Patient satisfaction with the clinical encounter: social psychological determinants.

Patient-practitioner transactions in the ambulatory setting have become an increasingly important focus for research in recent years. In particular, there is growing interest in providing empirical support for our anecdotal, 'common-sense' notions that clinical encounter experiences are a major determinant of outcomes such as the patient's satisfaction with the encounter. The present study was designed to look at this issue and addressed the following two research questions: Is there a relationship between fulfillment of patient requests for services and patient satisfaction with the clinical encounter? and What degree of satisfaction is explained by the qualities of the encounter as compared to the characteristics of the patient, physician, and system of health care? Four newly-developed instruments were administered to a convenience sample of 144 adult patients and their physicians prior to and following actual visits to a University Family Practice Center. Meeting patients' requests increased their satisfaction with the encounter. At least 19% of the variance in patient satisfaction could be attributed to request fulfillment. The implications of these findings for future research into the doctor-patient relationship are discussed.

Display of small-area variation in health-related data: a methodology using resistant statistics.

Health care planning requires characterization of the population to be served. Examination of available demographic and epidemiologic data is one early step in this process. However, aggregate data for the entire geographic area of concern often fail to reveal important differences among geographically defined sub-populations--differences that influence the form an effective delivery system should take. We present a methodology based on exploratory data analysis (EDA) techniques that we have found useful in examining health-related data for our ambulatory care catchment area. Our examples use three population characteristics that have major implications for health care planning for the elderly: 1970-1980 change in population aged 65+; the percent of the population aged 65+ below poverty level; and the percent of single-person households among households with one or more persons aged 65+. With these data for the 25 municipalities of Middlesex County, New Jersey, we illustrate a two-step process: (1) the construction of stem-and-leaf displays that permit examination of a data distribution for asymmetry, concentrations around specific values, gaps in values, and outliers; and (2) the use of the median, the fourth-spread, and other information from the stem-and-leaf display in the systematic selection of data value classes to be given distinct shadings on a map of the selected geographic area. Discussion emphasizes the usefulness of graphic display of data in detecting similarities and unusual data values. Comparison of maps based on the EDA techniques and maps based on several traditional methods of value classing for the same data illustrates the influence of classing choices on the interpretation of cartographic displays of health-related data.

Medical anthropology and the family physician.

As family physicians increasingly begin to practice in a variety of settings both in the U.S. and abroad, they are faced with the challenge of caring for patients from different ethnic and socioeconomic backgrounds. In particular it has been suggested that delivering effective and acceptable community oriented primary care requires a deeper understanding of the cultural background of patients, their families, and the social contexts in which they live. In this paper, the authors provide an introduction to the field of medical anthropology--the discipline which studies the cultural dimensions of health, illness, and the medical care system. The "anthropology of family medicine" (the theoretical focus) is distinguished from the "anthropology of family practice" (the applied focus), and contributions from medical anthropological research at the micro (practitioner-patient relationship), intermediate (family), and macro (community) levels of analysis are examined. In particular, three clinical case vignettes are presented which illustrate the ways in which cultural issues can become critical in the care of patients and their families. Finally, the activities of the STFM Task Force on Skills and Curriculum Development in Cross-Cultural Experiences are described, and future directions for research and teaching efforts are proposed.

Multicultural curricula in family practice residencies.

BACKGROUND AND OBJECTIVES: In 1985, results from a national survey indicated that 25% of family practice residencies taught about multicultural issues in their programs. Our current study identified the current status and content of the curricula and determined facilitating and impeding factors to multicultural curricula. METHODS: In 1998, the Society of Teachers of Family Medicine's Group on Multicultural Health Care and Education conducted a cross-sectional mail survey of all 476 family practice residency programs. RESULTS: With a 59% response rate, 58% of responding programs have an informal curriculum on multicultural issues, 28% have a formal curriculum, and 14% have no curriculum. Programs with a formal curriculum teach more content, employ more educational methods, use more evaluation techniques, and feel more successful than programs with an informal curriculum. Important factors that facilitate curricula include cultural diversity of communities and residents, multicultural interests of faculty and residents, and faculty's multicultural expertise. Factors that impede curricula include lack of time, money, resources, faculty expertise, and cultural diversity in the community. Programs with formal, informal, and no curriculum identify different facilitators and impediments. CONCLUSION: There was a marked increase in the prevalence of multicultural curricula in family practice residencies from 1985 to 1998.

Clinical hypothesis testing in family practice: a biopsychosocial perspective.

Recent studies of the clinical problem-solving process have demonstrated the importance of hypothesis generation and testing in shaping the nature of information gathering, differential diagnosis, and therapeutic decision making. Family physicians and other primary care physicians are often faced with complex and undifferentiated illness problems that require them to go beyond the traditional biomedical model and entertain an expanded range of psychosocial hypotheses. In this paper the authors draw upon clinically relevant behavioral and social science research and propose several biopsychosocial hypotheses that have proven useful in the management of family practice patients. Seven illustrative case studies are presented, and some implications of this biopsychosocial paradigm for practice, research, and teaching are discussed.

Reading and interpreting genograms: a systematic approach.

Family physicians continue to struggle with the problem of how to make optimal use of family information in everyday clinical practice. One important task in addressing this problem is describing systematically the categories of family information that are incorporated into the usual clinical problem-solving process used by physicians. In this article the usefulness of the genogram as a data-gathering and assessment tool is reexamined, and six information categories that can be used for generating and testing clinical hypotheses are outlined. Three clinical case studies are presented to demonstrate how physicians can read and interpret genograms systematically.

Primary care case management: a family physician's perspective.

"By working closely with other social and human services case managers, primary care physicians have the potential to play an important role in improving the delivery of needed biomedical and psychosocial services."

Patient requests in family practice: a focal point for clinical negotiations.

A growing body of literature has stressed the importance of eliciting the patient's views on the management of health and illness. In particular, it is recognized that patients frequently enter into clinical encounters with specific requests for services, that is ideas about how they hope to be helped. The present investigation examined the following two questions: what kinds of requests do adult patients coming to a family practice center have prior to seeing the doctor; and will factor analysis of a 25-item patient request questionnaire provide evidence of the basic or most common dimensions of patient requests in this population? Two newly-developed instruments were administered to a sample of 144 adult patients before their visit to the doctor. Factor analysis yielded five major request factors--'medical information', 'psychosocial assistance', 'therapeutic listening', 'general health advice', and 'biomedical treatment'--partially replicating the findings of an earlier pilot study. The clinical implications of eliciting patient requests in the light of current behavioural and social science research into the doctor-patient relationship are discussed. Future research directions are also outlined.