TORP was developed with input from clinicians, researchers, and patients. It is organized to reflect the major categories of patient-initiated interaction in primary care settings. The system relies on real-time coding during observation or from audiotapes (rather than transcripts) because we believe some requests are difficult to identify without hearing the requester’s intonation. Although there were relatively few uncodable requests, future versions of TORP will need to incorporate several new request categories.
Although we believe TORP is a useful system that could be productively applied to analysis of physician-patient interactions in a variety of settings, several opportunities for improvement remain. First, procedures for ensuring unitizing reliability (the ability of 2 raters to agree that a given segment of speech represents a request) should be developed and evaluated. Some types of requests may be easier to identify than others. Second, the rapidly changing health care environment virtually guarantees that any system for coding patient and physician behavior will require periodic updating. For example, as newer managed care models become dominant, request and response categories will be needed that account for the complex relationships among employers, insurers, medical groups, insurers, and patients. Third, codes are needed to acknowledge the involvement of family caregivers, especially in pediatric and geriatric settings. Fourth, greater attention to physician responses (including how clinicians promote effective negotiation) is needed. Fifth, TORP places a major emphasis on content; a more refined system that acknowledges form and emotionality may be needed when TORP is used for some research issues. One way to address this limitation would be to use TORP with an existing analysis system, such as RIAS.
More fundamentally, additional research is required to help researchers decide when direct observation is needed to understand critical elements of visit dynamics and when other data sources (such as patient or physician self-report, chart review, or administrative data) will suffice.22,23 Although audio-recording of visits can be intrusive and the coding of tapes is time consuming, direct observation is sometimes necessary because available evidence does not inspire optimism about the reliability of patient and physician reports of visit content.24-26 It is unlikely that reliance on self-report data alone can adequately support research on the give-and-take of clinical interactions.
Conclusions
TORP represents a new approach for understanding patients’ requests and physicians’ responses in office practice. This analysis system will provide new insights into a fundamental aspect of the physician-patient relationship that cannot be assessed by other means. By highlighting problematic requests and identifying successful and unsuccessful strategies for clinical negotiation, TORP may ultimately help clinicians to better meet patients’ needs in an increasingly demanding health care environment.
Acknowledgments
Data for this project were collected while Dr Kravitz was a Picker-Commonwealth Faculty Scholar. Analysis was performed with support from the Agency for Health Care Policy and Research (R03 HS09812-01). The authors thank Deirdre Antonius for coordinating the data collection effort, Shannon Quinlan for coding the audiotapes, and Charles E. Lewis, PhD, for providing mentorship and guidance.