Perceptions of Physicians and Patients With Organic and Functional Gastrointestinal Diagnoses

Transcription

1 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2004;2: Perceptions of Physicians and Patients With Organic and Functional Gastrointestinal Diagnoses CHRISTINE B. DALTON, DOUGLAS A. DROSSMAN, JOSEPH M. HATHAWAY, and SHRIKANT I. BANGDIWALA University of North Carolina Center for Functional GI and Motility Disorders, Chapel Hill, North Carolina Background & Aims: We studied patient after-hours telephone calls to gastrointestinal (GI) fellows at a university program to determine requests made,physicians responses,and perceptions of patients and physicians to these requests. Methods: During a 4-month period,4 GI fellows taking call were asked about reasons for patientinitiated after-hours telephone calls,actions taken,and their perceptions about the nature of the request,the illness impact,and their role in the care administered. Patients were telephoned within 1 week and asked the same questions about their perceptions of the call. Results: Patients (N 102) made 103 telephone calls, averaging 8.7 minutes,for symptoms (56%),procedurerelated concerns (19%),and medications (18%). Physicians usually referred the patient to the clinic or emergency room (40%) or provided discussion and reassurance (36%). Patients perceptions differed from physicians perceptions: patients believed their problems to be more severe and more disabling and requests were more reasonable than perceived by the physician. Furthermore,their interactions with physicians (physician helpfulness,satisfaction with the recommendation,and likeability of the physician) were more positive than believed by physicians. Physicians believed phone calls from patients with functional disorders were less serious and less reasonable,that these patients were less disabled,and also that these patients were less liked than patients with an organic diagnosis. Conclusions: In this study,physicians carried a lower perception of the importance of telephone requests,the impact of the disorder,and their perceived helpfulness to patients than did patients making these requests. Physician perceptions were significantly lower for all these factors for patients with functional GI diagnoses. Additional studies are needed to understand the reasons for differing perceptions between physicians and patients. Receiving and managing telephone calls from patients is an integral part of any outpatient clinical practice. It has been reported that 15% 27% of physician-patient contact in primary care and internal medicine occurs over the telephone. 1 However, physicians often are dissatisfied with telephone medicine in general. 2 A few studies have described the use of telephone medicine in internal and family medicine. 1,3 5 The information reported includes demographics, patient reason for calling, and physician response. Some studies have addressed the perceptions of patients or physicians about the call 2,4 or ways to possibly increase satisfaction. 4,6 Although only a few studies have explored physician and patient interactions related to telephone calls, none have compared physician and patient perceptions related to the patient s diagnosis. Within gastroenterology, patients with functional gastrointestinal (GI) disorders (e.g., irritable bowel syndrome [IBS], functional dyspepsia, chronic abdominal pain) comprise 40% of gastroenterology practice. 7,8 Calls received from these patients may be perceived differently than calls from patients with an organic diagnosis. The purpose of this study is to evaluate within a university-based GI fellowship program the nature of patient after-hours telephone calls and physicians responses. In addition, physicians and patients perceptions of these calls were compared according to diagnosis of functional or organic disorders. Methods Study Sample Patient-initiated night and weekend telephone calls made to 4 first-year gastroenterology fellows on rotating call at a university-based fellowship program between November 1999 and February 2000 were evaluated by questionnaire. All calls received during weekdays after 5:00 PM and before 8:00 AM and on weekends from 5:00 PM Friday to 8:00 AM Monday were eligible. Although most calls were recorded, an unknown number of calls received in the early morning hours were not. Abbreviations used in this paper: ER,emergency room; GI,gastrointestinal; IBS,irritable bowel syndrome by the American Gastroenterological Association /04/$30.00 PII: /S (03)

