients which they felt undermined their capacity to benefit from the consultation. GPs need to be more aware of patient anxieties about time, and to devise effective means of raising patients' sense of time entitlement in general practice consultations.

The association between three different measures of health status and satisfaction among patients with diabetes

Studies suggest that health status influences patient satisfaction, but little work has examined the influence of different measures of health status on satisfaction. The authors examined whether the association between health status and satisfaction varied for different measures of health status among 2000 diabetic patients receiving care across 25 Veterans Affairs facilities. Health status was measured using (1) the diabetes-related components of the Total Illness Burden Index (DM TIBI), a measure of diabetes severity and comorbidities; (2) the Short Form 36 (SF-36) Physical Function Index (PFI10); and (3) the SF-36 general health perceptions question (SF-1). Satisfaction was measured both by a 5-item scale on satisfaction with patient-provider communication and by a single item on overall diabetes care satisfaction. In adjusted models, worse health on all three health status measures correlated with lower satisfaction, but the DM TIBI explained more of the variation in satisfaction than either the PFI10 or SF-1. Moreover, when the DM TIBI was added to the model containing PFI10, PFI10 was no longer significantly associated with satisfaction. In this diabetes population, health status appears to have a substantial impact on patient satisfaction, and this effect is considerably greater for diabetes severity than for physical functioning.

Patients' perceptions of entitlement to time in general practice consultations for depression: qualitative study

OBJECTIVE

To investigate patients' perceptions of entitlement to time in general practice consultations for depression.

DESIGN

Qualitative study based on interviews with patients with mild to moderate depression.

SETTING

Eight general practices in the West Midlands and the regional membership of the Depression Alliance.

PARTICIPANTS

32 general practice patients and 30 respondents from the Depression Alliance.

RESULTS

An intense sense of time pressure and a self imposed rationing of time in consultations were key concerns among the interviewees. Anxiety about time affected patients' freedom to talk about their problems. Patients took upon themselves part of the responsibility for managing time in the consultation to relieve the burden they perceived their doctors to be working under. Respondents' accounts often showed a mismatch between their own sense of time entitlement and the doctors' capacity to respond flexibly and constructively in offering extended consultation time when this was necessary. Patients valued time to talk and would often have liked more, but they did not necessarily associate length of consultation with quality. The impression doctors gave in handling time in consultations sent strong messages about legitimising the patients' illness and their decision to consult.

CONCLUSIONS

Patients' self imposed restraint in taking up doctors' time has important consequences for the recognition and treatment of depression. Doctors need to have a greater awareness of patients' anxieties about time and should move to allay such anxieties by pre-emptive reassurance and reinforcing patients' sense of entitlement to time. Far from acting as "consumers," patients voluntarily assume responsibility for conserving scarce resources in a health service that they regard as a collective rather than a personal resource.

A qualitative assessment of 1st-year internal medicine residents' perceptions of evidence-based clinical decision making

BACKGROUND

Residents' perceptions about evidence-based clinical decision making remain largely unexplored.

PURPOSE

To understand how residents perceive and use evidence-based medicine in clinical decision making.

METHODS

Qualitative study using a semistructured questionnaire and focus group in a postgraduate training program in internal medicine at an academic U.S. medical center. Seventeen 1st-year internal medicine residents in their 1st postgraduate year were interviewed. Six additional 1st-year residents formed a validation group.

RESULTS

The interplay of time and expertise modified how physicians-in-training incorporate evidence into clinical decision making. When time was available, the residents preferred to answer their questions by searching and critically appraising the literature. This "self-acquired" expertise empowered them to help patients by using participatory decision-making styles. When time was limited, the residents turned to experts. Residents assumed that experts practiced evidence-based medicine. This "borrowed" expertise was thought to be the most efficient way of integrating evidence and clinical expertise, but it led to the use of a parental style when answers were taken back to the bedside.

CONCLUSION

The practice of evidence-based medicine empowers 1st-year residents and appears to affect their choice of decision-making style. Further research is needed to better understand the link between decision-making style and evidence-based medicine.

Pudor, honor, and autoridad: the evolving patient-physician relationship in Spain

The expression of emotion and the sharing of information are determined by cultural factors, consultation time, and the structure of the health care system. Two emblematic situations in Spain - the expression of aggression in the patient-physician encounter, and the withholding of diagnostic information from the patient - have not been well-described in their sociocultural context. To explore these, the authors observed and participated in clinical practice and teaching in several settings throughout Spain and analyzed field notes using qualitative methods. In this paper, we explore three central constructs - modesty (pudor), dignity (honor), and authority (autoridad) - and their expressions in patient-physician encounters. We define two types of emotions in clinical settings - public, extroverted expressions of anger and exuberance; and private, deeply held feelings of fear and grief that tend to be expressed through the arts and religion. Premature reassurance and withholding of information are interpreted as attempts to reconstruct the honor and pudor of the patient. Physician authority and perceived loyalty to the government-run health care system generate conflict and aggression in the patient-physician relationship. These clinical behaviors are contextualized within cultural definitions of effective communication, an ideal patient-physician relationship, the role of the family, and ethical behavior. Despite agreement on the goals of medicine, the behavioral manifestations of empathy and caring in Spain contrast substantially with northern European and North American cultures.

