Table of Contents

The Issue in Brief

How Experiencing Preventable Medical Problems Has Changed Patients' Interactions With Primary Healthcare

Nancy C. Elder, MD, MSPH , and colleagues

Background This study examines patients� experiences with problems in the primary care doctor�s office they believe could be prevented. In particular, the study looks at whether the patients were affected emotionally by the problems and whether the experience changed their health care behavior. Twenty-four patients were interviewed for the study.

What This Study Found atients report 3 groups of preventable errors, including communication problems (such as rudeness by doctors or miscommunication with an insurance company), administrative problems (such as long waits in the waiting room or telephone problems), and medical care problems (such as medication problems or a missed diagnosis). These experiences lead patients to feel anger, mistrust and resignation. They respond by avoiding going to the doctor, learning to deal with the problems, preparing for the problems, or advocating (such as getting a second opinion).

Implications

• Understanding how patients react to preventable problems can help strengthen the relationship between patients and doctors and improve the way the health care is delivered.

Time Spent in Face-to-Face Patient Care and Work Outside the Examination Room

Andrew Gottschalk, BS , and colleagues

Background It is widely thought that doctor visits are becoming shorter. According to national estimates by doctors, however, the length of primary care office visits increased during a 10-year period (1988-1998). One possible explanation is that when doctors estimate the length of patient visits, they combine face-to-face patient care time with patient-related work outside the examination room. This study examines that possibility by directly observing doctors� work time in and out of the examination room.

What This Study Found In this study, doctors work an average of 8.6 hours per day in the office. Face-to-face patient care accounts for 55% of the day; 14% of the day is spent on work outside the examination room related to current patients. One fifth (23%) of the day involves work related to patients not currently in the office. This includes writing or dictating notes, making phone calls about patient care, and interpreting laboratory results.

Implications

• When estimating the length of patient visits, doctors might include patient care responsibilities outside of the ex examination am room. It is therefore possible that face-to-face visit time has decre
• Office systems, such as electronic prescribing and electronic health records, could help streamline the doctor�s role and increase the efficiency of information management in the doctor�s office.

To Care is to Coprovide

Stephen A. Buetow

This essay argues that true health caring occurs when both patients and clinicians empower one another and provide their unique expertise. Although clinicians contribute clinical expertise, patients may be experts on their own bodies, life situations, values, beliefs,and preferences. If true care is to take place, both parties must be free to coprovide care, with mutual responsiveness and responsibility. The authors call for redefining family medicine/primary care as �first contact, continuous, comprehensive and coordinated care offered to, and by, patients, their informal caregivers and clinical providers.�

Physicians Answer More Clinical Questions and Change Clinical Decisions More Often With Synthesized Evidence: A Randomized Trial in Primary Care

Brian S. Alper, MD, MSPH , and colleagues

Background Doctors often need medical information quickly. One source for such information is a medical reference system that summarizes and updates clinical topics based on medical research findings. This study examines whether primary care doctors answer more clinical questions, change clinical decisions, or change their information search time using this system, called DynaMed, compared with their usual information resources.

What This Study Found In this study, primary care doctors who use DynaMed answer more of their clinical questions and find more answers that change their clinical decisions when compared with doctors not using the system. Search times are the same between both groups.

Implications

• A system that summarizes and combines medical research findings is one way to meet clinical information needs in primary care.

The Break-Even Point: When Mmedical Advances are Less Important Than Improving the Fidelity With Which They are Ddelivered

Stephen H. Woolf, MD, MPH , and colleagues

Society invests billions of dollars to develop new drugs and medical technologies, but the results are only modestly effective. This essay argues that more lives would be saved and more illnesses prevented if we spent less on technology and more to ensure that appropriate, high-quality medical care is available to all who need it.

Physician Activities During Time Out of the Examination Room

Valerie Gilchrist, MD , and colleagues

Background The limited time available for medical visits can be a source of frustration for patients and doctors. Doctors must divide their office time between direct patient care and other administrative and communication responsibilities. This study set out to learn more about how practicing primary care doctors spend their office time.