2 122 DALTON ET AL. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 2,No. 2 Figure 1. Telephone call card. Study Administration All first-year gastroenterology fellows taking evening and weekend call were asked to participate in a study to understand the content, physician actions, and perceptions of physicians and patients related to after-hours telephone calls. No mention was made with regard to specific hypotheses or whether differences in responses would be evaluated or expected based on diagnosis. When a patient made an after-hours telephone call, the responsible GI fellow recorded the requested information on a series of cards about the patient s reason for the call, the fellow s response, and the fellow s and patient s perceptions of the call. With each telephone call, the fellow first recorded the patient s name, age, sex, and race, as well as time spent on the call and telephone and medical record numbers on a preprinted telephone call card (Fig. 1). The fellow asked the patient to describe their primary diagnosis or why they were being followed up in the gastroenterology clinic. He then recorded the response on a diagnosis card that had 13 different diagnoses categorized into functional (esophageal, functional upper GI, IBS, other functional bowel, chronic functional abdominal pain, and other functional non- GI) or organic (inflammatory bowel disease, acid peptic disease, liver, pancreatic/biliary, or other organic GI disorder; Fig. 2). The fellow then asked the patient the primary reason for the call (Fig. 3): medication related, test result, procedure related, complaint, or other. If the reason was a complaint, the fellow Figure 3. Reason for call card. recorded 1 of 15 common complaints. The fellow s response, or action, included 5 possible choices (Fig. 4): (1) reassurance or discussion; (2) symptomatic treatment (nonprescription); (3) medication related (question, new, refill, dose change, no action), with the name of the medication; (4) referral to clinic/emergency room (ER)/doctor; or (5) other. Immediately after the call, the fellow answered a 6-part questionnaire on the back of the telephone card about his perceptions relating to this call. The questionnaire addressed (Fig. 5): (1) seriousness of the problem, (2) disability of the patient, (3) reasonableness of the request, (4) helpfulness of the doctor, (5) satisfaction with the recommendation, and (6) likeability between the doctor and patient. Fellows completed the questionnaires within 24 hours of the telephone call and gave the cards to the study assistant. After the study assistant received a card, she phoned the patient within 1 week of the original call (most within a few days) to administer a similar survey containing the 6 perceptual questions (Fig. 5). Only calls that had both doctor and patient perceptual questions completed were included in this study; Figure 2. Primary diagnosis card. Figure 4. Action card.

3 February 2004 PERCEPTIONS OF PHYSICIANS AND PATIENTS 123 Figure 5. Perception survey card. therefore, all data reported are matched sets of physician and patient responses. Data Analysis Main outcome variables for this study were the 6 perceptions asked separately of the patient and doctor. Responses to each perception were assessed by using a 5-point Likert scale (1 not at all, 5 very). The 4 fellows responses were treated as a group because there was no difference in mean scores among the 4 fellows for the first 3 questions. However, 1 fellow had significantly higher scores than the other 3 fellows for the remaining 3 questions, although he was responsible for only 11 of the 103 patient cards. To assess the concordance between patients and doctors on responses for calls, Likert scales were collapsed into dichotomous variables (1, 2, and 3 not endorsed vs. 4 and 5 positively endorsed). Given the matched-pairs design of the study, we used McNemar s test to examine whether disagreements in perceptions between doctors and patients are more likely in 1 direction or are equally likely. After examination of the overall concordance, we further examined concordance between doctors and patients within the subgroups defined by the primary diagnosis of the disorder; functional vs. organic. These data cannot be analyzed by comparing proportions between doctors and patients because the 2 samples are not independent. 9 Finally, we compared binomial proportions of positively endorsed responses between independent samples of organic and functional primary diagnoses for doctors and patients separately, using the standard Z test for binomial proportions. All statistical analyses were performed using SAS (version 8; SAS Institute, Cary, NC). Results Clinical and Demographic Features Of 104 questionnaires that were matched between patients and fellows, 1 fellow questionnaire was incomplete, leaving 103 assessable questionnaires. All 4 fellows were Caucasian men aged in their early 30s. Of patients, 69% were women, 65% (N 66) had an organic diagnosis, and 35% (N 36) had a functional diagnosis. One patient telephoned on 2 occasions. There was a greater proportion of women with functional diagnoses (86% women with functional vs. 58% women with organic diagnoses; P 0.006). Mean patient age was 42 years (range, yr), with no statistically significant difference by diagnosis. There also was no difference by diagnosis with regard to ethnicity: 86% were European American, 6% were African American, and 8% were other. Questionnaire Responses Length and reasons for the call. Mean time of the telephone call was minutes, and there was no difference in length of the call for patients with functional ( min) vs. organic ( min) diagnoses (P 0.35). The most common reason for telephone calls was GI symptoms (56%). Of these symptoms, about half related to abdominal pain (28%), followed by nausea (9%), bleeding (6%), and other reasons (13%). The next most common reasons for telephone calls related to questions about medications (18%) or procedures (19%; Table 1). Actions taken. There were 87 physician actions coded for the 103 questionnaires (85% response). Of these 87 actions, the most frequent action made by physicians to the telephone call was to refer the patient to the ER or clinic (40%), followed by providing reassurance or further discussion (36%), and 18% specifically prescribed medication or other treatment. There were a few (6%) other responses (e.g., giving directions, telling Table 1. Reasons for Telephone Calls Reason for telephone call (N 103) Frequency % Symptoms Abdominal pain Nausea 9 9 Bleeding 6 6 Other (indigestion, constipation, diarrhea, anorexia, other) Total % symptoms Medication related Procedure related Other (e.g., disability, x-ray, fistula drainage) 7 7 Total

