 |
|
Effects of Physician Awareness of Symptom-Related Expectations and Mental Disorders
A Controlled Trial
Jeffrey L. Jackson, MD, MPH;
Kurt Kroenke, MD;
Judith Chamberlin, MPH
Arch Fam Med. 1999;8:135-142.
ABSTRACT
| |
Objective To study whether physician awareness of symptom-related expectations and mental disorders reduces unmet expectations or improves patient satisfaction.
Design Prospective, before-after trial, with control (n=250) and intervention (n=250) groups. Outcomes were assessed immediately after the index office visit, at 2 weeks, and at 3 months.
Setting Ambulatory walk-in clinic.
Participants Five hundred adults with physical complaints. Exclusion criteria included upper respiratory tract infection and dementia. Follow-up was accomplished in 100% immediately after the visit, 92.6% at 2 weeks, and 82.6% at 3 months.
Interventions Two-hour physician workshop followed by information provided before each visit on patient expectations, illness worry, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorders.
Measurements Symptom-related expectations, satisfaction with care, symptom improvement, functional status, physician-perceived difficulty of the encounter, visit costs, and use of health care services.
Results Serious illness worry (64%), 1 or more specific expectations (98%), or a DSM-IV disorder (29%) were commonly present in study patients. Intervention patients were less likely to report unmet expectations (odds ratio, 0.52; 95% confidence interval [CI], 0.43-0.97) immediately after the visit and at 2 weeks, less likely to be perceived as difficult by their physician (odds ratio, 0.49; 95% CI, 0.24-0.98), and more likely to be fully satisfied at 2 weeks (odds ratio, 1.63; 95% CI, 1.14-2.00). By 3 months, groups were similar in terms of satisfaction and residual expectations. Symptom improvement occurred in most patients by 2 weeks (70.5%) and 3 months (81.2%), regardless of study group. There was also no difference in patients' serious illness worry during the follow-up. The intervention did not increase visit costs or use of health care services.
Conclusion Identifying symptom-related expectations and mental disorders in patients presenting with physical complaints may improve satisfaction with care at 2-week follow-up and physician-perceived difficulty of the encounter.
INTRODUCTION
PHYSICAL SYMPTOMS are common, with 75% of adults experiencing at least 1 symptom in any given week.1-6 Although only 25% of symptomatic adults seek medical care,2, 4 physical symptoms still account for more than half of all outpatient visits, an estimated 400 million US clinic encounters each year.7 Factors that increase the likelihood of seeing a physician include serious illness worry, symptom duration, specific expectations, disability, and the presence of mental disorders.1-3,8-13 Common expectations include wanting an explanation of the symptom's cause and prognosis as well as desiring diagnostic testing, referral, or treatment.14-16 Observational studies have found that unmet expectations and serious illness worry after the visit may adversely affect compliance,9, 17-19 patient satisfaction,9, 14, 16, 20-23 and possibly disease outcome.19, 23-26 However, symptom-related concerns and expectations are often not addressed by physicians.14-15,27-31
Depressive and anxiety disorders are also common, being present in 20% to 40% of primary care outpatients.32-37 Such disorders are also often undetected, perhaps because patients typically present in primary care settings with somatic rather than emotional complaints.38 Mental disorders have been found to amplify physical symptoms and to increase the likelihood of presenting to a health care provider,1, 8, 11, 39-41 particularly with multiple or unexplained physical complaints.10, 32 At least 25% to 33% of physical symptoms remain unexplained,32, 36, 42 and treatment is often disappointing.42-45 Patients with mental disorders also report greater functional impairment from their symptoms and are more likely to be perceived as difficult by their physician.39-40,46-51
We conducted a clinical trial to determine whether physician awareness of symptom-related expectations and mental disorders could improve outcome in patients presenting with common physical complaints. Our primary hypothesis was that such information would reduce unmet expectations and increase satisfaction. Secondary outcomes included symptom improvement, functional status, and visit costs.
PATIENTS AND METHODS
STUDY DESIGN
Five hundred adults presenting to the general medicine walk-in clinic at Walter Reed Army Medical Center, Washington, DC, with a chief complaint of a physical symptom were enrolled. Immediately before seeing the physician, patients completed a survey on symptom characteristics, serious illness worry, and visit expectations (causal explanation, expected duration, prescription, diagnostic test, referral, other). Serious illness worry was assessed by a single question inquiring whether the patient was worried that the symptom for which they were seeking care could represent a serious illness. The construct validity of these specific expectations was established in a previous study where they were the strongest independent correlates of patient dissatisfaction.14
In addition, patients completed the 6-item Medical Outcomes Study Short-Form General Health Survey (SF-6), a measure of functional status,52 and underwent evaluation for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)53 depressive and anxiety disorders with the PRIME-MD (Primary Care Evaluation of Mental Disorders).35, 54 The PRIME-MD consists of 2 parts, a self-administered patient questionnaire followed by a structured clinical interview of patients who respond positively to screening questions. All PRIME-MD interviews were conducted by 1 of 2 trained interviewers (J.L.J. or J.C.), whose assessments did not differ in the frequency or type of disorders diagnosed. The criterion and construct validity of PRIME-MD has been previously reported,35, 54 and its interobserver agreement is comparable to that obtained by mental health professionals using structured psychiatric interviews.35, 55 The first 30 participants completing questionnaires were interviewed to ensure that questions not part of validated instruments were clearly understood and unambiguous.
