Presence of observers at patient-practitioner interactions: impact on coordination of care and methodologic implications.

Starfield, Bárbara; Steinwachs, Donald; Morris, Ira; Bause, George S.; Siebert, Stephen F.; Westin, Craig

doi:10.2105/ajph.69.10.1021

Cited by 11 publications

(6 citation statements)

References 10 publications

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“…The presence of an observer in the consultation might influence the encounter, for example leading to avoidance of discussing sensitive issues [ 10 ]. We tried to minimize this by placing the observer out of sight of the patient.…”

Section: Discussionmentioning

confidence: 99%

What do patients bring up in consultations? An observational study in general practice

Bjørland

Brekke

2015

Scandinavian Journal of Primary Health Care

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Objective. The main aim of the study was to investigate how many and what kind of problems patients present in consultations with their general practitioner (GP). A secondary aim was to explore patients’ views on what is important in consultations. Design. Cross-sectional study including observation of unselected consultations with recording on a pre-designed scheme, and a brief questionnaire filled in by patients. Setting. Four general practices in Oslo, Norway. Subjects. A total of 201 patients in consultations and 177 patients waiting to see their GP. Main outcome measures. Number and characteristics of problems raised by patients, and whether the problems were handled by GPs during the ongoing consultation. Patients’ expectations for the consultation. Results. The mean number of problems raised was 2.6 (range 1–16), and when appointments for acute conditions were excluded, the mean number was 3.3. Somatic problems comprised about half of all problems, and in more than one-quarter of consultations a mental health issue was presented. Female sex and increasing age predicted an increasing number of problems raised. In one-quarter of encounters four or more problems were presented. The vast majority of problems were dealt with by the GPs during the ongoing consultation. “That I am able to address all the problems I have” was rated as highly important by patients. Conclusion. GPs deal with multiple and unrelated problems in daily consultations, which is highly valued by patients. Management of concurrent problems in brief encounters demands training and adequate working conditions, in order to sustain this core value of general practice.

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Section: Discussionmentioning

confidence: 99%

What do patients bring up in consultations? An observational study in general practice

Bjørland

Brekke

2015

Scandinavian Journal of Primary Health Care

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“…36 Furthermore, even direct observation studies are limited by the inability to describe those problems that are considered by the physician but do not lead to observable actions. The issue of what problems are addressed in the physician' s mind, even if not explicit, is central to understanding this aspect of the complexity of the visit.…”

Section: Limitationsmentioning

confidence: 99%

How Many Problems Do Family Physicians Manage at Each Encounter? A WReN Study

Beasley¹

2004

The Annals of Family Medicine

136

114

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PURPOSEThe number of problems managed concurrently by family physicians during patient encounters has not been fully explored despite the implications for quality assessment, guideline implementation, education, research, administration, and funding. Our study objective was to determine the number of problems physicians report managing at each visit and compare that with the number refl ected in the chart and the bill.METHODS Twenty-nine members of the Wisconsin Research Network reported on encounters with 572 patients using a physician problem log. The patient chart notes and the diagnoses submitted for billing from the encounters were compared with the information in these logs. RESULTSThe physicians reported managing an average of 3.05 problems per encounter and recorded 2.82 in the chart and 1.97 on the bill. For all patients, 37% of encounters addressed more than 3 problems, and 18% addressed more than 4. For patients older than 65 years, there was an average of 3.88 problems at each visit, and for diabetic patients there was an average of 4.60. There was evidence for the selective omission of mental health and substance problems from the diagnoses used for billing.CONCLUSIONS Family medicine involves the concurrent care of multiple problems, which billing data do not adequately refl ect. Our fi ndings suggest a mismatch between family medicine and current approaches to quality assessment, guideline implementation, education, research, administration, and funding. Activities in all these areas need to address the physician's task of prioritizing and integrating care for multiple problems concurrently. INTRODUCTIONT o measure quality realistically, develop and implement guidelines, educate physicians, design research, and administer and pay for services, it is important to understand the number of problems addressed concurrently during primary care encounters. It is also important to assess whether the commonly used data sources, such as chart review and billing data, adequately refl ect this aspect of the complexity of care.Based on previous work, including that of Flocke et al 1 and Zyzanski et al, 2 we hypothesized that family physicians manage multiple problems during routine outpatient visits. We further hypothesized that there are considerable differences from what actually occurs during primary care encounters (as measured by physician report), what is recorded in the chart, and what is listed on the bill.We therefore set out to describe the numbers of problems family physicians report managing during outpatient encounters and compare this number with the number generated from the more standard assessment of the content of the visit; that is, reviewing charts and billing data. This method is somewhat different from that used in direct observation studies, 406PROBLEMS PER ENCOUNTER as our study attempted to "get inside the physician' s head" to ascertain the problem content of the visit, regardless of whether it was observed or recorded. For example, a physician might see a depressed patient...

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“…Overall, the studies included for evaluation were highly heterogeneous making the data difficult to interpret . Most previous studies of the Hawthorne effect on health care visits compare different modes of measuring the content of visits but do not specifically examine the effect of observation . The few relevant empirical studies are limited by small samples of patients or physicians, comparison only of an observation period vs a nonobservation period and the examination of a single characteristic or the use of a single measure of observer effect …”

Section: Introductionmentioning

confidence: 99%

“…19 Most previous studies of the Hawthorne effect on health care visits compare different modes of measuring the content of visits but do not specifically examine the effect of observation. 2,[20][21][22][23][24][25][26][27][28][29][30][31][32][33] The few relevant empirical studies are limited by small samples of patients or physicians, 17,18 comparison only of an observation period vs a nonobservation period 7,33 and the examination of a single characteristic or the use of a single measure of observer effect. 33,34 Therefore, we took advantage of the unique opportunity to evaluate the Hawthorne effect in a large, multimethod direct observation study of outpatient service delivery.…”

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confidence: 99%

The Hawthorne effect in direct observation research with physicians and patients

Goodwin

Stange

Zyzanski

et al. 2017

Evaluation Clinical Practice

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Rationale, Aims, and Objectives This study examines the degree to which a “Hawthorne effect” alters outpatient-visit content. Methods Trained research nurses directly observed 4454 visits to 138 family physicians. Multiple data sources were used to examine the Hawthorne effect including: differences in medical record documentation for observed visits and the prior visit by the same patient, time use during visits on the first versus the second observation day of each physician, and report by the patient, physician, and observer of the effect of observation. Results Visits on the first versus the second observation day were longer by an average of 1 minute (p<.001); there were time-use differences for 4 of 20 behavior categories evaluated. No effect of the observer on the interaction was reported by 74% of patients and 55% of physicians. The majority of those that reported an affect indicated it was slight. Patients with non-white race, lower educational level and poorer health were more likely to report being affected by the observer. Conclusions In a study that was designed to minimize the Hawthorne effect, the presence of an observer had little effect on most patient-physician visits, but appeared to at least slightly effect a subgroup of vulnerable patients.

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Presence of observers at patient-practitioner interactions: impact on coordination of care and methodologic implications.

Cited by 11 publications

References 10 publications

What do patients bring up in consultations? An observational study in general practice

What do patients bring up in consultations? An observational study in general practice

How Many Problems Do Family Physicians Manage at Each Encounter? A WReN Study

The Hawthorne effect in direct observation research with physicians and patients

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