How well do physician and patient visit priorities align?

Possible study weaknesses. A potential weakness of this study is that alignment was rated by the physicians who elicited and recorded their patients’ reasons for the visit. It is possible that the central role of the physician as observer and analyst may have introduced bias and that an outside observer may have come to different conclusions about the extent to which priorities were aligned. However, by placing the physician-researcher at the center of both data collection and analysis, our study method reflects the realistic constraints of limited information on the processes of clinical discovery and sense-making that physicians regularly undertake with their patients, which we believe to be a strength of this study. While the inclusion of pediatric visits in the sample is another possible weakness, we believe that the diverse clinical settings and diverse patient populations potentially strengthen the findings. Replication with different samples of clinicians and patients is needed to assess the robustness of the findings.

Physicians tend to evaluate risk factors for future disease, while patients focus on symptomatically troublesome—though self-limiting— conditions.Root differences in physician and patient perspectives. Collectively, these findings suggest that patients’ and physicians’ differing approaches to prioritization may limit alignment. In general, physicians tend to evaluate the full scope of the patient’s health and risk factors for future disease, while patients more often focus on symptomatically troublesome—though often self-limiting— conditions. Physicians have the knowledge and clinical experience to prioritize or deprioritize patient concerns based on an assessment of long-term risks of morbidity and mortality, yet the future-orientation of treatments and surveillance for insensible conditions (like hypertension) is less likely to align with the immediately painful or worrisome symptoms of patients. This highlights the importance of patient education on chronic disease management and disease prevention, and cooperative agenda-setting. Further work needs to be done to examine the differences in patients’ and physicians’ cognitive processes of prioritization, with the ultimate goal of providing patient-centered care through shared decision-making.

Patients who are less likely to share the physician’s prioritization of their concerns may require more time and effort on the part of the physician to create a mutually acceptable agenda for the visit.Take-home messages for all stakeholders. Amidst growing time pressures and guideline-driven protocols for care, it is important to attend to the intersecting and diverging patient, physician, and payer agendas that drive the content of the visit. Patients who are less likely to share the physician’s prioritization of their concerns—including individuals with no insurance or public insurance and those with multiple medical problems—may require more time and additional effort on the part of the physician to create a mutually acceptable agenda for the visit. Attempts at pay-for-performance should consider patients’ priorities and preferences for care, particularly when those preferences differ from the priorities of physicians or health insurance plans. A more thorough understanding of patient and physician prioritization during primary care visits could potentially guide the organization of outpatient care and inform the mindful physician’s patient-centered practice to maximize patient benefit.

CORRESPONDENCE
Susan A. Flocke, PhD, Family Medicine Research Division, Case Western Reserve University, 11000 Cedar Avenue, Suite 402, Cleveland, OH 44106; susan.flocke@case.edu

ACKNOWLEDGEMENTS
This study was completed as part of the culture of inquiry fellowship, supported by Academic Administrative Units in primary care Grant #D54HP05444 from the Health Resources and Services Administration, US Department of Health and Human Services. Dr. Stange’s time is supported in part by a clinical research professorship from the American Cancer Society.