Immediately after the visit, patients completed the Medical Outcomes Study 9-item satisfaction survey and a questionnaire that assessed residual serious illness worry and unmet expectations. Using the automated clinical database, the total number of patient visits with physicians within the Walter Reed system, which includes a number of outlying clinics, was determined for 3 months before and after the index visit. Two weeks and 3 months after the visit, patients were mailed a questionnaire to assess symptom outcome, residual serious illness worry, unmet expectations, functional status, and satisfaction. Telephone contact of nonrespondents was attempted.
INTERVENTION
After the first 250 patients were enrolled, physicians attended a 2-hour workshop on addressing symptom-related expectations and mental disorders, consisting of a short didactic session, followed by an interactive period and role play. The workshop was held as part of a regular, weekly continuing medical education program for clinic physicians. Sessions began with a 45-minute lecture on previous research showing the impact of addressing patient serious illness worry and expectations on patient satisfaction as well as the impact of undiagnosed and untreated mental disorders on patient outcomes. This was followed by an interactive period and role play demonstrating the ease with which such patient information could be woven into a patient encounter.
For each patient seen during the intervention period (n=250), physicians received a 1-page summary attached to the patient's medical record before the visit, indicating the presence or absence of serious illness worry, expectations for care, and DSM-IV depressive or anxiety disorders. Throughout the study, physicians were unaware of study hypothesis and patient questionnaire items and responses after the visit. They were also unaware that patients were being surveyed 2 weeks and 3 months after the encounter or that data concerning cost and use of health care services were being collected.
PATIENTS
Five hundred twenty-eight adults were invited to participate. Exclusion criteria included dementia or an upper respiratory tract infection as the primary complaint, since more than 90% of upper respiratory tract infections improve by 2 weeks.14 All eligible patients presenting to the clinic on selected half days were invited to participate. Half days were selected on the basis of convenience, although the number of morning and afternoon clinics and day of the week sampled were balanced between study groups.
Patients were enrolled from October 11, 1994, to January 16, 1996, with the first 250 enrolled by July 1, 1995. The study was approved by the Walter Reed Clinical Investigation Committee, and the enrollment number was determined by sample size calculations based on 10% differences in outcomes. The demographics and case mix of patients in a military outpatient clinic are comparable with those of civilian settings,56 and study patients were similar to previously derived samples from this clinic.14 Walk-in patients were assigned to physicians on a queue system: first come, first assigned to the next available clinician, with clinicians listed alphabetically within each time slot.
PHYSICIAN VARIABLES
Before attending the workshop, physicians completed the 28-item Ashworth Scale57 to assess attitudes toward psychosocial problems and a knowledge questionnaire on depressive and anxiety disorders. After each patient visit, physicians completed the 10-item Difficult Doctor-Patient Relationship Questionnaire (DDPRQ) to assess clinician-perceived difficulty of the encounter46, 58 and indicated whether a subspecialty referral was provided. The DDPRQ can be scored as a continuous variable with scores varying from 10 to 60, or as a dichotomous variable using a score of 30 as indicative of a difficult encounter.
From the clinical database, prescription and diagnostic test orders were obtained for each patient. Tests and visit costs were tabulated using Health Care Financing Administration relative value units and converted to dollars using the 1996 Medicare schedule. Prescription costs were based on Health Care Financing Administration rates or generics (when available).
After study completion, physicians who participated in the intervention phase (n=22) were surveyed on usefulness of the intervention, its effect on visit quality and duration, personal preferences regarding future patient data, and barriers to use of the information provided.
The study was designed to run in real time in the clinic. Study measures were chosen for ease of administration and brevity. The average time spent completing patient forms among a random sample was 7 minutes. A structured PRIME-MD interview was required by 44.2% of patients, which averaged 4.3 minutes in duration.
ANALYSIS
Analyses were performed using commercially available software (STATA Version 4.0).59 Physician-rated patient difficulty and visit costs were analyzed with the physician as the unit of analysis, using the Cochran-Mantel-Haenszel stratified  2 test and analysis of variance, respectively. Outcomes such as residual expectations, serious illness worry, symptom improvement, and being fully satisfied were analyzed using logistic regression analysis. Use of health care services was analyzed using the Mann-Wilcoxon rank sum test.
Because of the possible confounding influence of the physician-on-patient reported outcomes (serious illness worry, expectations, satisfaction with care, functional status, and symptom resolution), multivariate logistic regression models were developed using patient characteristics and physician variables as independent variables. Physician variables explored as potential confounding or interacting terms included age, sex, race, years since medical school, psychosocial attitudes, psychiatric knowledge, physician self-reported compliance with addressing items identified on the previsit questionnaire, and physician-patient concordance on what each reported was performed during the visit.60-61 Multivariate adjustment for physician characteristics has been suggested as a preferred method of dealing with the unit of analysis issue for patient-reported outcomes that physicians do not directly determine but may influence.60, 62-63 A second adjustment strategy, logistic regression using dummy variables for each of the 38 participating physicians, resulted in similar conclusions. Since physician psychosocial attitudes (Ashworth score) were found to be the best-fitting variable to adjust for potential physician confounding, data adjusted by this score are presented. Adjusting for physician characteristics using either of these models accounted for no more than 5.2% of the variance.
