Methods
Seven first-year medical students observed patient care provided by their summer fellowship family physician preceptor and other physicians in the preceptor’s practice from June through August 1999. Six of the sites were located in Northeast Ohio, and one was in Tulsa, Oklahoma.
Each student collected data on one randomly selected adult patient encounter for each half day of precepting. At the beginning of each half-day of patient care the student rolled a die to generate a random number to select a patient from the patient schedule. To ensure random selection of encounters within each half-day session, on alternating days the random number was counted from the beginning or the end of the half-day schedule. If the selected patient was aged younger than 18 years, the patient or physician preferred the encounter not be observed, or the patient did not show up for the scheduled appointment, the next scheduled appointment was selected as a replacement. Patient age and sex were collected for those who were no-shows or chose not to be observed, so they could be compared with those patients who were observed. Each student was to collect data on approximately 50 patient encounters during the 6-week summer fellowship. The physicians were blinded to the study purpose and were not told which patient encounter would be included in the study.
A problem was operationalized as an issue requiring physician action in the form of a decision, diagnosis, treatment, or monitoring. Each item was listed as it was raised, and the type of problem, who raised it, and what physician actions were involved to address it were coded. Each problem was coded as 1 of 14 categories: acute, acute follow-up, chronic, chronic follow-up, prevention, prevention follow-up, psychosocial, psychosocial follow-up, work-related administrative, health care system-related administrative, other family member’s problem, pregnancy, emergent, and other. The person who raised the problem was coded as 1 of 3 options: the physician, the patient or another person in the room. Multiple physician actions could be coded for how the problem was addressed. The 19 physician action categories included: question, reassurance, examination, procedure, referral, return visit, advice, review tests, order laboratory testing, prescription, provide written material, imaging, admits uncertainty, counseling, return to work/time off work letter, defer, complementary/alternative medicine, ignored or lost, and other.
Patient characteristics, the duration of the visit, and the billing diagnoses for each visit were also recorded on the data collection form. Videotaped encounters were used to pilot test the data collection form, to allow the observers to practice using the form in real time, and to calibrate the observers before data collection in the field.
We used descriptive statistics to address most research questions. Student t tests and chi-square tests were used to compare age and sex differences between participants and nonparticipants. We tested the association of the number of problems with the duration of the visit with analysis of variance and a test for linear trend. A difference score of the number of problems observed and the number of problems recorded on the billing sheet for the encounter was computed and summarized graphically.
Results
We collected usable data on 266 encounters representing 37 physicians. Patient and visit characteristics are displayed in Table 1. The patients had an average age of 48 years, and 69% were women. They were predominately white. A large proportion was observed visiting their regular primary care physician (83%), and 85% were established patients of the practice. Most of the observed patients had some kind of commercial health care insurance, 19% had Medicare, and a small proportion had Medicaid or no insurance. The visit duration ranged from 2 to 65 minutes; the median was 15 minutes with a mean of 19.3 (standard deviation [SD]=12.7). The first problem raised was most commonly an acute problem (49%); prevention and chronic illness were the first problem raised during 21% and 19% of encounters, respectively. Patients who were randomly selected but were not observed (n=52, primarily no-shows) were similar in sex (67% women, c2 =0.119, P=.73 ) but were younger than those patients who were observed (mean age=32.1 years, t=3.79, P=.001).
On average, 2.7 problems were raised during an encounter Table 2. Forty-four percent of all problems were classified as acute, 30% chronic, 14% prevention, 4% administrative, 2% psychosocial, and 6% were classified as other. Of the observed encounters, 73% had more than one problem addressed. The physician raised 36% of these additional problems, and patients raised 58%. The problems raised by physicians were most frequently pertaining to chronic illness, prevention, and follow-up issues. The problems raised by patients were most likely to be acute illness problems. Additional problems were least likely to arise when the first problem addressed was an acute problem (61%) compared with visits during which the first problem addressed was chronic or prevention focused, where 88% and 87%, respectively, included additional problems during the visit (c2=21.2, P <.001).