ABSTRACT
BACKGROUND
“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.
OBJECTIVE
We aimed to determine associations between types of patient requests and PCP-perceived visit difficulty.
DESIGN
This was an observational study, nested in a multicenter randomized trial of depression engagement interventions.
SUBJECTS
We included 824 patient visits within 135 PCP practices in Northern California occurring from June 2010 to March 2012.
MAIN MEASURES
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.
RESULTS
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)].
CONCLUSIONS
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.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.REFERENCES
Hinchey SA, Jackson JL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med. 2011;26:588–94.
Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996;11:1–8.
Levinson W, Stiles WB, Inui TS, Engle R. Physician frustration in communicating with patients. Med Care. 1993;31:285–95.
Bair MJ. Patient encounters of a difficult kind. J Gen Intern Med. 2014;29:1083–4.
Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377–85.
Spickard A Jr, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002;288:1447–50.
Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159:1069–75.
Schafer S, Nowlis DP. Personality disorders among difficult patients. Arch Fam Med. 1998;7:126–9.
Lin EH, Katon W, Von Korff M, et al. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med. 1991;6:241–6.
Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor–patient relationship: somatization, personality and psychopathology. J Clin Epidemiol. 1994;47:647–57.
Kravitz RL, Bell RA, Azari R, Krupat E, Kelly-Reif S, Thom D. Request fulfillment in office practice: antecedents and relationship to outcomes. Med Care. 2002;40:38–51.
Kravitz RL, Epstein RM, Feldman MD, et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005;293:1995–2002.
Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. BMJ. 2004;328:444.
Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997;315:1211–4.
Rao JK, Weinberger M, Kroenke K. Visit-specific expectations and patient-centered outcomes: a literature review. Arch Fam Med. 2000;9:1148–55.
Paterniti DA, Fancher TL, Cipri CS, Timmermans S, Heritage J, Kravitz RL. Getting to “no”: strategies primary care physicians use to deny patient requests. Arch Intern Med. 2010;170:381–8.
Dobscha SK, Corson K, Flores JA, Tansill EC, Gerrity MS. Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med. 2008;9:564–71.
Matthias MS, Parpart AL, Nyland KA, et al. The patient-provider relationship in chronic pain care: providers’ perspectives. Pain Med. 2010;11:1688–97.
Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012;307:1377–8.
You JJ, Gladstone J, Symons S, Rotstein D, Laupacis A, Bell CM. Patterns of care and outcomes after computed tomography scans for headache. Am J Med. 2011;124:58–63 e1.
Kravitz RL, Franks P, Feldman MD, et al. Patient engagement programs for recognition and initial treatment of depression in primary care: a randomized trial. JAMA. 2013;310:1818–28.
Tancredi DJ, Slee CK, Jerant A, et al. Targeted versus tailored multimedia patient engagement to enhance depression recognition and treatment in primary care: randomized controlled trial protocol for the AMEP2 study. BMC Health Serv Res. 2013;13:141.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.
McIver JP, Carmines EG. Unidimensional Scaling. Beverly Hills, CA: Sage Publications; 1981.
Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172:405–11.
Sirovich BE, Woloshin S, Schwartz LM. Too Little? Too Much? Primary care physicians’ views on US health care: a brief report. Arch Intern Med. 2011;171:1582–5.
Stein T, Frankel RM, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Educ Couns. 2005;58:4–12.
Epstein RM, Franks P, Shields CG, et al. Patient-centered communication and diagnostic testing. Ann Fam Med. 2005;3:415–21.
Katz MH. Opioid prescriptions for chronic nonmalignant pain: driving on a dangerous road. JAMA Intern Med. 2013;173:178.
Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med. 2011;155:325–8.
Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307:1801–2.
Acknowledgements
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.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Fenton, J.J., Franks, P., Feldman, M.D. et al. Impact of Patient Requests on Provider-Perceived Visit Difficulty in Primary Care. J GEN INTERN MED 30, 214–220 (2015). https://doi.org/10.1007/s11606-014-3082-8
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-014-3082-8