How well do physician and patient visit priorities align?

ABSTRACT

Purpose We undertook this study to explore the factors associated with differences between patients’ stated main reasons for outpatient visits and physicians’ main concerns at those same visits.

Methods This cross-sectional, mixed-methods study examined 192 outpatient visits with 4 physicians at 4 diverse primary care practices. During each visit, participating physicians elicited the patient’s main reason for the visit. Immediately after each visit, physicians documented 1) their understanding of the patient’s stated reason and 2) their main concern for the patient during that visit, and 3) assessed the extent of their alignment with the patient’s reason for visit. We assessed bivariate and multivariable associations of patient and visit characteristics with alignment, and further examined cases with unaligned physician-patient priorities to identify patterns.

Results In 69% of visits, the patient’s stated reason for the visit was completely aligned with the physician’s main concern. In 12% of visits, we observed totally unaligned priorities; 19% were only partially aligned. Uninsured or publicly-insured patients and visits with more problems addressed were less likely to be fully aligned. In many visits with unaligned priorities, patients’ stated reason for the visit was a self-limiting, symptomatic concern while physicians prioritized potentially dangerous asymptomatic conditions or ill-managed chronic conditions.

Conclusions In diverse family medicine practices, lack of alignment between physician and patient visit priorities reflects differing prioritization processes. Patients presenting with concerns unaligned with their physician’s priorities may require more time or different approaches to ensure the relevance and patient-centeredness of their care. These findings may inform the design of systems of care that promote mindful attention to patients’ priorities while addressing medically urgent or preventive services delivery.

T
oday’s family physicians must balance patient’s acute concerns with chronic disease management, health promotion, and disease prevention. It’s not easy. As the content of outpatient visits expands and available time contracts,¹ patients’, clinicians’, and payers’ agendas compete for attention. From a patient experience perspective, the health care encounter may seem diminished when guideline-driven agendas championing chronic disease management and preventive service delivery appear to take precedence over their personal concerns.^2-4

In the matter of physician-patient alignment of visit priorities, prior research^5,6 inadequately reflects current practice realities such as increased time pressure,⁷ greater chronic disease prevalence,⁸ growing expectations for preventive care,¹ and increasing physician proactivity in longitudinal care.^9-12 With so much to do and so little time and mounting pressure to deliver patient-centered care and patient satisfaction, it would be helpful to have a better understanding of how often and with whom physicians choose to depart from a patient’s explicitly stated reasons for a visit and instead prioritize other concerns.

Patient 
factors that were independently associated with less than fully aligned visit priorities included having more problems to address and being publicly insured or uninsured. We sought to examine alignment between patients’ stated main reasons for a visit as understood by the physician and the physician’s main concern during that same visit. Using a diverse sample of family physician-researchers to serve as data collectors and analysts, this study aimed to identify patient and visit characteristics associated with differing physician-patient visit priorities.

METHODS

Study design and sample

Four family physicians participating in a research fellowship undertook this cross- sectional descriptive study of a sample of their outpatient encounters. Each physician’s practice was unique: a free clinic, an inner city family practice within a teaching hospital, a geriatric home visit practice, and a suburban pediatric practice. Using the card study method pioneered by the Ambulatory Sentinel Practice Network,^13,14 physicians collected observational and reflective data on a sample of 50 consecutive patients seen at his or her primary care practice. The University Hospitals Case Medical Center Institutional Review Board approved the study protocol.

Measures

Immediately following each patient visit, physicians recorded on a standardized data card the patient’s characteristics, visit characteristics, the reason for the visit provided to the office staff, the reason for visit reported by the patient at the beginning of the visit, and the physician’s own main concern for the patient during the visit. Patient characteristics included gender, age, race, type of insurance, and number of chronic conditions on the problem list. Visit characteristics included the total number of problems addressed, whether a second person (eg, family member, caregiver) was present in the exam room during the visit, and visit duration. To elicit the patient’s reason for the visit, physicians systematically asked, “How can I help you today?” If more than one problem was elicited from this prompt, the concern expressed as most important by the patient was noted.

In completing the data card, physicians also reflected on the extent to which the patient’s stated reason for the visit aligned with their own main concern for the patient during the visit, rating the relationship between their respective priorities as fully aligned, partially aligned, or totally unaligned. Visits were considered fully aligned if the patient’s reason for the visit and the physician’s concern were the same, or if the patient’s expressed concern was determined to be a symptom related to the physician’s main concern. Partial alignment occurred when the patient’s concern was shared by the physician but was not the physician’s main concern. Visit priorities were rated as totally unaligned if patient and physician concerns were different and determined not to be medically related.