‘The Hand on the Doorknob’: Visit Agenda Setting by Complex Patients and Their Primary Care Physicians

Journal of the American Board of Family Medicine: JABFM

Courtney Lyles^1¹  Andrea Altschuler^1²  Connie S. Uratsu^1³  Neetu Chawla^1⁴  Deanna B. McQuillan^1⁵  Christine P. Kowalski^1⁶ 

[1] Center for Vulnerable Populations, University of California–San Francisco, San Francisco (CL);Department of Family Medicine, University of Colorado School of Medicine, Aurora (EAB);Department of Internal Medicine, University of Michigan, Ann Arbor (MH)^1;Division of Research, Kaiser Permanente–Northern California, Oakland, CA (NC, AA, CSU, RWG);Institute for Health Research, Kaiser Permanente Colorado, Denver, CO (DBM, EAB);From the Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (CPK, MH)

关键词: Chronic Disease;    Documentation;    Lifestyle;    Primary Health Care;    Primary Care Physicians;    Risk;   

DOI  :  10.3122/jabfm.2018.01.170167

学科分类：过敏症与临床免疫学

来源: The American Board of Family Medicine

【 摘 要 】

Background: Choosing which issues to discuss in the limited time available during primary care visits is an important task for complex patients with chronic conditions. Design, Setting, and Participants: We conducted sequential interviews with complex patients (n = 40) and their primary care physicians (n = 17) from 3 different health systems to investigate how patients and physicians prepare for visits, how visit agendas are determined, and how discussion priorities are established during time-limited visits. Key Results: Visit flow and alignment were enhanced when both patients and physicians were effectively prepared before the visit, when the patient brought up highest-priority items first, the physician and patient worked together at the beginning of the visit to establish the visit agenda, and other team members contributed to agenda setting. A range of factors were identified that undermined the ability of patient and physicians to establish an efficient working agenda: the most prominent were time pressure and short visit lengths, but also included differing visit expectations, patient hesitancy to bring up embarrassing concerns, electronic medical record/documentation requirements, differences balancing current symptoms versus future medical risk, nonactionable items, differing philosophies about medications and lifestyle interventions, and difficulty by patients in prioritizing their top concerns. Conclusions: Primary care patients and their physicians adopt a range of different strategies to address the time constraints during visits. The primary factor that supported well-aligned visits was the ability for patients and physicians to proactively negotiate the visit agenda at the beginning of the visit. Efforts to optimize care within time-constrained systems should focus on helping patients more effectively prepare for visits. Physicians should ask for the patient's agenda early, explain visit parameters, establish a reasonable number of concerns that can be discussed, and collaborate on a plan to deal with concerns that cannot be addressed during the visit.

【 授权许可】

CC BY