Douglas R. Smucker, MD, MPH

In primary care practice, patients in the top 3% for attendance generate 15% of total office visits.¹ “Frequent attenders” are more likely to be older, divorced or widowed, in lower socioeconomic groups, and to have multiple physical and psychosocial ills, and vague physical symptoms with no obvious etiology.^2-7 At one extreme, frequent attenders are “heartsink patients” as described by O’Dowd⁸—individuals whose demands, behaviors, and dissatisfaction with care give the “doctor and staff a feeling of ‘heartsink’ every time they consult.” The memorable and sometimes overwhelming nature of encounters with such patients may lead to the conclusion that difficult encounters are the rule among frequent attenders.

Although the demographics and disease patterns among frequent attenders have been described, the detailed characteristics of their encounters with physicians have not been elucidated.

Multiple factors may influence the content of physician-patient encounters, including the character and severity of a patient’s symptoms, the level of patient concern, the patient’s interpersonal style, the interviewing style of the physician, the complexity of the patient’s medical and psychosocial difficulties, and the level of comfort and trust between patient and physician.^9,10 A better understanding of frequent attender visits could help guide more efficient management of patients’ problems and improve satisfaction for both the patient and the physician. The purpose of our paper is to describe the characteristics of encounters between family physicians and adult frequent-attender patients.

Methods

We drew the data used for this analysis from The Prevention and Competing Demands in Primary Care Study. This multimethod comparative case study of 18 community-based family practices involved extensive direct observation of clinical encounters and office systems by field researchers who spent 4 weeks or more in each practice. The primary data for this analysis were collected by field researchers who were trained to take chronological notes while observing outpatient encounters and later dictate them to create detailed descriptions of each encounter. Details of the sampling and data collection can be found elsewhere in this issue.¹¹

Field researchers directly observed and dictated descriptions of approximately 30 patient encounters with each of the more than 50 clinicians, and they audited the medical records of each of these patients. Visits with 1194 adults 21 years and older were observed. Non-pregnant patients were sorted by their number of visits in the previous 2 years as determined by medical record review. Those in the top 5% for visit frequency were selected for analysis.

Three family physician researchers with experience in qualitative methodology used an immersion/crystallization style to explore and characterize the physician-patient encounters.^12,13 In this interpretive style each researcher read the field notes independently and recorded his or her summary comments and possible themes. Over several sessions, the 3 reviewers met to compare observations, review each patient encounter in detail together, resolve disagreements regarding the characteristics of each physician-patient encounter, and identify major themes from the data. These themes gradually developed into a 3-dimensional framework for examining all encounters. This framework was refined through additional review of field notes and discussions with study collaborators familiar with the data. The field notes were further reviewed to identify individual encounters that illustrated the range of encounter types represented by the descriptive framework.

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.”

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.

We reported the number of visits in each category to provide a general impression of the variation of visit types among frequent attenders and how it differed from the non-frequent attender group. Given the qualitative study design and data collection methods, the distribution of visit types may not accurately represent all frequent attender visits to the physician practices in this study and may not be generalizable to other clinical settings.

For some patients frequent attendance is appropriate, and a one-size-fits-all approach to reducing frequent attendance is unlikely to be effective. In his qualitative study of the management styles of 2 experienced family physicians, Miller20 described a visit typology that included routine, drama, and ceremony visits. He observed that visits with frequent attenders were often “maintenance ceremonies” with a prescribed repetitive format guided by a skilled physician. The “ritual” or “tango” visit types described in our study were the most obvious instances of “maintenance ceremonies” that were based on a high level of familiarity between patient and physician. The ceremonies in such visits may not be based on published medical guidelines or outcomes studies but are likely, in some instances, to represent an effective and appropriate therapeutic response by a physician who has developed an intimate understanding of the complex medical and psychosocial needs of a patient. In other cases such a visit pattern may be an inappropriate pattern of care that allows the familiar routines to take the place of consideration of different diagnostic or therapeutic directions.

Conclusions

Our study provides a foundation for further understanding the variation in family practice patient encounters and holds implications for a number of other issues that require further study. Any evaluation of the appropriateness of outpatient utilization patterns should recognize the wide range of encounter types that may not be apparent from studies of administrative databases. Interventions designed to reduce “inappropriate” utilization also should consider such factors. Our study also provides a basis for teaching students and physicians how to understand and manage the complexities and variation of outpatient primary care encounters. By categorizing and reflecting on the pattern of visit types over time for particular patients, physicians may gain insight into how best to care for “difficult” frequent attenders.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776), a grant from the Health Resources and Services Administration (5D32HP10231), and a Family Practice Research Center grant from the American Academy of Family Physicians. We are grateful to the physicians, staff, and patients from the 18 practices, without whose participation this study would not have been possible. The authors also wish to thank Kurt C. Stange, MD, PhD, who provided helpful comments on earlier drafts of this paper.

