title: Behind closed doors: management of patient expectations in primary care practices.
abstract: BACKGROUND
  Managed care restrictions on resource use may affect communication between patients and health care professionals.
  
  
  METHODS
  To characterize negotiations between primary care physicians and patients with expectations for new medications, tests, or referrals, this observational study combined survey data with audiotape recordings of clinical encounters. Fifty-five physicians from 20 randomly selected primary care practices in a managed care network and 211 patients who voiced specific expectations in a previsit survey were included. From the recorded clinic visits we determined modes of negotiation of patient expectations and requests. From the surveys we determined patient previsit expectations, postvisit fulfillment of expectations, satisfaction, and trust.
  
  
  RESULTS
  Two-hundred fifty-six self-reported expectations were captured in 200 audiotape-recorded encounters. Of the previsit expectations, 97.3% were discussed during the encounter. Expectations were expressed by direct patient request (40.6%), mentioning of symptoms related to request (29.7%), or physician-initiated discussion (27.0%). Most expectations were met (66.8%); physicians suggested an alternative 21.6% of the time. Expectations for medications and tests were met more frequently than expectations for referrals (75.6% and 71.4% vs 40.8%). Patient satisfaction and trust remained high regardless of whether expectations were met. Physicians reported that they would not have ordered 62 (44.9%) of 138 requests had the patients not directly asked, and they were uncomfortable filling 8 requests (12.9%).
  
  
  CONCLUSIONS
  Previsit expectations for medications, tests, or referrals were discussed at the visit, and physicians met or offered alternatives for nearly 90%. