A Framework for Understanding Visits by Frequent Attenders in Family Practice

Although the initial purpose of the study did not include comparison of frequent attenders with other patients, it was unclear whether the descriptive framework that had emerged from the analysis was unique to frequent attenders or if it could be applied to patients who visit much less often. Thus, we reviewed additional encounters by non-frequent attenders to explore the applicability and relevance of the framework to other patients. Visits by patients with only 2 to 6 visits in the previous 2 years (non-frequent attenders) were matched by age and sex to the frequent attender sample (n=62). Each of the 3 reviewers independently read and characterized each non-frequent attender visit using the descriptive framework, then met to compare findings and determine major themes when comparing visits by frequent and non-frequent attenders.

Results

Frequent Attender Visits

Adult patients in the top 5% for visit frequency (n=62) had 25 or more visits over the previous 2 years Figure 1. The average number of encounters for frequent attenders over the previous 2 years was 32 (range= 25-52). The average age of these patients (65 years) was greater than that for all other adult patients (51 years), while the proportion of women was similar for frequent attenders and all other adult patients (68% and 66%, respectively).

Encounters with frequent attenders reflected a wide range of biomedical and psychosocial complexity and a variety of physician and patient communication patterns. We identified 3 major dimensions that distinguished differences in the content and characteristics of the encounters:

1. Biomedical complexity varied considerably in terms of the number and complexity of acute or chronic illnesses. During some visits only a single straightforward biomedical issue was addressed (biomedical=low), while other visits included review of more complex or more numerous acute or chronic conditions (biomedical=high).
2. Psychosocial complexity was evidenced by a patient’s need for reassurance or counseling from the clinician regarding family or relationship issues, discussions regarding lifestyle issues, a perceived need for general social support, an expression of nonspecific somatic symptoms, or presentation of symptoms of depression or anxiety. Some visits reflected minimal psychosocial issues (psychosocial=low), while others encompassed a wide range of expressed emotions, concerns, or symptoms related to psychosocial issues (psychosocial=high).
3. Dissonance between the patient and physician included a lack of mutual understanding and agreement between the patient and clinician, or frustration and/or confusion regarding diagnostic conclusions, goals and direction of treatment, and follow-up plans. Many visits included friendly chatting between the physician and the patient with evidence for a warm familiar understanding between patients, physicians, nurses, and office staff, and usually ended with an organized, mutually agreeable plan of action (dissonance=low). However, in some encounters patient concerns or symptoms were either only partially addressed by the physician or there seemed to be disagreement, confusion, frustration, or conflict about the diagnosis or therapeutic plan (dissonance=high).

A three-dimensional framework emerged from these themes to characterize the range of encounter types with frequent attenders Figure 2. Each encounter could be rated along a continuum from low to high on each axis, resulting in a wide range of visit types. The following description of frequent attender visits illustrates the 8 combinations of the lowest and highest dimension ratings within this framework:

