Our goal was to produce a classification system for patients’ requests that would be useful in understanding the links between patients’ unarticulated desires and expectations, patients’ articulated requests, physicians’ provision of health care services, and patients’ and physicians’ perceptions of the visit and of each other. We hypothesized that the characteristics, needs, and attitudes of patients and physicians would influence clinical negotiation Figure 1. Clinical negotiation, in turn, was posited to affect patient well-being and physician perceptions of the visit. In this schema, the negotiation is central. Patients are more than the passive recipients of doctors’ actions; they influence the clinical encounter through use of their own linguistic resources.
Methods
Development of the Taxonomy
On the basis of clinical experience and preliminary discussions, our research group defined patient requests as:
… an expression of hope or desire that the physician provide information or perform action. Requests may be expressed as questions, commands, statements, or conjecture. Most questions are requests, except rhetorical questions (“Who do you think I am?”), exclamations (“You’re kidding, aren’t you?”), questions related to the mechanics of the physical examination (“Where should I sit?”), and chatting on topics unrelated to health or medicine (“It’s sure been hot, hasn’t it?”)
Following this definition, our group generated an initial set of categories that included requests for examinations, tests, prescriptions, referrals, social or psychological help, and information. These categories were then reviewed in general terms by colleagues and by 2 patient focus groups. The focus groups consisted of adult patients who were receiving care from one academic general medicine clinic and one group model health maintenance organization. The sessions were 90 minutes long, and the patients were asked to describe what they wanted from their physicians, relate any recent experiences with physicians that fell short of expectations, and comment on the sorts of things they might ask of their physician. Using this input, the original set of categories was revised and applied to a set of audiotapes obtained from a convenience sample of 20 adult general medicine outpatients visiting a small single-specialty group practice. Following review of these tapes, additional categories were added, and others were amended or deleted. There seemed to be a natural division between requests for information and requests for action.
The final taxonomy (TORP) is shown in Table 1. There are 11 categories of patient requests for information and 8 categories of patient requests for action. In addition, physician responses to patient requests are coded as 1 of 8 mutually exclusive categories that are modified from Roter and colleagues:10 (1) ignores; (2) acknowledges only; (3) fulfills (performs action or provides requested information); (4) partially fulfills; (5) negotiates, with fulfillment; (6) negotiates, with partial fulfillment; (7) negotiates, with denial; or (8) denies.
Evaluation of the Taxonomy
Data collection. To assess the reliability and validity of TORP in office practice, we applied it to 139 physician-patient encounters selected at random from 318 studied as part of a larger project on patients’ expectations for care. Details of that study are described elsewhere.11 To summarize, data were collected in 1994 from a community-based university-affiliated 6-physician general internal medicine practice in northern California. Patients were eligible for enrollment if they were at least 18 years of age, could speak and understand English, had a telephone, and had scheduled an office visit at least 1 day in advance.
Using patient appointment lists obtained the day before the scheduled visit, we contacted 503 eligible individuals; 396 (79%) agreed to participate. Seventy-eight patients failed to attend their appointment, arrived late, withdrew consent, or could not be successfully audiotaped, leaving complete data for 318 patients. Of those, we randomly selected 139 patients for inclusion in our study. The mean age of patients in this sample was 52 years (standard deviation [SD] = 16); 49% were men; 72% were white. Thirty-five percent had a college degree, and the median family income range was $40,000 to $49,000. There were no meaningful differences in age, sex, race, education, or income between the 139 randomly selected individuals and the 179 remaining patients.
Just before the visit, all patients were asked about demographic characteristics and health status. All encounters were audiotaped using unobtrusive equipment. After the visit, patients completed postvisit questionnaires that included questions about visit satisfaction, and physicians reported on the type of visit, medical diagnoses, interventions requested (by the patients), interventions performed, and the extent to which they perceived the visit to be demanding.
Measures. Patient were asked about demographic characteristics (age, sex, education, income, and employment status) with straightforward questions. We evaluated health status in terms of the patients’ health perceptions (“In general, would you say your health is: excellent, very good, good, fair, poor?”); health worry (“How worried are you about your health?” and “How concerned are you that you might have a serious disease or condition today: extremely…not at all?” [a reliability for the 2-item scale = 0.79]); and a chronic disease count derived from a 12-item checklist completed by the treating physician. Patient satisfaction with the visit was assessed using the Ware and Hays12 5-item visit-specific scale (a = 0.90).