Abstract
OBJECTIVES: To understand the nature of patients’ expectations for parts of the physical examination and for diagnostic testing and the meaning patients ascribe to their desires.
DESIGN: Qualitative inquiry based on patient interviews and focused on perceived diagnostic omissions as “critical incidents.”
SETTING: Three general internal medicine practices (21 practitioners) in one mid-sized northern California city.
PATIENTS: Of 687 patients visiting these practice sites and completing a detailed questionnaire, 125 reported one or more omissions of care and 90 completed an in-depth telephone interview. This study focuses on the 56 patients interviewed who did not receive desired components of the physical examination or diagnostic tests.
MEASUREMENTS: Qualitative analysis of key themes underlying patients’ unmet expectations for examinations and tests, as derived from verbatim transcripts of the 56 interviews.
MAIN RESULTS: The 56 patients perceived a total of 113 investigative omissions falling into four broad categories: physical examination (47 omissions), conventional tests (43), highcost tests (10), and unspecified investigations (13). Patients considered omitted investigations to have value along both pragmatic and symbolic dimensions. Diagnostic maneuvers had pragmatic value when they were seen to advance the technical aims of diagnosis, prognosis, or therapy. They had symbolic value when their underlying purpose was to enrich the patient-physician relationship. Patients in this study were often uncomfortable with clinical uncertainty, distrusted empiric therapy, endorsed early detection, and frequently interpreted failure to examine or test as failure to care.
CONCLUSIONS: When patients express disappointment at failing to receive tests or examinations, they may actually be expressing concerns about the basis of their illness, the rationale for therapy, or the physician-patient relationship.
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References
Cutler P. Problem Solving in Clinical Medicine. Baltimore, Md: Williams & Wilkins; 1979.
Praiss I, Gjerde C. Cost containment through medical education. JAMA. 1980;244:53–5.
Eisenberg JM. The internist as gatekeeper: preparing the general internist for a new role. Ann Intern Med. 1985;102:537–43.
Shulkin DJ, Rosenstein AH. Promoting cost-effective physician behavior. Healthc Financ Manage. 1993;47:48,50,52–4.
Bastian H. Speaking up for ourselves: the evolution of consumer advocacy in health care. Int J Technol Assess Health Care. 1999;4:127–8.
Consumerism rampant: a critique of the view of medicine as a commercial enterprise. Mt Sinai J Med. 1993;60:15–9.
Gallagher TH, Lo B, Chesney M, Christensen K. How do physicians respond to patients’ requests for costly, unindicated services? J Gen Intern Med. 1997;12:663–8.
Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients’ expectations for care during office visits. J Gen Intern Med. 1994;9:75–81.
Joos SK, Hickam DH, Borders LM. Patients’ desires and satisfaction in general medicine clinics. Public Health Rep. 1993;108:751–9.
Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The relationship between patients’ satisfaction with their physicians and perceptions about interventions they desired and received. Med Care. 1989;13:562–9.
Good MJD, Good BJ, Nassi AJ. Patient requests in primary health care settings: development and validation of a research instrument. J Behav Med. 1983;6:151–68.
Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA. Concerns and expectations in patients presenting with physical complaints: frequency, physician perceptions and actions, and 2-week outcome. Arch Intern Med. 1997;157:1482–8.
Sox HC, Marguiles I, Sox CH. Psychologically mediated effects of diagnostic tests. Ann Intern Med. 1981;95(6):680–5.
La Combe MA. What is it patients want? Am J Med 1995;99:588–9.
Lazare A, Eisenthal S, Frank A. A negotiated approach to the clinical encounter, II: conflict and negotiation. In: Lazare A, ed. Outpatient Psychiatry: Diagnosis and Treatment. Baltimore, Md: Williams & Wilkins, 1979.
Botelho RJ. A negotiation model for the doctor-patient relationship. Fam Pract. 1992;9:210–8.
Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102:520–8.
Bertakis KD, Callahan EJ, Helms LJ, Azari R, Robbins JA, Miller J. Physician practice styles and patient outcomes: differences between family practice and general internal medicine. Med Care. 1998;36:879–91.
Kravitz RL, Callahan EJ, Paterniti D, Antonius D, Dunham M, Lewis CE. Prevalence and sources of patients’ unmet expectations for care. Ann Intern Med. 1996;125:730–7.
Miller RH, Lipton HL, Duke KS. Health System Change in the Greater Sacramento Area. Sacramento, Calif: Sierra Health Foundation; June 1997.
Lowes RL. Are you expected to see too many patients? Med Econ. 1995;72:52–3, 57–9.
Flanagan JC. The critical incident technique. Psychol Bull. 1954;51:327–58.
Bradley CP. Uncomfortable prescribing decisions: a critical incident study. BMJ. 1992;304:294–6.
Bradley CP. Turning anecdoetes into data—the critical incident technique. Fam Pract. 1992;9:98–103.
Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making. Boston, Mass: Butterworth Publications; 1988.
Feinstein AR. The ‘chagrin factor’ and qualitative decision analysis. Arch Intern Med. 1985;145(7):1257–9.
Ware JE Jr, Brook RH, Rogers WH, et al. Comparison of health outcomes at a health maintenance organisation with those of fee-for-service care. Lancet. 1986;1(8488):1017–22.
Ware JE Jr, Bayliss MS, Rogers WH, Kosinski M, Tarlov AR. Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems: results from the Medical Outcomes Study. JAMA. 1996;276:1039–47.
McCall TB. Some HMOs are bad news. (Is yours?) Redbook. 1996;187(4):47,48.
Rosenthal GE, Shannon SE. The use of patient perceptions in the evaluation of health-care delivery systems. Med Care. 1997;35(11 suppl):NS58–68.
Kravitz RL. Patients’ expectations for medical care: an expanded formulation based on review of the literature. Med Care Res Rev. 1996;53:3–27.
Skelton JA, Croyle RT, eds. Mental Representation in Health and Illness. New York, NY: Springer-Verlag; 1991.
Kee F. Patients’ prerogatives and perceptions of benefit. BMJ. 1996;312(7036):958–60.
Mazur DJ, Merz JF. Patients’ interpretations of verbal expressions of probability: implications for securing informed consent to medical interventions. Behav Sci Law. 1994;12(4):417–26.
Froehlich GW, Welch HG. Meeting walk-in patients’ expectations for testing: effects on satisfaction. J Gen Intern Med. 1996;11:470–4.
Rose G, Segesten K. Someone who cares—patients’ experiences concerning health examinations. Scand J Caring Sci 1995;9:105–12.
McLeod PJ, Tamblyn R, Benaroya S, Snell L. Faculty ratings of resident humanism predict patient satisfaction ratings in ambulatory medical clinics. J Gen Intern Med. 1994;9:321–6.
Lazare A, Eisenthal S, Wasserman L. The customer approach to patienthood. Arch Gen Psychiatry. 1975;32:553–8.
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Dr. Kravitz was a Picker/Commonwealth Faculty Scholar at the time this work was initiated.
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Kravitz, R.L., Callahan, E.J. Patients’ perceptions of omitted examinations and tests. J GEN INTERN MED 15, 38–45 (2000). https://doi.org/10.1046/j.1525-1497.2000.12058.x
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DOI: https://doi.org/10.1046/j.1525-1497.2000.12058.x