Journal of General Internal Medicine

, Volume 30, Issue 2, pp 214–220 | Cite as

Impact of Patient Requests on Provider-Perceived Visit Difficulty in Primary Care

  • Joshua J. FentonEmail author
  • Peter Franks
  • Mitchell D. Feldman
  • Anthony Jerant
  • Stephen G. Henry
  • Debora A. Paterniti
  • Richard L. Kravitz
Original Research



“Difficult visits” are common in primary care and may contribute to primary care provider (PCP) career dissatisfaction and burnout. Patient requests occur in approximately half of primary care visits and may be a source of clinician–patient miscommunication or conflict, contributing to perceived visit difficulty.


We aimed to determine associations between types of patient requests and PCP-perceived visit difficulty.


This was an observational study, nested in a multicenter randomized trial of depression engagement interventions.


We included 824 patient visits within 135 PCP practices in Northern California occurring from June 2010 to March 2012.


PCP-perceived visit difficulty was quantified using a three-item scale (relative visit difficulty, amount of effort required, and amount of time required; Cronbach’s α = 0.81). Using linear regression, the difficulty scale (score range 0–2 from least to most difficult) was modeled as a function of: patient requests for diagnostics tests, pain medications, and specialist referrals; PCP perception of likely depression or likely substance abuse; patient sociodemographics, comorbidity, depression; PCP characteristics and practice setting.


Patients requested diagnostic tests, pain medications, and specialist referrals in 37.2, 20.0 and 30.0 % of visits, respectively. After adjustment for patient medical and psychiatric complexity, perceived difficulty was significantly higher when patients requested diagnostic tests [parameter estimate (PE) 0.11, (95 % CI: 0.03, 0.20)] but not when patients requested pain medications [PE −0.04 (95 % CI: −0.15, 0.08)] or referrals [PE 0.04 (95 % CI: −0.07, 0.25)].


PCP-perceived visit difficulty is associated with patient requests for diagnostic tests, but not requests for pain medications or specialist referrals. In this era of “choosing wisely,” PCPs may be challenged to respond to diagnostic test requests in an evidence-based manner, while maintaining the provider–patient relationship and PCP career satisfaction.


primary care depression comorbidity patient communication patient satisfaction 



This work was supported by grants 1R01MH079387 (Kravitz) and K24MH072756 (Kravitz) from the National Institute of Mental Health.

Conflicts of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Joshua J. Fenton
    • 1
    • 2
    Email author
  • Peter Franks
    • 1
    • 2
  • Mitchell D. Feldman
    • 6
  • Anthony Jerant
    • 1
    • 2
  • Stephen G. Henry
    • 2
    • 3
    • 4
  • Debora A. Paterniti
    • 2
    • 3
    • 4
    • 5
  • Richard L. Kravitz
    • 2
    • 3
    • 4
  1. 1.Department of Family and Community MedicineUniversity of California, DavisSacramentoUSA
  2. 2.The Center for Healthcare Policy and ResearchUniversity of California, DavisSacramentoUSA
  3. 3.The Division of General MedicineUniversity of California, DavisSacramentoUSA
  4. 4.Department of Internal MedicineUniversity of California, DavisSacramentoUSA
  5. 5.Department of SociologyUniversity of California, DavisSacramentoUSA
  6. 6.Division of General Internal MedicineUniversity of CaliforniaSan FranciscoUSA

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