BACKGROUND: The goal of our investigation was to facilitate research on clinical negotiation between patients and physicians by developing a reliable and valid classification system for patients’ requests in office practice.
METHODS: We developed the Taxonomy of Requests by Patients (TORP) using input from researchers, clinicians, and patient focus groups. To assess the system’s reliability and validity, we applied TORP to audiotaped encounters between 139 patients and 6 northern California internists. Reliability was assessed with the k statistic as a measure of interrater agreement. Face validity was assessed through expert and patient judgment of the coding system. Content validity was examined by monitoring the incidence of unclassifiable requests. Construct valdity was evaluated by examining the relationship between patient requests and patient health status; patient request fulfillment and patient satisfaction; and patient requests and physician perceptions of the visit.
RESULTS: The 139 patients made 772 requests (619 requests for information and 153 requests for physician action). Average interrater agreement across a sample of 40 cases was 94% (k = 0.93; P <.001). Patients with better health status made fewer requests (r = -0.17; P = .048). Having more chronic diseases was associated with more requests for physician action (r = 0.32; P = .0002). Patients with more unfulfilled requests had lower visit satisfaction (r = -0.32; P <.001). More patient requests was also associated with physician reports of longer visit times (P = .016) and increased visit demands (P = .006).
CONCLUSIONS: Our study provides evidence that TORP is a reliable and valid system for capturing and categorizing patients’ requests in adult primary care. Further research is needed to confirm the system’s validity, expand its applicability, and explore its usefulness as a tool for studying clinical negotiation.
Requests are the primary means of patient-initiated action in office practice. But these requests can be problematic because they consume time and resources. In particular, patients’ requests for diagnostic tests, medications, and referrals can be costly to capitated practices and may cause physician-patient discord if not handled appropriately. Patients who participate actively in their own care, however, often achieve better outcomes than those who do not.1 Managing the negotiation triggered by these requests is a fundamental clinical skill. Unfortunately, few empiric data are available to help physicians select effective negotiation strategies. One barrier to necessary research is the lack of a reliable, valid, and comprehensive system for describing and classifying patients’ requests.
Uhlmann and colleagues2 defined patient requests as “desires explicitly communicated [to the physician] through either verbal or written language.” In their formulation, desires are defined as wishes regarding medical care. Requests in turn are defined as desires that the patient communicates to the physician.
The definition of patient requests proposed by Uhlmann and coworkers is operationally explicit. However, few studies of patient requests have adhered to this definition. For Lazare and colleagues3 requests were “what patients wish or hope will occur”; for DelVecchio and coworkers4 they were ways patients indicate to the research assistant how the “clinic can help you at this time”; for Uhlmann and colleagues,5 “health problems you feel should be dealt with today”; for Like and Zyzanski,6 the “types of help [patients] would like to receive at that day’s visit”; for Eisenthal and coworkers,7 responses to the question, “How do you hope the doctor (or clinic) can be of help to you today?”; and for Valori and colleagues,8 requests were defined as previsit desires for “explanation and reassurance, for emotional support, and for investigation and treatment.”
A common feature of most of this literature is the blending of “requests” (what patients ask for) with “desires” (what patients want) and “expectancies” (what patients think their physicians will do). Previsit patient surveys can only elicit desires and expectancies, while requests are more readily assessed by postvisit patient or physician reports or by direct observation. The operational distinction between desires and requests is important if we are to focus on how patients influence the content of their visits by asking questions or making statements that affect physician behavior. Some desires (eg, diagnostic imaging) may be more frequently converted into explicit requests than other desires (eg, therapeutic listening).
As a method for studying patients’ requests, direct observation using audiorecording or videorecording has several advantages over other approaches, such as patient or physician reports. First, patients’ requests and physicians’ responses can be captured precisely by recording them. Second, tapes (or transcripts) can be preserved and used for reliability checking and post-hoc analyses. Third, behavioral observation is the only method that can capture the interactional dynamics of clinical negotiations. Although these advantages are countered by a potential Hawthorne effect, this bias is manageable.9 Existing systems for the analysis of interactions were not specifically designed to describe the content of clinical negotiation. Therefore, we developed a new system called Taxonomy of Requests by Patients (TORP) for classifying patient requests and physician responses in office practice. The main features of TORP are that it relies on direct observation, focuses on request content, can be applied in real time, and is designed for use in general medical settings.