Because of the before-after study design, propensity score analysis64-66 using the 47 previsit patient variables collected was also conducted to evaluate and adjust for differences in patient characteristics between study groups due to lack of randomization. Stratification on propensity score can be used to adjust for any differences found.67
RESULTS
Of the 528 patients approached, 94.6% agreed to participate. Participants were similar to nonparticipants in terms of age, race, sex, and type of complaint. There were no differences between control and intervention groups with regard to any previsit variable collected, as reflected in Table 1. There was also no difference between groups when assessed using propensity score analysis. One patient participated in control and intervention phases.
|
|
|
|
Table 1. Previsit Characteristics of 500 Patients Presenting With Physical Complaints*
|
|
|
Five hundred patients were seen by 38 physicians, with 17 physicians seeing 10 or more patients. No physician contributed less than 5 patients or more than 20 patients to either group. Fourteen physicians participated in control and intervention phases and contributed most (n=383) of the patients. Sixteen physicians participated only in the control phase and 8 only in the intervention phase. Participating physicians had an average of 12.6 years of clinical experience (median, 14 years; range, 0-24 years).
BASELINE CHARACTERISTICS
Patients had a mean age of 54.7 years. More than half (51.8%) were women, 48.6% were white, and 44.8% were African American. Patients presented with a variety of symptoms that we collapsed into 14 categories (Table 1). More than 1 physical symptom was present in 15.2%, with pain reported 64.9% of the time. The leading symptom category was musculoskeletal complaints, present in 31.6% of subjects. The majority (55.4%) in each group had experienced their symptom less than 2 weeks and 68.3% less than 1 month.
Most patients (97.9%) had at least 1 previsit expectation, including a desire for a causal explanation (80.3%), anticipated time for recovery (62.6%), medication prescription (65.8%), diagnostic test (56.1%), or subspecialty referral (46.9%); 63.6% were worried that their symptom might represent a serious illness. A depressive or anxiety disorder was present in 29.5% of patients, with 10.7% experiencing 2 or more disorders. Major depression was present in 8.4%, other depressive disorders in 17.4%, panic disorder in 1.4%, and other anxiety disorders in 14.2% of patients.
IMMEDIATE OUTCOMES AFTER VISIT
The proportion of patients still worried that their symptom represented a serious illness after the index visit declined substantially from 63.6% to 31.9%. The small further absolute reduction in serious worry among intervention patients compared with controls (6%) was not statistically significant (Table 2), although the study's power to detect such a difference was only 0.29.
|
|
|
|
Table 2. Outcomes According to Study Group*
|
|
|
Unmet expectations were reduced by 49% among intervention patients compared with controls (P=.02). Patients in the intervention group had lower mean difficulty scores (22.4 [SD, 0.79] vs 17.6 [SD, 0.61]; P<.001) and were less likely to be rated as difficult (P=.04), regardless of the presence or absence of depressive or anxiety disorders. In both groups, 52.2% of patients were fully satisfied with the care they received. There was no difference in patient care costs during the index visit between groups ($207 for control vs $212 for intervention).
2-WEEK OUTCOMES
Two-week data (Table 2) were available in 463 patients (92.6%), including 234 control (93.6%) and 229 intervention patients (91.6%). Respondents and nonrespondents were similar with regard to baseline characteristics. Most patients (70.5%) noted symptomatic improvement at 2 weeks, regardless of study group. Whereas the proportion of patients reporting unmet expectations was greater at 2 weeks than immediately after the visit in both groups, intervention patients were 48% less likely than controls to report unmet expectations at 2 weeks (P=.03). Intervention patients were also more likely to be fully satisfied with the medical care they had received (P=.008). Patients self-reported functional status improved in 5 of the 6 domains measured by the SF-6 at 2 weeks compared with the index visit, with no difference between groups.
3-MONTH OUTCOMES
Three-month outcome data (Table 2) were available in 413 patients (82.6%), with no differences between respondents and nonrespondents in both arms. Regardless of study group, 79.1% experienced symptomatic improvement. There were no differences between control and intervention groups in any variable measured, including the proportion with serious illness worry (29.2% overall), with unmet expectations (33.8% vs 28.1%), or fully satisfied (60.9% vs 65.2%). Also, control and intervention groups had similar numbers of clinic visits in the subsequent 3 months (median of 4 visits in both groups; P=.94). The improvement in functional status seen at 2 weeks was sustained at 3 months but without significant further improvement.
PHYSICIAN PERCEPTION OF INTERVENTION
Twenty (90.9%) of the 22 physicians participating in the intervention phase of the trial completed the poststudy physician survey. Most physicians believed that information on symptom-related expectations at the time of the visit increased the likelihood of satisfying the patient (Table 3). Many physicians believed this knowledge made visits easier, and few believed visit length was increased. Whereas 45.0% (n=9) believed they might be more likely to order diagnostic tests or a subspecialty referral, independent assessment did not show this to be the case. Most physicians desired having this information on symptom-related expectations routinely provided in future patients presenting with physical complaints.
|
|
|
|
Table 3. Physician Attitudes Toward Specific Types of Feedback*
|
|
|
In contrast, only 45.0% (n=9) of physicians believed that knowledge of depressive and anxiety disorders increased the likelihood of satisfying patients, and 80.0% (n=16) reported an increase in visit length by at least several minutes. More than half thought this knowledge made the visit more difficult. Major barriers endorsed for not addressing mental disorders included disorder not related to physical symptom (25.0%; n=5), patients might get upset (30.0%; n=6), and physician inexperience treating mental disorders (30.0%; n=6). Despite this, most physicians (75.0%; n=15) desired that patient mental disorder information be routinely provided.
