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

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 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.

Watchful Waiting Strategy May Reduce Low-Value Diagnostic Testing

“…A watchful waiting approach may also improve the physician experience by reducing the greater perceived difficulty of visits with patients who request diagnostic tests. 8 Although previous observational analyses suggested that patient-centered communication may be associated with lower overall diagnostic testing, 1,14 more patient-centered communication was not associated with test ordering in our study. While prior studies have examined practice patterns among physicians with more versus less patient-centered communication styles, our study examined the association between patientcenteredness and test ordering within a specific visit when a low-value test was requested.…”

Perceived Barriers to Implementing Individual Choosing Wisely® Recommendations in Two National Surveys of Primary Care Providers

“…In addition, clinicians know that many patients believe that more health care is better than less health care 11. As a result, clinicians may find it difficult to deny requests for specific services,12 and they could preemptively order tests to avoid eliciting such requests from patients 613 …”

Development of the Chronic Pain Coding System (CPCS) for Characterizing Patient-Clinician Discussions About Chronic Pain and Opioids

“…42, 43 Another important construct was the presence of negotiation between patients and clinicians (operationalized as patient requests and clinician recommendations). Negotiation around diagnosis and treatment has been linked to clinician-reported visit difficulty 39, 44 and is important in communication about other commonly contested medical problems. 45, 46 Other communication patterns that we considered likely to be associated with the outcomes of interest included patient assessments of their physical pain and assessments of pain treatment options.…”

“…We advanced H2b because two prior studies found that patient requests for diagnostic tests were associated with more difficult visits. 39, 44 As noted above, request subcategories (such as requests for diagnostic tests) were too infrequent to analyze separately; therefore, we analyzed patient requests for action as a group. Finally, we hypothesized that, even though patients and clinicians often agree on treatment plans by the end of a visit, 8 discussion of opioid risks would be associated with greater visit difficulty (H1c) given how frequently clinicians report this topic as contentious.…”