What This Study Found On average, doctors in this study spend 8 hours and 8 minutes in the office per day and have 20 patient visits. Visits last an average of 17.5 minutes. Doctors spend 23 percent of the office day on medical activities other than patient visits, including completing patient charts, dictating medical notes, reviewing reports, consulting medical resources, consulting colleagues, and communicating with patients. This does not include time spent delivering medical care in other settings, such as hospitals, nursing homes, or emergency rooms.

Implications

• If out-of- examination room medical care activities were considered part of the patient visit, visit time would increase by about 7 minutes, or 40 percent. This does not include the many other respons
• Medical care activities outside the examination room reflect the complexity of managing primary care patients; however, patients and payers often do not recognize this care.
• To help ensure high-quality care and satisfaction, medical policy and reimbursement should reflect the actual work performed by clinicians.

Suicidal Ideation and Risk Among Primary Care Patients With Uncomplicated Depression

Herbert C. Schulberg, PhD, MSHyg , and colleagues

Background Primary care doctors play an important role in identifying and treating suicidal patients. Because depression is a major risk factor for suicide, this study examines rates of suicidal thoughts and risk levels for suicide among depressed primary care patients.

What This Study Found Using both a screening test and an interview, patients with depression were classified according to their risk for suicide. After 3 months and 6 months, almost all patients were at the same or a lower risk level.

Implications

• The two-stage process in this study, using a screening test and interview, appears to be successful for assessing depressed patients� risk of suicide.

Improving Detection of Suicidal Ideation Among Depressed Patients in Primary Care

Paul A. Nutting, MD, MSPH , and colleagues

Background Past research suggests that patients often visit their primary care doctors before completing an act of suicide. It is difficult to identify suicidal patients, however, because completed suicide is relatively rare among primary care patients, and patients don�t usually volunteer that they are having suicidal thoughts. This study examines whether two approaches to improving depression care have an effect on identifying and treating patients with suicidal thoughts.

What This Study Found Two different approaches to improving care of depression among primary care patients also improves clinicians� detection of patients with suicidal thoughts. Brief training of primary care clinicians to improve depression care can double the rate at which they initially detect suicidal patients.

Implications

• Future approaches to depression care should include a focus on preventing suicide.
• This focus includes assessing whether patients have suicidal thoughts and their level of risk for suicide, as well as treating potentially suicidal patients or referring them to mental health professi

Quick Assessment of Literacy in Primary Care: The Newest Vital Sign

Barry D. Weiss, MD , and colleagues

Background As many as one half of all American adults lack the literacy skills needed to obtain and understand health information and services. This can affect their health and their ability to make medical decisions. Existing tests to determine patients� level of health literacy are often long or available only in English. This study tested a new tool, available in English and Spanish, that is designed to be quick and accurate.

What This Study Found The new test (called the Newest Vital Sign) is the first literacy screening tool available in both English and Spanish that can be administered in approximately 3 minutes. It is suitable for testing patients� literacy level in primary care practices.

Implications

• The Newest Vital Sign is quick and effective in the primary care setting.
• Future research could determine whether the Newest Vital Sign is effective in different medical settings, and whether raising clinicians� awareness of health literacy by using the test leads to better

What is the Quality of Work Life of Independent vs Employed Family Physicians in Wisconsin? A WRen Study

John W. Beasley, MD , and colleagues

Background Increasing numbers of doctors are employed by large health care organizations, such as hospitals, HMOs, and multispecialty clinics. This study compares the quality of work life of family doctors who are employed by health care organizations with that of doctors in independent practices.

What This Study Found Doctors in independent practice report higher quality of work life than doctors employed by health care organizations. In particular, they report better work relationships, more influence over management decisions, more satisfaction with family time, more satisfaction with being a doctor, and better perception of the quality of care they provide. Independent doctors in this study have been in practice longer than employed doctors and report working longer hours.

Implications

• The growing number of doctors employed by health care organizations face important quality-of-work-life issues, including lack of control and lack of social support.
• By addressing these issues, health care organizations might encourage a more satisfied, effective, and stable workforce.