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J Am Board Fam Med. 2018 Jan-Feb;31(1):29-37. doi: 10.3122/jabfm.2018.01.170167.

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

Author information

1
From the Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (CPK, MH); Institute for Health Research, Kaiser Permanente Colorado, Denver, CO (DBM, EAB); Division of Research, Kaiser Permanente-Northern California, Oakland, CA (NC, AA, CSU, RWG); 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).
2
From the Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (CPK, MH); Institute for Health Research, Kaiser Permanente Colorado, Denver, CO (DBM, EAB); Division of Research, Kaiser Permanente-Northern California, Oakland, CA (NC, AA, CSU, RWG); 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). Richard.W.Grant@KP.org.

Abstract

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.

KEYWORDS:

Chronic Disease; Documentation; Lifestyle; Primary Care Physicians; Primary Health Care; Risk

PMID:
29330237
PMCID:
PMC5893137
DOI:
10.3122/jabfm.2018.01.170167
[Indexed for MEDLINE]
Free PMC Article

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