Family physicians everywhere can relate to that sinking feeling when, just as a medical visit has seemingly concluded and the physician turns to exit, the patient says, "Doc, there's just one more thing …"
It's widely recognized among primary care physicians as the "hand on the doorknob phenomenon," said Richard Grant, M.D., M.P.H., lead author of a study related to the topic that was published in the March/April issue of Annals of Family Medicine.
Grant told AAFP News that the study, "Visit Planning Using a Waiting Room Health IT Tool: The Aligning Patients and Providers Randomized Controlled Trial,"(www.annfammed.org) comes at a critical juncture in the world of medicine.
"In many ways, primary care is in a state of crisis," said Grant. "The aging of the population, combined with the increasing number of evidence-based preventive and chronic disease guidelines that physicians need to follow, means that there is more to do during a primary care visit than ever before.
"And visits are not getting longer. They may even be getting shorter, and the heavy workload is contributing to physician burnout," he added.
- Researchers used a waiting room Visit Planner tool to help patients identify and voice their top priorities before seeing the physician.
- Researchers hypothesized that setting priorities would enhance patient/physician interactions in the exam room and close care gaps.
- Use of the Visit Planner tool did improve communication during time-limited visits, but the ultimate goal will be improving clinical outcomes.
Grant is an internal medicine physician but spends the majority of his time as a research scientist at Kaiser Permanente Northern California. He reserves one day a week for patient care.
"One of the joys of being a physician researcher is that I can take my own clinical experiences as inspiration for the research that I do," he said.
For this study, researchers designed a health IT tool dubbed the Visit Planner and made it available via tablets in clinic waiting rooms to select adult patients to help them identify the top priorities for their visit and then communicate that information to their physician in the exam room.
"We tested the hypothesis that patients who were supported in identifying and communicating their visit priorities would have more effective visit interactions, which in turn would lead to more effective primary care measured as fewer evidence-based clinical care gaps compared with control peers after six months," wrote the authors.
The research, funded by the Patient-Centered Outcomes Research Institute, was conducted as a randomized controlled trial in eight primary care practices -- all included in Kaiser Permanente Northern California's integrated care delivery system.
The study included 73 primary care physicians and 1,110 patients between the ages of 30 and 80 who either had two or more chronic conditions or were new to their primary care physicians. Patients had at least one clinical care gap related to health issues such as cancer screening, chronic condition monitoring or smoking.
Physicians and patients were evenly split between the intervention arm and the control arm. Patient visits occurred between March 31, 2016, and June 30, 2017, with followup assessments done six months after the final patient visit.
Patients in the intervention arm were given a tablet in the office waiting room on which the Visit Planner was loaded. When launched, the planner began with an introductory video about the tool and the importance of patients communicating their concerns to physicians early in the visit.
Users were prompted to choose their top one or two priorities from a list of six categories with space for free-form entries. Patients also were asked to express how they would stay involved with their care -- either during or after the visits -- via activities such as note taking, physician questions and visiting a patient portal.
The researchers set out to explore whether the Visit Planner would
- improve patient visit preparation and problem/concern prioritization;
- lead to improved efficiency and productivity during primary care visits, including changes to the management plan; and
- improve quality of care as measured by meeting evidence-based care guidelines.
Findings showed that patients who used the planner reported "significantly greater visit preparation and discussion of their priorities" when compared to patients in the control group.
"These results advance our current understanding of primary care visit interactions by proving that a fairly simple, patient-centered health IT tool can improve key components of effective patient-physician communication during time-limited visits," they wrote.
However, researchers also reported that the Visit Planner "did not have a significant impact on our primary clinical outcome of closing care gaps" because over time, both groups of patients sustained improvements in quality measures.
Authors suggested the limited ability to improve overall processes of care in this particular Kaiser integrated health care system was due to an existing "proactive, team-based approach to identify and close clinical care gaps," and that in less-integrated care settings, the Visit Planner could in fact have a direct role in closing gaps in care.
Researchers also tapped into clinicians' perspectives on patient behavior and time constraints through an initial baseline survey.
According to those survey results,
- 96 percent of physician said they never, rarely or only sometimes had enough time during patient visits;
- 49 percent said patients usually or always came to visits prepared with their top concerns; and
- 43 percent said patients usually or always raised concerns near the end of a visit.
"The insufficient time during visits reported by our study physicians underscores the challenges clinicians face in addressing patient concerns during time-limited visits," noted the authors.
Furthermore, they suggested that "efforts to prepare patients for their visits may represent a potential pathway to the overall goal of improving primary care."
"Our findings add to the research that suggests physicians should elicit their patients' top visit priorities at the beginning of the visit" to help curtail those hand-on-the-doorknob moments, said Grant.
However, there's much more work to do.
"This study focused just on the very first step of patients identifying priorities. We would like to extend the previsit planning concept to also get patients to think about what they want to do about their priorities," he added.
Authors called the study's success in improving patients' ability to prioritize via the Visit Planner "a building block toward the next generation of tools that address communication barriers related to care planning -- with the ultimate goal of improving clinical outcomes."
Journal of the American Board of Family Medicine: 'The Hand on the Doorknob': Visit Agenda Setting by Complex Patients and Their Primary Care Physicians(www.jabfm.org)