Addressing Multiple Problems in the Family Practice Office Visit

,

Original Research

Addressing Multiple Problems in the Family Practice Office Visit

J Fam Pract. 2001 March;50(3):211-216

By

Susan A. Flocke, PhD

References

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OBJECTIVES: The purpose of the study was to describe the number of problems addressed during family practice outpatient visits, the nature of additional problems raised, how they affect the duration of the visit, and how well they are reflected in the billing record.

STUDY DESIGN: Cross-sectional

POPULATION: We studied a total 266 randomly selected adult patient encounters representing 37 physicians.

OUTCOMES MEASURED: A problem was defined as an issue requiring physician action in the form of a decision, diagnosis, treatment, or monitoring. Visit duration and the number of billing diagnoses were also assessed.

RESULTS: On average, 2.7 problems and 8 physician actions were observed during an encounter. More than one problem was addressed during 73% of the encounters; 36% of these additional problems were raised by the physician and 58% by the patient. On average, each additional problem increased the length of the visit by 2.5 minutes (P <.001). The concordance between the number of problems observed and the number of problems on the billing sheet indicated a trend toward underbilling the number of problems addressed.

CONCLUSIONS: Multiple problems are commonly addressed during family practice outpatient visits and are raised by both the physicians and the patients. Our findings suggest that current views of physician productivity and the billing record are poor indicators of the reality of providing primary care.

Primary care disciplines continue to have a central role in the health care of Americans. They provide breadth of care within an ongoing relationship, bridging the boundaries between health and illness and guiding access to more narrowly focused care when needed.¹ The ability to orchestrate a broad health agenda during a visit is central to primary care, but this ability is challenged by competing demands for time.²

Attempts to influence provision of care and treatment decisions by primary care physicians, such as financial incentives, administrative restrictions, and the implementation of evidence-based clinical guidelines add to the demands on physicians’ time and may affect how time is allocated during the day and with each patient. Within this context a primary care physician must prioritize the agenda for each patient visit. This may include providing services beyond the patient’s primary reason for the visit as time permits, such as including preventive services,³ follow-up of acute or chronic illnesses,¹ mental health⁴ or family issues,^5-7 or investigating “by the way” patient comments that may indicate serious medical issues.

The competing demands for time are compounded by patient requests during the visit. Based on an audiotape of 139 patient encounters, Kravitz and colleagues⁸ reported that on average a patient makes 5 requests for physician action or information per visit, and the number of unfulfilled requests was negatively associated with patient satisfaction. Such findings may fuel a sense of pressure to address patient requests. Also, another recent report indicates that the majority of patients do not have the opportunity to express all of their concerns before the physician redirects the interview; once redirected, additional patient concerns are rarely elicited.⁹ Fitting both the physician’s and patient’s agenda into the time allotted for an outpatient visit has important implications for the duration of the visit, physician productivity, and possibly patient outcomes.

Data on the number of problems raised and addressed have been limited by the lack of appropriate collection methods. Primarily audio and video technology have been used for the study of physician-patient communication.^10-12 Direct observation of patient encounters^12,13 and incorporation of ethnographic approaches have more recently been employed to fill a large void in the understanding of the content, context, and complexity of primary care.^13-15 Findings from the Direct Observation of Primary Care study, which employed such methods, indicate that among 4454 patient visits care was provided to a secondary patient during 18% of the visits and preventive services were addressed during 32% of the illness visits.³ Data from that study provide a glimpse into some types of problems addressed in addition to the main reason for the visit; however, data about the number of problems addressed during patient encounters were not specifically collected by the nurse observer.

When additional issues are raised during a patient encounter, little is known about the nature of these problems, how additional problems affect the duration of the visit, and how well additional problems are reflected in the billing record. This led us to conduct an observational study to ask: How many problems are addressed during family practice outpatient visits, and who is raising additional problems? How much work and time is associated with addressing problems raised beyond the initial problem? How well does the billing list represent the number of problems addressed during the outpatient visit? Our study was designed to directly observe and record how many problems were raised and addressed during outpatient visits to family physicians.