In primary care practice, patients in the top 3% for attendance generate 15% of total office visits.¹ “Frequent attenders” are more likely to be older, divorced or widowed, in lower socioeconomic groups, and to have multiple physical and psychosocial ills, and vague physical symptoms with no obvious etiology.^2-7 At one extreme, frequent attenders are “heartsink patients” as described by O’Dowd⁸—individuals whose demands, behaviors, and dissatisfaction with care give the “doctor and staff a feeling of ‘heartsink’ every time they consult.” The memorable and sometimes overwhelming nature of encounters with such patients may lead to the conclusion that difficult encounters are the rule among frequent attenders.

Although the demographics and disease patterns among frequent attenders have been described, the detailed characteristics of their encounters with physicians have not been elucidated.

Multiple factors may influence the content of physician-patient encounters, including the character and severity of a patient’s symptoms, the level of patient concern, the patient’s interpersonal style, the interviewing style of the physician, the complexity of the patient’s medical and psychosocial difficulties, and the level of comfort and trust between patient and physician.^9,10 A better understanding of frequent attender visits could help guide more efficient management of patients’ problems and improve satisfaction for both the patient and the physician. The purpose of our paper is to describe the characteristics of encounters between family physicians and adult frequent-attender patients.

Methods

We drew the data used for this analysis from The Prevention and Competing Demands in Primary Care Study. This multimethod comparative case study of 18 community-based family practices involved extensive direct observation of clinical encounters and office systems by field researchers who spent 4 weeks or more in each practice. The primary data for this analysis were collected by field researchers who were trained to take chronological notes while observing outpatient encounters and later dictate them to create detailed descriptions of each encounter. Details of the sampling and data collection can be found elsewhere in this issue.¹¹

Field researchers directly observed and dictated descriptions of approximately 30 patient encounters with each of the more than 50 clinicians, and they audited the medical records of each of these patients. Visits with 1194 adults 21 years and older were observed. Non-pregnant patients were sorted by their number of visits in the previous 2 years as determined by medical record review. Those in the top 5% for visit frequency were selected for analysis.

Three family physician researchers with experience in qualitative methodology used an immersion/crystallization style to explore and characterize the physician-patient encounters.^12,13 In this interpretive style each researcher read the field notes independently and recorded his or her summary comments and possible themes. Over several sessions, the 3 reviewers met to compare observations, review each patient encounter in detail together, resolve disagreements regarding the characteristics of each physician-patient encounter, and identify major themes from the data. These themes gradually developed into a 3-dimensional framework for examining all encounters. This framework was refined through additional review of field notes and discussions with study collaborators familiar with the data. The field notes were further reviewed to identify individual encounters that illustrated the range of encounter types represented by the descriptive framework.

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.”

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.

We reported the number of visits in each category to provide a general impression of the variation of visit types among frequent attenders and how it differed from the non-frequent attender group. Given the qualitative study design and data collection methods, the distribution of visit types may not accurately represent all frequent attender visits to the physician practices in this study and may not be generalizable to other clinical settings.

For some patients frequent attendance is appropriate, and a one-size-fits-all approach to reducing frequent attendance is unlikely to be effective. In his qualitative study of the management styles of 2 experienced family physicians, Miller20 described a visit typology that included routine, drama, and ceremony visits. He observed that visits with frequent attenders were often “maintenance ceremonies” with a prescribed repetitive format guided by a skilled physician. The “ritual” or “tango” visit types described in our study were the most obvious instances of “maintenance ceremonies” that were based on a high level of familiarity between patient and physician. The ceremonies in such visits may not be based on published medical guidelines or outcomes studies but are likely, in some instances, to represent an effective and appropriate therapeutic response by a physician who has developed an intimate understanding of the complex medical and psychosocial needs of a patient. In other cases such a visit pattern may be an inappropriate pattern of care that allows the familiar routines to take the place of consideration of different diagnostic or therapeutic directions.

Conclusions

Our study provides a foundation for further understanding the variation in family practice patient encounters and holds implications for a number of other issues that require further study. Any evaluation of the appropriateness of outpatient utilization patterns should recognize the wide range of encounter types that may not be apparent from studies of administrative databases. Interventions designed to reduce “inappropriate” utilization also should consider such factors. Our study also provides a basis for teaching students and physicians how to understand and manage the complexities and variation of outpatient primary care encounters. By categorizing and reflecting on the pattern of visit types over time for particular patients, physicians may gain insight into how best to care for “difficult” frequent attenders.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776), a grant from the Health Resources and Services Administration (5D32HP10231), and a Family Practice Research Center grant from the American Academy of Family Physicians. We are grateful to the physicians, staff, and patients from the 18 practices, without whose participation this study would not have been possible. The authors also wish to thank Kurt C. Stange, MD, PhD, who provided helpful comments on earlier drafts of this paper.

