Stories from Frequent Attenders: A Qualitative Study in Primary Care

Analysis

The interview schedule can be found in the Supplemental Appendix, available online only at http://www.annfammed.org/cgi/content/full/3/4/318/DC1. Interviews were audiotaped and transcribed. Analysis was undertaken using NVIVO. All of the transcripts were open coded by the lead author, and 10 transcripts were open coded by a member of the team who was a qualitative researcher. The next stage of analysis involved generating themes that emerged from the interviews through a review of the open codes. The themes that emerged for the purposes of this report included frequency of consulting, reasons for consulting, bodily perceptions and reassurance, dissatisfaction with consultations, and overcoming obstacles. All of the interviews were included in the analysis; there were no disconfirming cases.

Frequency of Consulting

There were 2 types of frequent attenders in this sample. Most participants (27 of 30, 90%) were unable to give a clear indication of their frequency of consultations. Typical responses to the question on the frequency of consultations included the following:

“Don’t really know, depends what’s wrong with me.” (Interview 09)

“Went to the doctor’s last week.” (Interview 22)

“Must be a couple of weeks ago now.” (Interview 13)

“Quite a lot.” (Interview 02)

“I’ve got to go up to the hospital on … think it’s Friday, to see the doctor about my pains.” (Interview 10)

“Well, it’s just round the corner, only 5 minutes away … if it’s nice I walk round, if it’s bad, you know raining, I go in the car.” (Interview 14)

“Not sure really, can’t really say, hard to remember how much … not something I keep in my head.” (Interview 21)

The second group were crisis patients, with a clear stressor that precipitated high rates of consultation for a specific period.²⁰ Three respondents reflected on their high rates of consultation and offered explanations, for example:

“I was going through a really bad patch … went to see Dr A, and he was really good.” (Interview 04)

“Had lots of problems last year and couldn’t cope.” (Interview 18)

Implicit here is the notion that, for these patients, there were particular times when they were undergoing specific life problems (work-related stress and marital problems) and reported that their family doctors provided considerable support during these times. The separation between acute periods, when they were experiencing life problems, and other times, when they did not need such support from their family doctor, is illustrated by the following response

“Normally twice a year and that would be it.” (Interview 11)

Reasons for Consulting

Reasons for consulting a family doctor were based on representations of family doctors as respected authority figures who are the most appropriate to consult for the distinctive and extensive physical sensations or symptoms that patients perceived to require medical care and reassurance.

Representations of family doctors as having high esteem and status is illustrated by the following quotes:

“They’re like your mother and father, you can tell them anything.” (Interview 01)

“I suppose they’re similar to a priest, somebody you can trust.” (Interview 14)

“I don’t know … they know lots, don’t they?” (Interview 05)

“They’ve had all that training and that, they have those books they look things up in.” (Interview 12)

“I tell my doctor things I wouldn’t say to anybody else, not even the wife. You know when you tell them something, it’s between you and him, you know it’s not going to get out.” (Interview 24)

The belief that a family doctor was the most appropriate and obvious person to manage and treat their symptoms is illustrated below:

“Doctor can sort it out.” (Interview 03)

“Well, that’s where you go when there’s something wrong with you, isn’t it?” (Interview 25)

“They know what they’re doing, don’t they? They know what to get for you, you know, the right drugs and that.” (Interview 20)

“They’re the ones who tell you what’s wrong, they work it out.” (Interview 10)

The ability of family doctors to be a part of an individual’s unique suffering was expressed by 1 interviewee for whom there was overlap between experiencing prolonged caring (and eventual bereavement for a close family member) and increased contact with his family doctor:

“It was all so difficult when John got ill. We couldn’t get any answers from all those doctors, they couldn’t do anything, and to make things even worse, I started to get ill, had to give up work … been there for 23 years. I was trying to cope with his [son’s] terrible suffering, and the wife was going out of her mind, knowing he could die at any time. And at the same time … he was so young, and we thought at first he’d be cured … it just got worse and worse. When he died, our lives fell apart. There was nothing … and those doctor’s, they don’t help me, I’ve been everywhere … I’m still waiting for test results.” (Interview 26)

The interrelationship between periods of extreme stress and illness are evident in this passage, along with a sense of disappointment in the ability of clinician to prevent this child’s death. Furthermore, the extreme—and for this interviewee unique—circumstances of his suffering were perceived to be unnoticed by clinicians.

