A Framework for Understanding Visits by Frequent Attenders in Family Practice

Non-Frequent Attender Visits

The researchers were able to easily categorize non-frequent attender visits using the descriptive framework Figure 2. A majority of non-frequent attender visits (87%) were classified along the “biomedical” continuum from type 1 (simple medical; n=34) to type 3 (complex medical; n=20) visits. Psychosocial complexity and dissonance were less prominent and were addressed less often than with frequent attenders, and only one visit approached the heartsink corner of the framework. Non-frequent attender visits encompassed fewer exchanges of humor and small talk than observed in the frequent attender encounters and generally showed less evidence of familiarity between patient and physician. The visits were less dramatic in the range of characteristics defined by the descriptive framework and were less memorable than those of the frequent attenders.

Discussion

Our study is the first to provide a detailed description of the characteristics of encounters between family physicians and adult frequent attenders. We found wide variation in the content of these encounters. A framework emerged that describes the degree of biomedical complexity, psychosocial complexity, and dissonance between the patient and the physician for each encounter. Although previous epidemiologic studies and case series suggest that frequent attenders may generate many difficult heartsink visits, the encounters we studied were scattered across the entire 3-dimensional framework from very simple single issue visits to highly complex emotionally taxing visits.^2-7,14 The dimensions of the descriptive framework were applicable to non-frequent attender visits, but the range of psychosocial complexity and dissonance was greater among visits by frequent attenders.

Many frequent attenders seemed to have developed an intricate and harmonious relationship with the physician and the office staff and nurses in the practice. Visits by frequent attenders often included friendly chatting and humor among patients, staff, and physicians. These findings are consistent with the Direct Observation of Primary Care (DOPC) study, where chatting was a part of 69% of all visits to family physicians and accounted for almost 8% of overall visit time.¹⁵ Older patients who had longer visits and spent more time chatting with their physicians in the DOPC study reported greater satisfaction with care.¹⁶ We hypothesize that patients who find a “medical home” where they can talk comfortably with physicians and staff and gain a level of general social support are likely to return often. If such familiarity is interrupted by seeing a physician other than the patient’s continuity provider, as happened in the “medical disharmony” visit we described, confusion about treatment or other visit-specific dissonance may result between the treating physician and the patient.

The content of an encounter is influenced by physicians’ interviewing skills and techniques and whether patients voice all of their concerns, symptoms, and health questions during the visit.^10,17,18 Many factors determine whether psychosocial concerns are elicited and addressed during a visit as described in another article in this issue.¹⁹ Over multiple visits, patients and physicians are likely to reach an equilibrium of expectations regarding patterns of communication and to develop mutually acceptable parameters for the relationship. Frequent attenders have many opportunities to learn a physician’s style and approach to medical and psychosocial problems. Some encounters in our study suggested that a ritual pattern of discussion or visit procedures had developed over time within a trust-filled continuity relationship.

Patients who develop a strong continuity relationship may be less likely to present a question or a request that they know will not be agreed to by the physician. This may explain why the “simple frustration” visit type was not well represented in the frequent attender sample. When patients disagree with physicians on straightforward treatment issues, such as antibiotic prescription for an uncomplicated upper respiratory infection, they usually will either come to some understanding and acceptance of the physician’s views or eventually seek care from another physician.

Limitations

Our descriptive study has a number of limitations. Field notes from the nurse observers described the interaction between the physician and patient and included subjective interpretations of each encounter that may not have accurately reflected the tone of the physician-patient interaction. The observers did not actively seek information about patients’ unvoiced concerns, thus our conclusions regarding the degree of dissonance in the encounter were implied only from written observations. Other than occasional field notes recorded from physicians’ comments after the patient left the office, the observers also did not measure the physician’s emotional response to encounters. These limitations may have led us to misclassify a given encounter on one or more of the 3 dimensions. Also, we cannot conclude from these data whether the sampled visit for each patient represented a typical visit for that patient, and we cannot judge the appropriateness of the care provided.