COMMENT
Information provided to clinicians on symptom-related expectations and mental disorders improved satisfaction with care among patients presenting with common physical complaints at 2 weeks and reduced unmet expectations immediately after the visit and at 2 weeks. Moreover, physicians experienced fewer of the encounters as difficult. The differences between groups in unmet expectations and satisfaction were no longer significant by 3 months. Physicians found information regarding symptom-related expectations particularly useful and did not believe that addressing these issues substantially increased visit length. Our intervention relied primarily on brief questionnaires that patients could complete in the clinic before their visit. Providing this information to clinicians did not increase health care costs or subsequent use of clinic services.
Our simple intervention had no effect on patient symptom improvement (70.5% at 2 weeks vs 79.1% at 3 months), functional status, visit costs, use of health care services, or residual worry about serious illness. The reduction in expectations in our study was likely due to dialogue between clinicians and patients rather than simply fulfilling requests, since patients in the intervention group were no more likely to receive tests, prescriptions, or referrals than control patients. Unexpectedly, serious illness worry and symptom-related expectations were more prevalent 2 weeks later than immediately after the visit. This rebound cannot be explained by our data, but potential reasons include slower recovery or less improvement than hoped for, dwindling efficacy of the physician's reassurance, or recurrent doubts and fears. Although rebound occurred in both groups, intervention patients continued to report significantly fewer unmet expectations at 2 weeks than did controls.
Previous patient expectation questionnaires used in research27, 30-31,68-70 have been lengthy (16-86 items) and thus impractical for busy outpatient settings. Our study, coupled with previous work,14 suggests that the 5 most common symptom-related expectations are a causal explanation (including potential seriousness), an estimate of duration to recovery, and desires for medications, tests, or referral. Identifying these by questionnaire or direct inquiry is feasible even when time is limited.
Patient satisfaction is an increasingly important health care outcome. The increase we found, from 52.2% to 66.9% fully satisfied at 2 weeks, is notable since managed care organizations often consider improvements in satisfaction of even a few percentage points an important indicator of clinician performance. Patient dissatisfaction affects compliance with treatment regimens, follow-up recommendations,17-19 and certain disease outcomes, as well as predicting patients likely to leave a health care plan.19, 23-26
It is not clear why the intervention did not affect satisfaction immediately following the visit, despite reducing unmet expectations and increasing 2-week satisfaction. Patient satisfaction depends on many factors, with most studies unable to explain more than 20% of the variance in satisfaction.71-74 The relationship between expectation fulfillment and overall satisfaction may be complex and has varied among studies.14, 74 Perhaps information provided specifically on symptom-related expectations resulted in a more lasting effect on this outcome. Both patient groups experienced a rise in unmet expectations during the subsequent 2 weeks, with a greater rise in controls. This greater prevalence of unmet expectations in controls may have prevented them from experiencing the increased satisfaction that occurred among intervention patients 2 weeks after the index visit. Patient recall for the specific encounter, diluted by the large number of intervening clinic visits with other clinicians, likely explains the lack of effects on patient residual expectations and satisfaction at 3 months. Alternatively, the finding of increased patient satisfaction solely at 2 weeks could be due to chance from multiple comparisons, although given the conservative nature of the tests involved, this seems less likely.
Joos et al74 studied an intervention in which physicians received training on eliciting and responding to patients' concerns and requests along with the results of surveys patients filled out before the visit on their requests for services. In audiotapes of the physician-patient encounter, they found an increase in the frequency that physicians solicited patient concerns and in the amount of information given. However, they also found no changes in patient satisfaction immediately after the visit, on compliance with prescriptions or appointments, or use of health care services.
Whereas patient satisfaction has been investigated extensively, the clinician's perspective has received less attention. Previous studies have found that physicians consider 1 of 6 outpatient encounters difficult.46, 59 Among strong predictors of difficulty are multiple or unexplained physical symptoms and the presence of mental disorders.46-51,59 A simple intervention that reduces by half the number of patient encounters considered difficult may be valuable to health service organizations trying to attract physicians to primary care careers.
By 3 months, the modest differences between intervention and control groups had dissipated. This is not surprising, since addressing patient concerns and expectations likely has its greatest impact early after an encounter, particularly since most symptomatic episodes are self-limited. Confounding by inaccurate patient recall for remote physician encounters as well as the effect of subsequent patient-physician interactions (a median of 4 per patient) may also have occurred.
Whereas depressive and anxiety disorders were prevalent in our study, it is uncertain how often physicians acted on this information. Patients in the intervention group were not more likely to receive a mental health referral or to start psychotropic therapy, despite clinician awareness of disorders. This corroborates physician reports that they addressed psychiatric problems much less frequently than symptom-related expectations. Failure to identify and treat mental disorders has been a consistent finding in primary care, and this may have been enhanced in our study because patients undergoing evaluation were nearly always seeing the physicians for the first time. An established physician-patient relationship may be important to overcome barriers to addressing emotionally laden issues.