Bodily Perceptions and Reassurance

Some patients described experiencing a relatively high number of physical sensations that were difficult for them to endure and required reassurance from their family doctor:

“I want to know what’s wrong with me, there’s always something. Never seem to get clear. Think I’m getting sorted, then something else pops up. Doctor says I’ve got high blood pressure, you see, and have to be careful. It could be to do with that.” (Interview 29)

“Well, like the other morning, I woke up and I had this terrible lump [points to throat]. I couldn’t breathe, it was really … so had to phone the doctors. Couldn’t carry on with that, could I? What if I couldn’t have breathed? Don’t want to wait around with that, do I? Might have ended up in hospital. Then, like another time had this funny breathing, and it just wouldn’t stop. I was getting worried so had to go to the doctor’s for that.” (Interview 01)

“Doctor said, ‘Come back if it happens again.’ And I’d had another one, felt really bad, didn’t know what was going on, just wouldn’t go, this funny tingling right the way down here [indicates back of leg], couldn’t walk hardly. Then it went here [points to arm], could be something to do with my heart, heard you get funny pains there, you know, before a heart attack.” (Interview 15)

“I’d been woken up by it, must’ve been 2 o’clock. Didn’t feel right at all, couldn’t get back to sleep, tried everything, thought of calling doctor out to come and see me, but thought, best leave it to morning. And doctor saw me and said I was all right. I was really worried, just couldn’t get right in myself. When it’s that bad, you have to go see him.” (Interview 23)

Dissatisfaction with Consultations

Despite holding their doctors in high regard, slightly more than 2 thirds of the interviewees (n = 22) expressed some form of dissatisfaction with their treatment:

“I told her what was wrong and she said I had, it was to do with my heart. It was my throat that were wrong, so I don’t know.” (Interview 17)

“I keep telling them, ‘What’s up? I can’t sleep.’ They don’t seem to be able to do anything, they don’t understand.” (Interview 21)

“It’s a bit annoying, really. I keep saying there’s something draining behind my cheek, and then that goes down my throat, some gloopy stuff, but he keeps saying it’s something to do with my teeth. I know it’s not, it’s something behind there. I’ve been to the dentist, and he can’t find anything.” (Interview 11)

“I’ve been a few times to see her, and the last time she said to get on with life, just enjoy it. How can I when I’ve got this banging going on in my ear? It won’t go away by itself, I’m going to have to go back and get it seen to.” (Interview 09)

“You see, they can’t find out what’s wrong with me. They keep saying one thing and giving me these pills. They don’t do any good, so I go back, they give me others.” (Interview 16)

“She gave me some cream, it didn’t do any good, I put it in the bath and had to go back.” (Interview 12)

Overcoming Obstacles

Most interviewees (n = 23) reported obstacles to consulting with their family doctor:

“You can never get through, and when you do, they’re so rude, you’d think they don’t want you, and you can never get the doctor you want … you have to take next week, but that’s no good is it? I want to see Dr B when I’m not well.” (Interview 17)

“You have to be up early, get on the phone at quarter past eight and keep ringing ‘til you get through.” (Interview 13)

“It’s a daft system, if you ask me. Used to be all right. Can’t see the doctor for 2 weeks—don’t have any appointments. I might not be ill then, and the girls say if it’s an emergency, then you have to call back, but try getting through—it’s always engaged.” (Interview 30)

In spite of considerable logistical problems, such as telephone systems and reception staff, there was a sense from the interviews that a consultation with a family doctor would be achieved.

A minority (n = 7) reported friendly relationships with reception staff:

“I can go anytime, just phone up and they fit me in. The girls on the telephone know me really well and always sort me out.” (Interview 07)

Strengths and Limitations of the Study

We used a novel method to determine which patients family doctors consider to frequent attenders. Although, similar to other research,³⁰ we used quantitative definitions of frequent attendance to generate lists of patients who had office visits at twice the mean rate for the practice and age ranges, the rating of these lists of patients was undertaken by family doctors for whom “no significant clinical outcome” was used as an identifier for patients who frequently attend. There may have been differences between doctors in their use of the criteria (which would require further refinement), as evidenced by the 3 interviewees in this study who could be considered to be crisis patients rather than frequent attenders. We believe, however, that using family doctors to identify those patients who they consider attend frequently is a useful strategy that can be further developed.

It was difficult to find patients who would agree to an interview for this study. Ethical considerations, however, constrained us from determining whether the potential participants who were not interviewed (60%) are the more challenging for family doctors in terms of their consultation rates and symptoms.

Implications for Future Research and Clinical Practice

Clinical management of patients who attend frequently is characterized by mutual frustration and a lack of reciprocity.³⁷ Frequent attenders require consistent acknowledgment and legitimization of their perceived unique suffering. An increased awareness by physicians of their patients’ perceptions and expectations is essential. Instead of giving patients medications for their symptoms, clinicians might find it more helpful to focus on reassurance techniques using explanations that relate to the patient’s conceptual framework and exempt the patient from blame.³² To design effective educational interventions, we need future research that examines clinicians’ interactions with patients who attend frequently.