We obtained physicians’ perceptions of how demanding the visit was by using a brief form with a single question and 5-point response scale (“Compared to your average patient visit, how demanding would you rate this visit in terms of the amount of effort required?” 1 = far more demanding than average; 5 = far less demanding).
Coding procedures. A research assistant reviewed all 139 audiotapes selected for this analysis. After identifying a patient request, she transcribed the request verbatim, assigned an appropriate request code and response code, and continued listening until the visit was over. A request-response exchange was coded as a “negotiation” when the physician’s initial demurral was met by a counter-request or demand from the patient. When a physician’s ultimate response to a patient request differed from the physician’s initial response, the lead coder recorded both an initial and final response code. Variables were created to reflect, at the patient level, the number of requests made, the number and proportion of requests not fulfilled, and the number of requests negotiated before ultimate fulfillment.
Assessment of reliability and validity. The first author reviewed all transcribed segments from the first 20 tapes and coded each segment independently. Interrater agreement was assessed using the k statistic.12 To determine whether reliability degraded with time, the lead author also coded transcribed segments from the last 20 tapes. Face validity was assessed through frequent discussion among the coinvestigators and by obtaining feedback from practicing physicians and patient focus groups. Content validity was assessed by monitoring the number of unclassifiable requests. Construct validity was evaluated quantitatively on the basis of tests of the following hypotheses: (1) patients with worse health status will make a greater number of requests; (2) greater request fulfillment will be associated with greater patient satisfaction; and (3) more requests will be associated with longer visit times and more demanding visits as perceived by physicians. The relevant associations were assessed using Pearson Product-Moment Correlation coefficients, t tests, chi-square tests, and analysis of variance, as appropriate, using Stata software, release 5.0 (Stata Corporation, College Station, Texas).13 Associations between patient requests and physicians’ perceptions of visit time, and those between patient requests and physicians’ perceptions of the visit’s demands were assessed using multiple linear regression, with Huber-White adjustment of standard errors to account for clustering of patients by physician.14 Power to identify bivariable correlations of moderate size (r >0.30) exceeded 0.90 for all inferential tests of significance. Two-tailed P values less than .05 were considered statistically significant. Explicit corrections for multiple statistical comparisons were not made.
Results
Interrater Agreement
On review of the first 20 cases, the lead coder identified and transcribed a total of 147 requests. Overall agreement between the lead and secondary coder was 94% (k = 0.93; P <.001), indicating excellent agreement beyond chance. Of the 9 coding disagreements, 2 were “major” (one coder classified a request as an “action request” and the other as an “information request”). There was no degradation of interrater reliability over time (agreement for the last 20 cases = 95%; k = 0.94; P <.001).
Prevalence of Patient Requests
Table 2 shows that the 139 patients made 772 requests (mean = 5.6; range = 0 to 32). Of these, 619 were requests for information (mean = 4.5 requests per patient) and 153 were requests for action (mean = 1.1). For any given patient, the number of information and action requests were only weakly correlated (r = 0.18; P = .04; data not shown in table). The most common information requests involved questions about medications or treatments (191 requests) and about symptoms, problems, or diseases (178 requests). The most prevalent action request was for medications or treatments Table 2. Among the 772 requests, only 33 (4.3%) were not classifiable into 1 of the 17 standing categories and had to be coded as “other requests for information” or “other requests for action.”
Patient Requests in Relation to Health Status
In assessing the construct validity of TORP, we hypothesized that patients with worse health perceptions, greater health worry, and more chronic diseases would make more requests of their physicians. As shown in Table 3, patients who rated their general health more positively made fewer total requests (r = -0.17; P = .048). The inverse relationship between health perceptions and requests was stronger for action requests (r = -0.25; P = .004) than for information requests (r = -0.11; P = .19). Greater health worry or concern was marginally associated with making more information requests. Having more chronic diseases was associated with more action requests (r = 0.32; P = .0002). Taken together, these results suggest that greater illness burden (as reflected by general health perceptions and number of chronic conditions) is associated with more health care resource needs, while greater health-related anxiety is associated with more informational needs.