The strengths of our study include the use of a simple intervention and the measurement of multiple, symptom-relevant outcomes at different times in the patient's care. Response rates were high, with 92.6% at 2-week and 82.6% at 3-month follow-ups. Although not randomized, most patients were seen by providers who participated in both phases of the study. The before-after design may control partly for outcomes such as patient and physician satisfaction, residual serious illness worry, unmet expectations, and visit costs, influenced by individual physicians' communication skills and psychosocial attitudes. Having the same physician see patients in both phases of the study may allow better elucidation of the effect of information provided to the physician, since the individual physician's communication skills and psychosocial attitudes presumably would be constant during the short time frame of the study and particularly a physician sample composed largely of experienced clinicians. Propensity score analysis confirmed the lack of subtle multivariate differences between patients sampled in both study groups.
DECISIONS ON the appropriate unit of analysis remain a controversial issue among researchers who are intervening with physicians and then measuring patient outcomes.60-63 For variables predominantly controlled by the physician (eg, providing a subspecialty referral, ordering a test or medication, or labeling a patient as difficult), the physician should be the unit of analysis. Hence, in our study, the physician was the unit of analysis for physician-rated encounter difficulty and symptom outcome. For outcomes reported by patients but potentially influenced by physicians, such as symptom outcome, functional status, and patient expectations and satisfaction, choosing physicians as the unit of analysis may result in missing important differences.60, 62-63 Rather, analyzing by patient but adjusting for physician characteristics is an acceptable strategy.60 Using 2 different adjustment strategies in our analysis produced similar findings, thus strengthening our conclusions.
Limitations of our study must be acknowledged. First, because the sample consisted of walk-in patients usually seeing a particular physician for the first time, one should be cautious in generalizing these findings to established clinician-patient relationships. However, even in continuity-of-care settings, patient expectations and illness concerns often go unrecognized.27-31 Second, the study design was quasi-experimental (before-after) rather than a randomized clinical trial. Propensity score analysis indicated that confounding by important variables that were measured, such as functional status, mental disorders, type of symptom, or other patient characteristics, did not seem to occur. Whereas a before-after design might better control for the physician effect (ie, the impact of a particular physician's communication skills and psychosocial attitudes on certain outcomes), this design lacks the advantage of randomization that better ensures the equal distribution of measured and unmeasured variables. Therefore, our findings should be further substantiated in a clinical trial involving randomization of a larger number of physicians to control and intervention groups. Third, although our study had 2 principal hypotheses, that the intervention would reduce unmet expectations and improve patient satisfaction, we measured a number of secondary outcomes. We used conservative tests of statistical significance, using the physician as the unit of analysis for difficulty and visit costs and making statistical adjustment for potential physician influence on patient outcomes. However, because of multiple comparisons and the modest effects we found, the differences we saw may have been due to chance.
Fourth, our intervention had several components, including a workshop followed by providing physicians the following 2 types of information on each patient: symptom-related expectations and presence of a depressive or anxiety disorder. Although our physician survey indicated that information on symptom-related expectations was particularly valuable, future investigators might consider separating our 2 "bundled" interventions. The workshop alone probably would have had only a minor effect on changing physician behavior,75 but it would be useful to determine the effect of providing information to physicians on just symptom-related expectations rather than expectations and mental disorders. Fifth, we used a brief checklist to detect symptom-related expectations at baseline and during follow-up. Although we invited patients to write in other expectations, they did so infrequently. Using much longer instruments or interviews, Kravitz et al15 and other investigators30-31 have identified other common expectations (eg, physician preparation for the visit, history taking, physical examination) that we did not measure. Although we do not wish to oversimplify the personal meaning of symptoms and the diversity of patient expectations, it is promising that addressing even a limited number of the most prevalent expectations is beneficial.
Sixth, although our workshop was "masked" by its inclusion in regular clinic continuing medical education activities, and although physicians were unaware of our study hypothesis and of the specific data being collected after the visit, we cannot entirely exclude a Hawthorne effect. The fact that results were similar in the 121 patients seen by physicians participating in only 1 study period compared with the 383 patients seen by physicians participating in both periods argues that a Hawthorne effect, if present, was small. Seventh, since we did not directly observe or record the physician-patient encounter, our postvisit patient and physician questionnaires depend on recall of what occurred. A potential drawback of directly observing or recording the visit would be potentiating any Hawthorne effect. Also, the outcomes we measured did not require knowing specific details of the encounter itself. The Ashworth measure of physician psychosocial attitudes, found to be the best adjusting variable for physician confounding in our study, has been demonstrated to correlate with better physician communication skills in observed encounters.76
In conclusion, identifying symptom-related expectations can reduce unmet expectations, improve patient satisfaction at follow-up, and decrease the number of difficult encounters for the clinician without increasing resource use. However, dealing with depressive or anxiety disorders adequately in a single encounter may be more difficult and may require a longer initial visit, follow-up visits, or collaboration with mental health professionals.
AUTHOR INFORMATION
Accepted for publication February 6, 1998.
Supported by intramural grant CO83Z-01 from the Uniformed Services University of the Health Sciences, Bethesda, Md.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
Reprints: Jeffrey L. Jackson, MD, MPH, Department of Medicine-EDP, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 (e-mail: jejackson{at}usuhs.mil).
