B. Mitchell Peck

Do Unmet Expectations for Specific Tests, Referrals, and New Medications Reduce patients' Satisfaction?

AbstractBACKGROUND: Patient-centered care requires clinicians to recognize and act on patients’ expectations. However, relatively little is known about the specific expectations patients bring to the primary care visit. OBJECTIVE: To describe the nature and prevalence of patients’ specific expectations for tests, referrals, and new medications, and to examine the relationship between fulfillment of these expectations and patient satisfaction. DESIGN: Prospective cohort study. SETTING: VA general medicine clinic. PATIENTS/PARTICIPANTS: Two hundred fifty-three adult male outpatients seeing their primary care provider for a scheduled visit. MEASUREMENTS AND MAIN RESULTS: Fifty-six percent of patients reported at least 1 expectation for a test, referral, or new medication. Thirty-one percent had 1 expectation, while 25% had 2 or more expectations. Expectations were evenly distributed among tests, referrals, and new medications (37%, 30%, and 33%, respectively). Half of the patients who expressed an expectation did not receive one or more of the desired tests, referrals, or new medications. Nevertheless, satisfaction was very high (median of 1.5 for visit-specific satisfaction on a 1 to 5 scale, with 1 representing “excellent”). Satisfaction was not related to whether expectations were met or unmet, except that patients who did not receive desired medications reported lower satisfaction. CONCLUSIONS: Patients’ expectations are varied and often vague. Clinicians trying to implement the values of patient-centered care must be prepared to elicit, identify, and address many expectations.

Measuring patient expectations: Does the instrument affect satisfaction or expectations?

Background.Fulfillment of patients’ expectations may influence health care utilization, affect patient satisfaction, and be used to indicate quality of care. Several different instruments have been used to measure expectations, yet little is known about how different assessment methods affect outcomes. Objective.The object of the study was to determine whether different measurement instruments elicit different numbers and types of expectations and different levels of patient satisfaction. Design.Patients waiting to see their physician were randomly assigned to receive 1 of 2 commonly used instruments assessing expectations or were assigned to a third (control) group that was not asked about expectations. After the visit, patients in all 3 groups were asked about their satisfaction and services they received. Subjects.The study subjects were 290 male, primary care outpatients in a VA general medicine clinic. Measures.A “short” instrument asked about 3 general expectations for tests, referrals, and new medications, while a “long” instrument nested similar questions within a more detailed list. Wording also differed between the 2 instruments. The short instrument asked patients what they wanted; the long instrument asked patients what they thought was necessary for the physician to do. Satisfaction was measured with a visit-specific questionnaire and a more general assessment of physician interpersonal skills. Results.Patients receiving the long instrument were more likely to express expectations for tests (83% vs. 28%, P <0.001), referrals (40% vs. 18%, P <0.001), and new medications (45% vs. 28%, P <0.001). The groups differed in the number of unmet expectations: 40% of the long instrument group reported at least 1 unmet expectation compared with 19% of the short instrument group (P <0.001). Satisfaction was similar among the 3 groups. Conclusions.These different instruments elicit different numbers of expectations but do not affect patient satisfaction.

Age-Related Differences in Doctor-Patient Interaction and Patient Satisfaction

Background. Relatively little is known about patient characteristics associated with doctor-patient interaction style and satisfaction with the medical visit. Objective. The primary study objectives are to assess: whether doctors interact in a more or less patient-centered style with elderly patients and whether patient age moderates the relationship between interaction style and satisfaction, that is, whether elderly patients are more or less satisfied with patient-centered medical encounters. Methods. We collected pre- and post-visit questionnaire data from 177 patients at a large family medicine clinic. We audiotaped the encounters between doctors and patients. Patient-centered interaction style was measured from coding from the audiotapes of the doctor-patient interactions. Patient satisfaction was measured using the Patient Satisfaction Questionnaire. Results. We found physicians were more likely to have patient-centered encounters with patients over age 65. We also found patient age moderated the association between interaction style and patient satisfaction: older patients were more satisfied with patient-centered encounters. Conclusion. Patient age is associated with style of interaction, which is, in turn, associated with patient satisfaction. Understanding the factors and processes by which doctors and patients interact has the potential to improve many facets of health care delivery.

Disparities in the Conduct of the Medical Encounter

The U.S. health care system continues to struggle to meet the needs of all members of society. Health disparities are a major concern of the health care system. There are differences in health outcomes related to gender, race, ethnicity, age, and other social indicators. Previous research has focused on differences in access to health care and differences in the delivery of specific medical services. More recently, researchers have examined the way doctors and patients interact to understand health disparities. The current study examines differences in the way doctors and patients interact in terms of information gathering, communicating information, and relationship building, as well as general conduct of the interaction and patient’s satisfaction with the encounter. The study uses data coded from audiotapes of 221 doctor–patient encounters. The results suggest medical encounters differ in important ways depending on patient and physician characteristics. These differences can create and contribute to health disparities.

Socio-Environmental Factors Associated With Pubertal Development in Female Adolescents: The Role of Prepubertal Tobacco and Alcohol Use

PURPOSE Alcohol administered to laboratory animals has been shown to suppress puberty-related hormones and delay puberty by interfering with ovarian development and function. The effects of early substance use on human pubertal development are relatively unexplored. METHODS This cross-sectional study of 3,106 female adolescents, aged 11-21 years, evaluated the association between prepubertal alcohol and tobacco use and the onset of puberty. Ages at initial breast development, body hair growth, and menarche were self-reported. Prepubertal alcohol and tobacco use were defined as the age at first use before the age of pubertal development and accompanied by regular use. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox proportional hazard models. Logistic regression was used to estimate the association between substance use and delayed puberty, defined as lack of breast development by the age of 13 years. RESULTS Unadjusted models indicated prepubertal tobacco use was associated with a longer time required for breast development (HR = 0.74; 95% CI, 0.65-0.85) and body hair growth (HR = 0.81; 95% CI, 0.71-0.93). Prepubertal alcohol use was associated with late breast development (HR = 0.71; 95% CI, 0.57-0.88). The direction of the observed associations remained consistent after adjusting for covariates, but the magnitude of effects were attenuated and the upper bound of the 95% CIs exceeded the null value. Girls who used alcohol before puberty had four times the odds of having delayed puberty (OR = 3.99; 95% CI, 1.94-8.21) as compared with nonusers. CONCLUSION The results of this study suggest that the endocrine-disrupting effects of alcohol and tobacco use may alter the timing of pubertal development. These cross-sectional findings warrant further investigation.

Talking with Me or Talking at Me? The Impact of Status Characteristics on Doctor-Patient Interaction:

Over the last two decades, the way doctors and patients interact has changed. There has been a shift away from what Talcott Parsons described as a paternalistic model of interaction to a more collaborative, participatory, patient-centered model of interaction. Yet not all interactions between doctors and patients are collaborative. Using status characteristics theory, the authors hypothesized that medical encounters are more likely to be physician dominated when the status differences between doctors and patients are higher. They tested hypotheses about race, gender, and socioeconomic status differences between doctors and patients. The authors found support for the hypotheses, especially regarding status differences for race and gender. Doctor-patient interactions were most physician-centered when doctors had higher status than patients on race (white versus non-white) and gender (male versus female)