4 124 DALTON ET AL. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 2,No. 2 Table 2. Physician and Patient Perceptions: Percentage Responding A Great Deal or Very Survey question Physician Patient Problem was serious a Patient was disabled a Request was reasonable a Doctor was helpful a Satisfied with recommendation b Liked the doctor/patient a a P b P the patient to call the primary physician on Monday, etc.). Perceptions. In Table 2, perceptions of physicians and patients are compared with the telephone requests. As noted, all 6 questions were significantly different between physicians and patients. The patients believed their problems were more serious, they were more disabled, and their requests were reasonable. In addition, more patients than physicians were satisfied with the recommendations and found the doctor to be helpful. Finally, more patients perceived the physician as more likeable than the physicians perceived the patient to be. Perceptions for patients with organic and functional diagnoses. When data are compared by type of diagnosis (Table 3), it is noted that doctors perceived that patients with organic diagnoses had more serious problems, greater disability, and more reasonable requests, and they liked them more (P 0.05 to P 0.001). However, these perceptions between patients with organic and functional diagnoses were similar, except that patients with functional disorders believed they were more disabled than those with organic disorders (P 0.05; Table 3). Additional analyses comparing physician and patient perceptions separately for each diagnostic group (statistics not listed in Table 3) indicated that significant differences between perceptions of physicians and patients with organic diagnoses were retained for all items (P 0.05 to P ), except for degree of disability, for which no difference was noted. Similarly, for patients with functional diagnoses, there were highly significant differences (P ), except for satisfaction with the treatment. Discussion As the Western health care system seeks to streamline the cost and efficiency of patient care, use of telephone communication may gain increasing importance. To date, there are only a small number of studies relating to the nature of after-hours telephone calls and attitudes and behaviors of physicians accepting them. A limited number of studies from primary care practices indicated that about one quarter of primary care communications are through the telephone 1 and relate primarily to questions about symptoms. 10 Whereas physicians and residency program directors report being generally unsatisfied with the concept of using telephone calls for care, 2,6 patients seem satisfied, 4 and this communication method is not likely to decrease. Thus, it becomes important to understand the role with which telephone calls impact on health care. To do so requires evaluation of the nature of these calls and responses to them. Our data involving telephone calls to GI fellows in an academic gastroenterology program confirms previous studies showing that telephone calls are relatively brief, lasting fewer than 7 or 8 minutes, 4,5,11 and with regard to GI practice, there is no difference in telephone call duration between patients with organic or functional GI diagnoses. Callers are primarily middle-aged women, and 65% of calls are from patients with organic diagnoses, which replicates the composition of patients seen in clinical GI practice. 7,8 Reasons for calls relate primarily to symptoms, 3,5 and for a GI specialty, 10 these are specifically abdominal pain, nausea, or GI bleeding; the latter may be procedure related. 10 We also confirmed that our GI fellows most often respond by referring the patient to either the clinic or ER. 10 The next most frequent actions relate to discussion, reassurance, and prescribing medication. However, in primary care, the most frequent response is reassurance and discussion. 5 An important component of our study is an evaluation of the attitudes and perceptions of physicians and pa- Table 3. Physician and Patient Perceptions by Functional or Organic Diagnosis: Percentage Responding A Great Deal or Very Physician Patient Survey question Organic Functional Organic Functional Problem was serious 35 3 a Patient was disabled 36 6 a b Request was reasonable a Doctor was helpful Satisfied with recommendation Liked doctor/patient c a P for doctor response about patients with functional and organic diagnoses. b P 0.05 between patients with functional and organic diagnoses. c P 0.05 for doctor response about patients with functional and organic diagnoses.