From the Departments of Medicine (Drs Jackson and Kroenke) and Preventive Medicine and Biometrics (Dr Chamberlin), Uniformed Services University of the Health Sciences, Bethesda, Md, and the Department of Medicine, Walter Reed Army Medical Center, Washington, DC (Dr Jackson). Dr Kroenke is now with the Regenstrief Institute for Health Care and Indiana University School of Medicine, Indianapolis.
REFERENCES
| |
1. Banks MH, Beresford SA, Morrell DC, Waller JJ, Watkins CJ. Factors influencing demand for primary medical care in women aged 20-44 years: a preliminary report. Int J Epidemiol. 1975;4:189-195.
FREE FULL TEXT
2. Verbrugge LM, Ascione FJ. Exploring the iceberg: common symptoms and how people care for them. Med Care. 1987;25:539-569.
FULL TEXT
|
ISI
| PUBMED
3. Hurwicz ML, Berkanovic E. Care seeking for musculoskeletal and respiratory episodes in a Medicare population. Med Care. 1991;29:1130-1145.
FULL TEXT
|
ISI
| PUBMED
4. White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. 1961;265:885-892.
5. Egan KJ, Beaton R. Response to symptoms in healthy, low utilizers of the health care system. J Psychosom Res. 1987;31:11-21.
FULL TEXT
|
ISI
| PUBMED
6. Hammond EC. Some preliminary findings on physical complaints from a prospective study of 1,064,004 men and women. Am J Public Health. 1964;54:11-23.
7. Schappert SM. National ambulatory medical care survey: 1989 summary. Vital Health Stat 3. 1992;13:1-17.
8. McFarland BH, Freeborn DK, Mullooly JP, Pope CR. Utilization patterns among long-term enrollees in a prepaid group practice health maintenance organization. Med Care. 1985;23:1221-1223.
FULL TEXT
|
ISI
| PUBMED
9. Barsky AJ, Borus JF. Somatization and medicalization in the era of managed care. JAMA. 1995;274:1931-1934.
FREE FULL TEXT
10. Berkanovic E, Teleskay C, Reeder S. Structural and social psychological factors in the decision to seek medical care for symptoms. Med Care. 1981;7:693-709.
11. Zoccolillo MS, Cloninger CR. Excess medical care of women with somatization disorder. South Med J. 1986;79:532-535.
FULL TEXT
|
ISI
| PUBMED
12. Pilowsky I, Smith QP, Katsikits M. Illness behavior and general practice utilization: a prospective study. J Psychsom Res. 1987;31:177-183.
FULL TEXT
|
ISI
| PUBMED
13. Barsky AJ. Hidden reasons some patients visit doctors. Ann Intern Med. 1981;94:492-498.
14. Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA. Concerns and expectations in patients presenting with physical complaints: frequency, physician perceptions and actions, and 2-week outcome. Arch Intern Med. 1997;157:1482-1488.
FREE FULL TEXT
15. Kravitz RL, Callahan EJ, Paterniti D, Antonius D, Dunham M, Lewis CE. Prevalence and sources of patients' unmet expectations for care. Ann Intern Med. 1996;125:730-737.
FREE FULL TEXT
16. Uhlmann RF, Inui TS, Carter WB. Patient requests and expectations: definitions and clinical applications. Med Care. 1984;22:681-685.
FULL TEXT
|
ISI
| PUBMED
17. Francis V, Korsch BM, Morris MJ. Gaps in doctor-patient communication: patients' response to medical advice. N Engl J Med. 1969;280:535-540.
18. Eisenthal H, Emery R, Lazare A, Udin H. Adherence and the negotiated approach to patienthood. Arch Gen Psychiatry. 1979;36:393-398.
FREE FULL TEXT
19. Linn MW, Linn BS, Stein SR. Satisfaction with ambulatory care and compliance in older patients. Med Care. 1982;20:606-614.
FULL TEXT
|
ISI
| PUBMED
20. Korsch B, Gozzi EK, Francis V. Gaps in doctor-patient communication, I: doctor patient interaction and patient satisfaction. Pediatrics. 1968;42:855-871.
FREE FULL TEXT
21. Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received. Med Care. 1989;27:1027-1035.
FULL TEXT
|
ISI
| PUBMED
22. Sanchez-Menegay C, Hudes ES, Cumming SR. Patient expectations and satisfaction with medical care for upper respiratory infections. J Gen Intern Med. 1992;7:432-434.
ISI
| PUBMED
23. Eisenthal S, Lazare A. Evaluation of the initial interview in a walk-in clinic. J Nerv Ment Dis. 1976;162:169-176.
ISI
| PUBMED
24. Kaplan S, Greenfield S, Ware J. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27(suppl):S110-S127.
25. Uhlmann RF, Inui TS, Pecoraro RE, Carter WB. Relationship of patient request fulfillment to compliance, glycemic control and other health care outcomes in insulin dependent diabetes. J Gen Intern Med. 1988;3:458-463.
ISI
| PUBMED
26. Brody DS, Miller SM. Illness concerns and recovery from a URI. Med Care. 1986;24:742-748.
FULL TEXT
|
ISI
| PUBMED
27. Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients' expectations for care during office visits. J Gen Intern Med. 1994;9:75-81.
ISI
| PUBMED
28. Starfield B, Steinwachs D, Morris I, Bause G, Siebert S, Westin C. Patient-doctor agreement about problems needing follow-up visit. JAMA. 1979;242:344-346.
