Behind closed doors: management of patient expectations in primary care practices.

BACKGROUND: Managed care restrictions on resource use may affect communication between patients and health care professionals. METHODS: To characterize negotiations between primary care physicians and patients with expectations for new medications, tests, or referrals, this observational study combined survey data with audiotape recordings of clinical encounters. Fifty-five physicians from 20 randomly selected primary care practices in a managed care network and 211 patients who voiced specific expectations in a previsit survey were included. From the recorded clinic visits we determined modes of negotiation of patient expectations and requests. From the surveys we determined patient previsit expectations, postvisit fulfillment of expectations, satisfaction, and trust. RESULTS: Two-hundred fifty-six self-reported expectations were captured in 200 audiotape-recorded encounters. Of the previsit expectations, 97.3% were discussed during the encounter. Expectations were expressed by direct patient request (40.6%), mentioning of symptoms related to request (29.7%), or physician-initiated discussion (27.0%). Most expectations were met (66.8%); physicians suggested an alternative 21.6% of the time. Expectations for medications and tests were met more frequently than expectations for referrals (75.6% and 71.4% vs 40.8%). Patient satisfaction and trust remained high regardless of whether expectations were met. Physicians reported that they would not have ordered 62 (44.9%) of 138 requests had the patients not directly asked, and they were uncomfortable filling 8 requests (12.9%). CONCLUSIONS: Previsit expectations for medications, tests, or referrals were discussed at the visit, and physicians met or offered alternatives for nearly 90%. Patients generally received what they asked for and altered physician behavior nearly half of the time.

Studying communication in oncologist-patient encounters: the SCOPE Trial.

STUDY OBJECTIVE: Most oncologists have not received adequate training in physician-patient communication, and existing effective courses tend to be time and resource intensive. We are developing and testing a tailored CD-ROM educational intervention that includes feedback on oncologists' own audio-recorded conversations with their advanced cancer patients. In this report, we describe the study methods and identify challenges to implementation and how these were overcome. STUDY DESIGN: A three-phase, randomized, controlled trial. In Phase 1, we audio-recorded oncologist-patient clinic encounters. In Phase 2, oncologists were randomly assigned to a communication CD-ROM intervention or control. Phase 3 consisted of audio-recording all participating oncologists conversing with a new sample of patients, two to 12 months after the intervention, to assess its effectiveness. SETTING: Oncology clinics at Duke University Medical Center (DUMC) and the Durham Veterans Affairs Medical Center (DVAMC) in Durham, NC, and the University of Pittsburgh Medical Center (UPMC) in Pittsburgh, PA. PARTICIPANTS: Medical, radiation and gynecological oncologists and their patients with advanced cancer. INTERVENTION: A tailored CD-ROM that contains an interactive educational interface with reference materials and video-clips of model conversations, along with the oncologists' own Phase 1 audio-recorded conversations. CONCLUSION: We present challenges and solutions to oncologist recruitment, identifying appropriate patients with advanced cancer, adapting to clinic flow, and developing a self-administered communications intervention.