5 February 2004 PERCEPTIONS OF PHYSICIANS AND PATIENTS 125 tients relating to the telephone calls. We believe these factors can affect clinical decision making for better or worse, which, in turn, may influence patient satisfaction with care, adherence to treatment, and even clinical outcome Importantly, our study shows that doctors and patients perceptions relating to off-hours telephone calls differ. Patients believed their requests were more reasonable, their problems were more serious, they were more disabled, doctors were more helpful, and recommendations were more satisfying than did physicians. Furthermore, they liked the physicians more than physicians liked them. Some of these findings are similar to a family practice study 4 in which 19 residents received 192 calls in 1 month, primarily for symptom complaints (62%). Overall, patients believed these symptoms were more serious, rating 29% as severe, whereas residents rated only 8% as severe, although most patients (76%) reported being helped by the physician. We also found that differing perceptions between physicians and patients were amplified for patients with functional GI diagnoses. Physicians reported that their perceptions were that telephone call requests from patients with functional GI diagnoses were less serious and less reasonable and that patients with functional GI diagnoses were less disabled and less likeable than patients with organic diagnoses. This finding is particularly notable because there were no differences on 5 of 6 self-perceptions between the functional and organic groups (Table 3). However, the only difference between patient groups was that those with functional GI diagnoses perceived their conditions as more disabled than those with organic diagnoses. Although this may seem unexpected, empiric evidence from a 1-year prospective health status study showed that patients with functional GI diagnoses experience greater pain, spend more days in bed, experience more psychological distress and worse daily function, and undertake more physician visits and operations than those with organic diagnoses. 17 These differing perceptions between physicians and patients, and particularly for patients with functional GI diagnoses, need to be understood further because of their implications for health care. Many doctors report a sense of frustration when caring for patients with functional GI disorders, 12,18 and this may affect their communication style. 14 These feelings may result from lack of training in patient-centered biopsychosocial care 19,20 and faulty or inadequate teaching of communication skills in medical school or subspecialty training. 12,14 One study of family physicians and gastroenterologists found that physicians held 2 definitions of IBS; one public, akin to a textbook definition, and another private, influenced by experiential knowledge and the absorption of prejudices from others about patients with IBS. 18 Thus, patients making telephone calls after hours are susceptible to the application of such biases. They may feel unheard or invalidated in their concerns or, in the least, not satisfied that their requests were met properly. Emerging research shows that patients are more satisfied if their beliefs and concerns are elicited and validated; the physician provides positive affect, empathy, and support; and the patient has an active role in the plan of care 16,18 ; all of this is associated with improved health outcomes. 16,21 Interestingly, our study indicates that, in general, patients were satisfied with physicians responses, even more than the physicians thought they provided. The degree to which such perceptions, as shown in this study, influence clinical behaviors in GI practice requires additional study. One limitation to this study relates to the generalizability of the findings. It is unclear whether data obtained from 4 first-year fellows early in their training are representative of senior fellows or experienced physicians in academic or clinical practice. Possibly, perceptions by physicians early in training may change with clinical experience. It also is possible that the nature of the illnesses and behaviors of patients seen in referral practices may not adequately represent the majority of patients who have these diagnoses when seen in primary care or community GI practice. 