FREE FULL TEXT
29. Sanchez-Menegay C, Stalder H. Do physicians take into account patients' expectations? J Gen Intern Med. 1994;9:404-406.
ISI
| PUBMED
30. Good MJD, Good BJ, Nassi AJ. Patient requests in primary health care settings: development and validation of a request instrument. J Behav Med. 1983;6:151-168.
FULL TEXT
|
ISI
| PUBMED
31. Uhlmann RF, Carter WB, Inui TS. Fulfillment of patient requests in a general medicine clinic. Am J Public Health. 1984;74:257-258.
FREE FULL TEXT
32. Kroenke K, Spitzer RL, Williams JB, et al. Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch Fam Med. 1994;3:774-779.
FREE FULL TEXT
33. Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in primary care. Arch Gen Psychiatry. 1988;45:1100-1106.
FREE FULL TEXT
34. Schulberg HC, Burns BJ. Mental disorders in primary care: epidemiologic, diagnostic and treatment direction. Gen Hosp Psychiatry. 1988;10:79-87.
FULL TEXT
|
ISI
| PUBMED
35. Spitzer RL, Williams JBW, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 Study. JAMA. 1994;272:1749-1756.
FREE FULL TEXT
36. Kroenke K, Price R. Symptoms in the community: prevalence, classification and psychiatric comorbidity. Arch Intern Med. 1993;153:2474-2480.
FREE FULL TEXT
37. Philbrick JT, Connelly JE, Wofford AB. The prevalence of mental disorders in rural office practice. J Gen Intern Med. 1996;11:9-15.
ISI
| PUBMED
38. Ormel J, Koster MWJ, Van Den Brink W, Van De Villige G. Recognition, management, and course of anxiety and depression in general practice. Arch Gen Psychiatry. 1991;48:700-706.
FREE FULL TEXT
39. Spitzer RL, Kroenke K, Linzer M, et al. Health-related quality of life in primary care patients with mental disorders: results from the PRIME-MD 1000 Study. JAMA. 1995;274:1511-1517.
FREE FULL TEXT
40. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA. 1989;262:914-919.
FREE FULL TEXT
41. Smith GR, Monson RA, Ray DC. Patients with multiple unexplained symptoms: their characteristics, functional health, and health care utilization. Arch Intern Med. 1986;146:69-72.
FREE FULL TEXT
42. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy and outcome. Am J Med. 1989;86:262-268.
FULL TEXT
|
ISI
| PUBMED
43. Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med. 1990;150:1685-1689.
FREE FULL TEXT
44. Speckens AE, van Hemert AM, Spinhoven P, et al. Cognitive behavioral therapy for medically unexplained physical symptoms: a randomized controlled trial. BMJ. 1995;311:1328-1332.
FREE FULL TEXT
45. Barsky AJ, Cleary PD, Klerman G. Determinants of perceived health status of medical outpatients. Soc Sci Med. 1992;10:1147-1154.
46. Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: prevalence, psychopathology and functional impairment. J Gen Intern Med. 1996;11:1-8.
ISI
| PUBMED
47. Crutcher JE, Bass MJ. The difficult patient and the troubled physician. J Fam Pract. 1980;11:933-938.
ISI
| PUBMED
48. Novack DH, Landau C. Psychiatric diagnoses in problem patients. Psychosomatics. 1985;26:853-858.
FREE FULL TEXT
49. Merrill JM, Laux L, Thornby JI. Troublesome aspects of the patient-physician relationship: a study of human factors. South Med J. 1987;80:1211-1215.
FULL TEXT
|
ISI
| PUBMED
50. Schwenk TL, Marquez JT, Lefever RD, Cohen M. Physician and patient determinants of difficult physician-patient relationships. J Fam Pract. 1989;28:59-63.
FULL TEXT
|
ISI
| PUBMED
51. Lin EH, Katon W, Von Korff M, Bush T, Lipscomb P, Russo J. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med. 1991;6:241-246.
ISI
| PUBMED
52. Ware JE, Nelson EC, Sherbourne CD, Stewart AL. Preliminary tests of a 6-item general health survey: a patient application. In: Ware JE, Stewart EL, eds. Measuring Functioning and Well Being: The Medical Outcomes Study Approach. Durham, NC: Duke University Press; 1992:291-308.
53. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.
54. Mulrow CD, Williams JW, Gerety MB, et al. Case-finding instruments for depression in primary care settings. Ann Intern Med. 1995;122:913-921.
FREE FULL TEXT
55. Williams JBW, Gibbon M, First MB, et al. The structured clinical interview for DSM-III-R (SCID), II: multisite test-retest reliability. Arch Gen Psychiatry. 1992;49:630-636.
FREE FULL TEXT
56. Johnson JE, Jenkins TR, Pinholt EM, Carpenter JL. Content of ambulatory internal medicine practice in an academic army medical center and an army community hospital. Mil Med. 1988;153:21-25.
ISI
| PUBMED
57. Ashworth CD, Williamson P, Montanco D. A scale to measure physician beliefs about psychosocial aspects of patient care. Soc Sci Med. 1984;19:1235-1238.
58. Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol. 1994;47:647-657.
FULL TEXT
|
ISI
| PUBMED
59. STATA Version 4.0. College Station, Tex: Stata Press; 1995.
60. Whiting-O'Keefe QE, Henke C, Simborg DW. Choosing the correct unit of analysis in medical care experiments. Med Care. 1984;22:1101-1114.