1. Simple medical (biomedical=low, psychosocial=low, dissonance=low; n=12): An 83-year-old man came to the office with an acute foot injury. The physician completed a focused history and physical examination. A radiograph was negative for fracture. The patient expressed no other symptoms and had no questions about the prescribed treatment.
2. Ritual visit (biomedical=low, psychosocial=high, dissonance=low; n=9): A 54-year-old woman with chronic low back pain was seen first by a nurse practitioner who chatted with the patient about a number of relationship and lifestyle issues while giving her multiple lidocaine trigger point injections in the low back and buttocks, a procedure that had occurred during previous visits. When asked by the nurse practitioner whether she needed any other trigger points injected, the patient answered “no” and got dressed. The physician entered the room 15 minutes later and asked, “Should I do another spot for you?” During a number of additional trigger point injections by the physician, the patient discussed additional family and relationship issues with the physician.
3. Complicated medical (biomedical=high, psychosocial=low, dissonance=low; n=15): A 68-year-old man presented for follow-up of diabetes mellitus type 2, recent myocardial infarction, smoking cessation efforts, and an injured hand from a recent fall. After history taking and physical examination were completed, a plan for each problem was stated and readily agreed to by the patient. The encounter was efficient and friendly, including a few inside jokes between the physician and the patient. There was no mention of psychosocial issues or related symptoms.
4. The tango (biomedical=high, psychosocial=high, dissonance=low; n=11): A 49-year-old woman with multiple minor biomedical problems completed “the most unusual visit” that the nurse researcher had ever observed. The encounter began when the patient “just barged in” to the physician’s administrative office and asked to watch a TV game show. After watching the show together for a few minutes they moved to the examination room where the patient proceeded to “tell the doctor what to do” for her multiple complaints. The physician appeared to take all this in stride and facilitated a series of friendly negotiations for a list of medical issues including sore throat, arthritis pain, and chronic respiratory symptoms. There seemed to be a mutually acceptable resolution and a plan for each issue that emerged from this complicated “dance”.
5. Simple frustration (biomedical=low, psychosocial=low, dissonance=high; n=1): Only one visit in the sample had elements of this visit type but was not a clear exemplar, since the dissonance expressed by the patient was not directly related to the physician encounter itself. A 71-year old woman with severe back pain was unhappy about “waiting for a week to get something done” for her pain, and both she and her husband expressed significant frustration about difficulties with scheduling an epidural injection at the hospital. The physician assisted with rescheduling the procedure for the following day, but some confusion remained at the end of the visit as to where the patient was to meet with the anesthesiologist. After the visit the patient’s husband commented to the field researcher that “we live next door to (this physician), so we have to give him a hard time.”
6. Psychosocial disconnect (biomedical=low, psychosocial=high, dissonance=high; n=7): A 33-year-old man came to the office for a chronic leg ulcer caused by an underlying metabolic disorder. After he briefly checked the ulcer and applied a new dressing, the physician expressed dismay and frustration about the patient’s ongoing reluctance to quit smoking. He lectured the patient about the harm caused by smoking, particularly given his underlying condition. They discussed options for smoking cessation and other lifestyle issues. The physician then encouraged the patient to follow through with his previous suggestion to screen his infant son for metabolic disorders. The patient was reluctant, since the child’s pediatrician “didn’t seem too concerned.” The physician replied that “the pediatrician should be concerned” and to “consider taking him to another physician.” During their discussion of lifestyle and family concerns, there was no indication that the patient agreed with the physician’s advice or planned to take action.
7. Medical disharmony (biomedical=high, psychosocial=low, dissonance=high; n=4): A 52-year-old woman presented with left-sided chest and shoulder pain. There was confusion regarding which medications she was currently taking for hypertension, sleep disorder, headache, and gastrointestinal symptoms. During the physical examination, active range of motion of both shoulders elicited no increase in pain. The only stated plan by the physician was that a “short burst of steroid” was best because “it’s an inflammatory thing, I think.” After the physician left the room the patient repeated her concern to the observer that she had “a lot of pain in my shoulder.” There were no expressed psychosocial needs and little evidence for significant interpersonal connection between the physician and the patient during the visit.
8. The heartsink visit (biomedical=high, psychosocial=high, dissonance=high; n=3): A 57-year-old woman came to the office with multiple minor medical problems and chronic depression. With English as her second language, a communication barrier complicated the encounter. During the visit diagnoses of urinary tract infection, arthritis, and gastritis were discussed, an abdominal radiograph obtained, and new medications prescribed. The patient cried as she described a number of sick family members who lived in Mexico and implied that she was unable to visit them because the physician would not adequately treat her pain. She threatened to “go on the street and get any drug I want for pain.” Although there was evidence that the physician had been compassionate and persistent in his attempts to assist her, there seemed to be little agreement with the patient on the direction for further diagnosis or therapy. Seemingly frustrated by the encounter, the physician concluded the visit by saying “Well, we will see you back here in a month and you’ll be feeling better, right?” The patient “kind of looked at him” and said, “Okay, bye, Doctor.”