A Framework for Understanding Visits by Frequent Attenders in Family Practice
STUDY DESIGN: This was a cross-sectional observational study using qualitative analysis of family physician visits. Three family physician researchers reviewed detailed field notes for each patient based on direct observation of a single office visit to determine major themes and characteristics of physician-patient encounters.
POPULATION: Non-pregnant adults in the top 5% for visit frequency, and age-and sex-matched non-frequent attenders were identified from among 1194 adult patients in 18 Midwestern family practice offices as part of The Prevention and Competing Demands in Primary Care Study.
RESULTS: Visits by 62 patients who had made at least 25 visits in the previous 2 years were selected (frequent attender visits). Three major dimensions emerged to distinguish different encounter types: (1) biomedical complexity, (2) psychosocial complexity, and (3) the degree of dissonance between the patient and the physician. These 3 dimensions were used in a descriptive framework to characterize visit types as: simple medical, ritual visit, complicated medical, the tango, simple frustration, psychosocial disconnect, medical disharmony, and the heartsink visit.
CONCLUSIONS: The discovery of a wide variation of encounter types among adult frequent attenders and the resulting descriptive framework laid a foundation for defining the appropriateness of outpatient health care utilization, for designing interventions to reduce inappropriate utilization, and for educating physicians regarding effective management of frequent-attender patients.
In primary care practice, patients in the top 3% for attendance generate 15% of total office visits.1 “Frequent attenders” are more likely to be older, divorced or widowed, in lower socioeconomic groups, and to have multiple physical and psychosocial ills, and vague physical symptoms with no obvious etiology.2-7 At one extreme, frequent attenders are “heartsink patients” as described by O’Dowd8—individuals whose demands, behaviors, and dissatisfaction with care give the “doctor and staff a feeling of ‘heartsink’ every time they consult.” The memorable and sometimes overwhelming nature of encounters with such patients may lead to the conclusion that difficult encounters are the rule among frequent attenders.
Although the demographics and disease patterns among frequent attenders have been described, the detailed characteristics of their encounters with physicians have not been elucidated.
Multiple factors may influence the content of physician-patient encounters, including the character and severity of a patient’s symptoms, the level of patient concern, the patient’s interpersonal style, the interviewing style of the physician, the complexity of the patient’s medical and psychosocial difficulties, and the level of comfort and trust between patient and physician.9,10 A better understanding of frequent attender visits could help guide more efficient management of patients’ problems and improve satisfaction for both the patient and the physician. The purpose of our paper is to describe the characteristics of encounters between family physicians and adult frequent-attender patients.
Methods
We drew the data used for this analysis from The Prevention and Competing Demands in Primary Care Study. This multimethod comparative case study of 18 community-based family practices involved extensive direct observation of clinical encounters and office systems by field researchers who spent 4 weeks or more in each practice. The primary data for this analysis were collected by field researchers who were trained to take chronological notes while observing outpatient encounters and later dictate them to create detailed descriptions of each encounter. Details of the sampling and data collection can be found elsewhere in this issue.11
Field researchers directly observed and dictated descriptions of approximately 30 patient encounters with each of the more than 50 clinicians, and they audited the medical records of each of these patients. Visits with 1194 adults 21 years and older were observed. Non-pregnant patients were sorted by their number of visits in the previous 2 years as determined by medical record review. Those in the top 5% for visit frequency were selected for analysis.
Three family physician researchers with experience in qualitative methodology used an immersion/crystallization style to explore and characterize the physician-patient encounters.12,13 In this interpretive style each researcher read the field notes independently and recorded his or her summary comments and possible themes. Over several sessions, the 3 reviewers met to compare observations, review each patient encounter in detail together, resolve disagreements regarding the characteristics of each physician-patient encounter, and identify major themes from the data. These themes gradually developed into a 3-dimensional framework for examining all encounters. This framework was refined through additional review of field notes and discussions with study collaborators familiar with the data. The field notes were further reviewed to identify individual encounters that illustrated the range of encounter types represented by the descriptive framework.