In primary care practice, patients in the top 3% for attendance generate 15% of total office visits.¹ “Frequent attenders” are more likely to be older, divorced or widowed, in lower socioeconomic groups, and to have multiple physical and psychosocial ills, and vague physical symptoms with no obvious etiology.^2-7 At one extreme, frequent attenders are “heartsink patients” as described by O’Dowd⁸—individuals whose demands, behaviors, and dissatisfaction with care give the “doctor and staff a feeling of ‘heartsink’ every time they consult.” The memorable and sometimes overwhelming nature of encounters with such patients may lead to the conclusion that difficult encounters are the rule among frequent attenders.

Although the demographics and disease patterns among frequent attenders have been described, the detailed characteristics of their encounters with physicians have not been elucidated.

Multiple factors may influence the content of physician-patient encounters, including the character and severity of a patient’s symptoms, the level of patient concern, the patient’s interpersonal style, the interviewing style of the physician, the complexity of the patient’s medical and psychosocial difficulties, and the level of comfort and trust between patient and physician.^9,10 A better understanding of frequent attender visits could help guide more efficient management of patients’ problems and improve satisfaction for both the patient and the physician. The purpose of our paper is to describe the characteristics of encounters between family physicians and adult frequent-attender patients.

Methods

We drew the data used for this analysis from The Prevention and Competing Demands in Primary Care Study. This multimethod comparative case study of 18 community-based family practices involved extensive direct observation of clinical encounters and office systems by field researchers who spent 4 weeks or more in each practice. The primary data for this analysis were collected by field researchers who were trained to take chronological notes while observing outpatient encounters and later dictate them to create detailed descriptions of each encounter. Details of the sampling and data collection can be found elsewhere in this issue.¹¹

Field researchers directly observed and dictated descriptions of approximately 30 patient encounters with each of the more than 50 clinicians, and they audited the medical records of each of these patients. Visits with 1194 adults 21 years and older were observed. Non-pregnant patients were sorted by their number of visits in the previous 2 years as determined by medical record review. Those in the top 5% for visit frequency were selected for analysis.

Three family physician researchers with experience in qualitative methodology used an immersion/crystallization style to explore and characterize the physician-patient encounters.^12,13 In this interpretive style each researcher read the field notes independently and recorded his or her summary comments and possible themes. Over several sessions, the 3 reviewers met to compare observations, review each patient encounter in detail together, resolve disagreements regarding the characteristics of each physician-patient encounter, and identify major themes from the data. These themes gradually developed into a 3-dimensional framework for examining all encounters. This framework was refined through additional review of field notes and discussions with study collaborators familiar with the data. The field notes were further reviewed to identify individual encounters that illustrated the range of encounter types represented by the descriptive framework.

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.”

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.

We reported the number of visits in each category to provide a general impression of the variation of visit types among frequent attenders and how it differed from the non-frequent attender group. Given the qualitative study design and data collection methods, the distribution of visit types may not accurately represent all frequent attender visits to the physician practices in this study and may not be generalizable to other clinical settings.

For some patients frequent attendance is appropriate, and a one-size-fits-all approach to reducing frequent attendance is unlikely to be effective. In his qualitative study of the management styles of 2 experienced family physicians, Miller20 described a visit typology that included routine, drama, and ceremony visits. He observed that visits with frequent attenders were often “maintenance ceremonies” with a prescribed repetitive format guided by a skilled physician. The “ritual” or “tango” visit types described in our study were the most obvious instances of “maintenance ceremonies” that were based on a high level of familiarity between patient and physician. The ceremonies in such visits may not be based on published medical guidelines or outcomes studies but are likely, in some instances, to represent an effective and appropriate therapeutic response by a physician who has developed an intimate understanding of the complex medical and psychosocial needs of a patient. In other cases such a visit pattern may be an inappropriate pattern of care that allows the familiar routines to take the place of consideration of different diagnostic or therapeutic directions.

Conclusions

Our study provides a foundation for further understanding the variation in family practice patient encounters and holds implications for a number of other issues that require further study. Any evaluation of the appropriateness of outpatient utilization patterns should recognize the wide range of encounter types that may not be apparent from studies of administrative databases. Interventions designed to reduce “inappropriate” utilization also should consider such factors. Our study also provides a basis for teaching students and physicians how to understand and manage the complexities and variation of outpatient primary care encounters. By categorizing and reflecting on the pattern of visit types over time for particular patients, physicians may gain insight into how best to care for “difficult” frequent attenders.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776), a grant from the Health Resources and Services Administration (5D32HP10231), and a Family Practice Research Center grant from the American Academy of Family Physicians. We are grateful to the physicians, staff, and patients from the 18 practices, without whose participation this study would not have been possible. The authors also wish to thank Kurt C. Stange, MD, PhD, who provided helpful comments on earlier drafts of this paper.