FULL TEXT
|
ISI
| PUBMED
61. Divine GW, Brown JT, Frazier LM. The unit of analysis error in studies about physician's patient care behavior. J Gen Intern Med. 1992;7:623-629.
ISI
| PUBMED
62. Robbins JM, Kirmayer LJ, Cathebras P, Yaffe MJ, Dworkind M. Physician characteristics and the recognition of depression and anxiety in primary care. Med Care. 1994;32:795-812.
ISI
| PUBMED
63. Cebul RD. Randomized, controlled trials using the Metro Firm System. Med Care. July 1991; 29(7 suppl):JS9-JS18.
64. Robins JM, Mark S. Estimating exposure effects by modeling the expectation of exposure conditional on confounders. Biometrika. 1992;48:479-495.
FULL TEXT
65. Cook EF, Goldman L. Asymmetric stratification: an outline for an efficient method for controlling confounding in cohort studies. Am J Epidemiol. 1988;127:626-639.
FREE FULL TEXT
66. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70:41-55.
FREE FULL TEXT
67. Connors AF, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA. 1996;276:889-897.
FREE FULL TEXT
68. Joos SK, Hickman DH, Border LM. Patients' desires and satisfaction in general medicine clinics. Public Health Rep. 1993;108:751-759.
ISI
| PUBMED
69. Delvecchio-Good MJ, Good BJ, Nassi AJ. Patient requests in primary health care settings: development and validation of a research instrument. J Behav Med. 1983;6:151-168.
70. Like R, Zyzanski SJ. Patient satisfaction with the clinical encounter: social psychological determinants. Soc Sci Med. 1987;24:351-357.
71. Linder-Pelz SU. Social psychological determinants of patient satisfaction: a test of five hypotheses. Soc Sci Med. 1982;16:583-589.
72. Williams B. Patient satisfaction: a valid concept? Soc Sci Med. 1994;38:509-516.
73. Froehlich GW, Welch G. Meeting walk-in patients' expectations for testing: effects on satisfaction. J Gen Intern Med. 1996;11:470-474.
ISI
| PUBMED
74. Joos SK, Hickman DH, Gordon GH, Baker LH. Effects of a physician communication intervention on patient care outcomes. J Gen Intern Med. 1996;11:147-155.
ISI
| PUBMED
75. Greco PG, Eisenberg JM. Changing physicians' practices. N Engl J Med. 1993;329:1271-1274.
FREE FULL TEXT
76. Levinson W, Roter D. Physicians' psychosocial beliefs correlate with their patient communication skills. J Gen Intern Med. 1995;10:375-379.
ISI
| PUBMED
RELATED ARTICLE
The Archives of Family Medicine Continuing Medical Education Program
Arch Fam Med. 1999;8(2):107-109.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
A Multisource and Repeated Measure Approach to Assessing Patient--Physician Relationship and Patient Satisfaction
Weng
Eval Health Prof 2009;32:128-143.
ABSTRACT
Prevalence, Impact, and Prognosis of Multisomatoform Disorder in Primary Care: A 5-Year Follow-up Study
Jackson and Kroenke
Psychosom. Med. 2008;70:430-434.
ABSTRACT
| FULL TEXT
Effect of race on patient expectations regarding their primary care physicians
Guerra et al.
Fam Pract 2008;0:cmn005v1-cmn005.
ABSTRACT
| FULL TEXT
Quality of life is decreased in female patients treated for microprolactinoma
Kars et al.
Eur J Endocrinol 2007;157:133-139.
ABSTRACT
| FULL TEXT
Outcome and Impact of Mental Disorders in Primary Care at 5 years
Jackson et al.
Psychosom. Med. 2007;69:270-276.
ABSTRACT
| FULL TEXT
Managing future Gulf War Syndromes: international lessons and new models of care
Engel et al.
Phil Trans R Soc B 2006;361:707-720.
ABSTRACT
| FULL TEXT
Medical downgrading, self-perception of health, and psychological symptoms in the British Armed Forces.
Rona et al.
Occup. Environ. Med. 2006;63:250-254.
ABSTRACT
| FULL TEXT
Health Concerns of Patients With Nonbacterial Prostatitis/Pelvic Pain
Turner et al.
Arch Intern Med 2005;165:1054-1059.
ABSTRACT
| FULL TEXT
Screening for Psychological Illness in Military Personnel
Rona et al.
JAMA 2005;293:1257-1260.
FULL TEXT
Gender and Symptoms in Primary Care Practices
Jackson et al.
Psychosomatics 2003;44:359-366.
ABSTRACT
| FULL TEXT
Patient Expectations Regarding Eye Care: Focus Group Results
Dawn et al.
Arch Ophthalmol 2003;121:762-768.
ABSTRACT
| FULL TEXT
Measuring Patients' Expectations and Requests
Kravitz
ANN INTERN MED 2001;134:881-888.
ABSTRACT
| FULL TEXT
The Effect of Unmet Expectations among Adults Presenting with Physical Symptoms
Jackson and Kroenke
ANN INTERN MED 2001;134:889-897.
ABSTRACT
| FULL TEXT
Visit-Specific Expectations and Patient-Centered Outcomes: A Literature Review
Rao et al.
Arch Fam Med 2000;9:1148-1155.
ABSTRACT
| FULL TEXT
|
