Is patients' perception of time spent with the physician a determinant of ambulatory patient satisfaction?

BACKGROUND: Time management in ambulatory patient visits is increasingly critical. Do patients who perceive a longer visit with internists report increased satisfaction? METHODS: Prospective survey of 1486 consecutively encountered ambulatory visits to 16 primary care physicians (PCPs) in an academic primary care clinic. Patients were queried regarding demographics, health status, perception of time spent before and after ambulatory visits, whether the physician appeared rushed, and visit satisfaction. Physicians were queried regarding time spent, estimated patient satisfaction, and whether they felt rushed. RESULTS: In 69% of 1486 consecutive visits, patient previsit expectation of visit duration was 20 minutes or less. Patient and PCP postvisit estimates of time spent significantly exceeded patient previsit time expectation. Patients who estimated that they spent more time than expected with the PCP were significantly more satisfied with the visit. When patient postvisit estimate of time spent was less than the previsit expectation, visit satisfaction was significantly lower independent of time spent. Patient worry about health and lower self-perceived health status were significantly associated with patient expectation for longer visits. Primary care physicians felt rushed in 10% of encounters. Although PCPs estimated patient satisfaction was significantly lower when they felt rushed, patient satisfaction was identical when PCPs did and did not feel rushed. Patients indicated that PCPs appeared rushed in 3% of encounters, but this perception did not affect patient satisfaction. CONCLUSION: Perceived ambulatory visit duration and meeting or exceeding patient expectation of time needed to be spent with the physician are determinants of patient satisfaction in an ambulatory internal medicine practice.

Physician sex and other factors associated with type of breast cancer surgery in older women.

HYPOTHESIS: Physician-related factors as well as patient characteristics may explain why women aged 65 years or older with early-stage breast cancer undergo lumpectomy less often than younger women, despite National Institutes of Health recommendations favoring lumpectomy over mastectomy. DESIGN: A descriptive and analytical retrospective computer-assisted telephone survey. SETTING: A population-based random sample of breast cancer survivors in Colorado, identified from the Colorado Central Cancer Registry. PATIENTS: Women aged 65 to 84 years when diagnosed as having stage I or II breast cancer, treated 1 to 6 years previously with mastectomy or lumpectomy, and without recurrence or second primary cancers. Among women contacted, 58% participated. Results of 198 interviews are reported. METHODS: Survey questions included patient decision-making participation and physician recommendations, sources and amount of treatment information provided by physicians, physician characteristics, and patient surgery preferences and demographic characteristics. A multivariate logistic regression model identified factors independently associated with lumpectomy. RESULTS: Lumpectomy was strongly associated with higher patient education, female physician sex, patient age 75 years or older, and amount of physician-provided information. The number of physician-provided information sources was associated with surgery explanations, and female physicians provided more sources of information. A physician decision or recommendation for surgery type was reported by 61% of women, of whom 93% underwent the recommended procedure. A subset of patients (13%) reported deferring the surgery decision to someone else. CONCLUSIONS: These results suggest that better-educated and better-informed older women are more likely to undergo lumpectomy, and that physicians may influence breast cancer patients' decisions about surgery type.

Use of cell surface antigen phenotype in guiding therapeutic decisions in chronic myelomonocytic leukemia.

The myelodysplastic syndromes are a heterogeneous group of hematopoietic stem cell diseases in which both diagnosis and prognosis are determined by cellular morphologic criteria. In some patients, prognosis is poor due to proliferation of immature cells, i.e. development of acute leukemia. An important clinical decision for patients with myelodysplastic syndromes is whether to treat with supportive care or to use cytoreductive drugs to control the proliferative component of these illnesses. Two cases of chronic myelomonocytic leukemia are presented where cell surface antigen phenotype analysis showed characteristics suggestive of proliferative disease and the patients were treated and obtained remission with cytoablative therapy. Cell surface marker analysis may be useful in guiding therapeutic decisions in myelodysplasia.

Intravenous gammaglobulin treatment for immune thrombocytopenia associated with infectious mononucleosis.

Severe thrombocytopenia is an uncommon (incidence less than 1%) but serious complication of infectious mononucleosis. Corticosteroids have been used for therapy with variable responses reported. Five consecutive patients with infectious mononucleosis-related severe thrombocytopenia were treated with intravenous gammaglobulin (IVIG) at a dose of 400 mg/kg/day for 2-5 days. All patients appear to have had an immunologic or consumptive etiology for their thrombocytopenia as determined by increased marrow megakaryocytes. All patients were initially treated with oral prednisone 1 mg/kg/day. Due to the relatively slow response to prednisone (platelet count less than 20,000/microliters on the 8th to 13th hospital day) or increased bleeding symptoms, IVIG was initiated. Four of the five patients rapidly developed significant increases in their platelet counts (range 44,000/microliters to 97,000/microliters). Two of these responses were sustained and two relapses occurred (while on continued steroid therapy) which again responded to booster doses of IVIG at similar doses. IVIG has been previously shown to be effective in treating patients with idiopathic thrombocytopenia purpura. Historically, patients with infectious mononucleosis-related severe thrombocytopenia often are refractory to corticosteroid therapy and our limited experience suggests that IVIG may also be effective in infectious mononucleosis-related severe thrombocytopenia.

Thrombotic thrombocytopenic purpura: recovery after splenectomy associated with persistence of abnormally large von Willebrand factor multimers.

A patient with thrombotic thrombocytopenic purpura (TTP) responded transiently to four courses of plasma exchange therapy, then subsequently had a sustained completed remission following splenectomy. The von Willebrand factor multimeric pattern during remission following each plasma exchange and during the entire postsplenectomy period showed abnormally large forms that were not present on presentation and with each clinical relapse. These findings support prior observations regarding the presence of abnormal von Willebrand factor multimers in relapsing TTP and suggest that the multimers contribute to platelet aggregation and the thrombotic lesions. The association of sustained remission and persistence of the abnormally large plasma multimers after splenectomy suggests that this response was not coincidental. This supports the concept that a subgroup of patients with TTP may exist in which the pathophysiology of disease is significantly modulated by the spleen and in which splenectomy may induce long-lasting remission.