Factors associated with older patients' satisfaction with care in an inner-city emergency department

STUDY OBJECTIVES

We sought to assess older patients' satisfaction with care in the emergency department and to identify factors associated with global satisfaction with care.

METHODS

We performed a prospective cohort study of 778 patients 65 years of age and older presenting to an urban academic ED between 1995 and 1996, of whom 79% were black and 63% were female. A baseline survey at presentation to the ED asked for demographic information, medical history, and health-related quality of life information. A follow-up satisfaction survey asked patients to rate the care they received in the ED on a 5-point Likert scale (1=excellent, 5=poor). Overall satisfaction with care, dichotomized into responses of "excellent" versus all others, was the primary dependent variable in our bivariate analyses.

RESULTS

Of respondents, 40% rated their ED care as "excellent." Variables significantly correlated with high satisfaction include having the perception of time spent in the ED as not "too long," having the emergency physicians and nurses clearly answer patients' questions, having a relationship of trust with an ED staff member, being told why tests were done, feeling involved in decisions about care as much as they wanted, having pain addressed fully, having a perception of greater health status, and having fewer comorbid conditions at the time of the ED visit. Results may be applicable only to urban academic EDs and may be limited by time elapsed between ED visits and follow-up surveys.

CONCLUSION

To improve quality of care for older adults in the ED, physicians should be more attentive to older patients' concerns and questions, recognize and aggressively treat pain, and reduce the patients' perception of a long waiting time.

A comparison of hourly block appointments with sequential patient scheduling in a dermatology practice

BACKGROUND

There is significant demand for dermatologic care, and manpower is limited. Increasing patient encounters stress office processes. Analyses of the effects of schedule manipulation in a high-volume dermatology office have not been described.

OBJECTIVE

The purpose of this article is to study the effects of block versus sequential scheduling on patient waiting times, length of patient encounters, and physician patient-free time in two busy dermatology clinics.

METHODS

A dermatologist attended at two dermatology clinics, one using sequential patient scheduling and the other, block hourly scheduling. Time of patient arrival, scheduled appointment time, waiting time, time of physician entry into the examining room, face-to-face time with the physician, appointment type, number of same-day cancellations and nonattendance by visit type, length of each clinic, time of clinic closure, and patient-free time were recorded for each clinic and patient encounter.

RESULTS

There were no significant differences between patient waiting times at the two clinics. Patients were seen by the physician a mean of 2.6 minutes before their scheduled appointment time using block scheduling of appointments and 6 minutes after their scheduled appointment times with sequential scheduling. Similar times were spent by the physician with the patients at both sites. After adjustment for differing nonattendance rates, block scheduling yielded 330 minutes of additional patient-free time during the course of this study when compared with sequential scheduling. With block scheduling, the clinic finished a mean of 35 minutes earlier than clinics using sequential scheduling.

CONCLUSION

Within the parameters of this study, block scheduling did not significantly affect patient waiting times. Block scheduling created more patient-free time for the physician and clinical staff than did sequential scheduling. Block scheduling increased the quality of the practice environment from the perspective of the physician and the staff.

Patient-centeredness and its correlates among first year medical students

OBJECTIVE

This research was performed to study the attitudes that medical students hold concerning their relationships with patients, and whether such attitudes are gender-related, affect career plans, and influence their evaluation of psycho-social and biomedical issues.

METHODS

One hundred fifty-three first year students at the Boston University School of Medicine completed the Patient-Practitioner Orientation Scale (PPOS), a scale that differentiates between a patient-centered vs. doctor-centered orientation toward medical practice, indicated their interest in community and primary care practice, and rank ordered psycho-social and biomedical clinical issues in terms of their perceived relative importance.

RESULTS

The data revealed that female medical students were more patient-centered, and that (across sexes) patient centeredness was positively associated with an interest in community and primary care practice and the ranking of psycho-social issues.

CONCLUSIONS

These findings indicate that differences in the practice attitudes of males and females exist very early on in medical training, and that these differences are associated with anticipated career choices. They also suggest that the PPOS may prove useful in measuring the attitudes of practicing physicians toward their clinical roles and might predict physicians' behavioral strategies and patient medical outcomes.