12,17,22 In conclusion, we find differences in perceptions between physicians in training and patients relating to the nature and severity of their illness and the impact on health care behaviors in the context of after-hours telephone calls. In addition, for the first time, we identify that these differences are reflected most in patients with functional GI diagnoses. It is hoped that more studies will be performed to understand the reasons for these differing perceptions. References 1. Studdiford JS III, Panitch KN, Snyderman DA, Pharr ME. The telephone in primary care. Primary Care 1996;23: Hannis MD, Hazard RL, Rothschild M, Elnicki DM, Keyserling TC, DeVellis RF. Physician attitudes regarding telephone medicine. J Gen Intern Med 1996;11: Peters RM. After-hours telephone calls to general and subspecialty internists: an observational study. J Gen Intern Med 1994; 9: Greenhouse DL, Probst JC. After-hours telephone calls in a family practice residency: volume, seriousness, and patient satisfaction. Fam Med 1995;27: Johnson BE, Johnson CA. Telephone medicine: a general internal medicine experience. J Gen Intern Med 1990;5: Cykert S, Flannery MT, Huber EC, Keyserling T, Moses GA, Elnicki DM, Hannis M. Telephone medical care administered by internal

6 126 DALTON ET AL. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 2,No. 2 medicine residents: concerns of program directors and implications for residency training. Am J Med Sci 1997;314: Russo MW, Gaynes BN, Drossman DA. A national survey of practice patterns of gastroenterologists with comparison to the past two decades. J Clin Gastroenterol 1999;29: Mitchell CM, Drossman DA. Survey of the AGA membership relating to patients with functional gastrointestinal disorders. Gastroenterology 1987;92: Siegal S, Castellan NJ. Nonparametric statistics for behavioral sciences. New York, McGraw-Hill, Jacobson BC, Strate L, Baffy G, Huang L, Mutinga M, Banks PA. The nature of after-hours telephone medical practice by GI fellows. Am J Gastroenterol 2001;96: Cotton MF. Telephone calls to an infectious diseases fellow. Pediatrics 1995;95: Drossman DA. Challenges in the physician-patient relationship: feeling drained. Gastroenterology 2001;121: Drossman DA, Chang L. Psychosocial factors in the care of patients with GI disorders. In: Yamada T, ed. Textbook of gastroenterology. Philadelphia: Lippincott-Raven, 2002: Drossman DA. Psychosocial sound bites: exercises in the patient-doctor relationship. Am J Gastroenterol 1997;92: Chang L, Drossman DA. Optimizing patient care: the psychosocial interview in the irritable bowel syndrome. Clin Perspect Gastroenterol 2002;5: Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M. Evidence on patient-doctor communication. Cancer Prev Control 1999;3: Drossman DA, Li Z, Leserman J, Toomey TC, Hu Y. Health status by gastrointestinal diagnosis and abuse history. Gastroenterology 1996;110: Dixon-Woods M, Critchley S. Medical and lay views of irritable bowel syndrome. Fam Pract 2000;17: Drossman DA. Presidential address: gastrointestinal illness and biopsychosocial model. Psychosom Med 1998;60: Ouyang A, Camilleri M, Drossman DA, Kahrilas PJ, Reynolds JC, Shaker R. Task force on training in motility, diverticular disease, and functional illness. Gastroenterology 1996;110: Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The impact of patient-centered care on outcomes. J Fam Pract 2000;49: Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology 2002; 123: Address requests for reprints to: Douglas A. Drossman,M.D.,Division of Digestive Diseases,1110 Bioinformatics Building,CB #7080, University of North Carolina,Chapel Hill,North Carolina Fax: (919) The authors thank Albena Halpert,M.D.,for helpful comments.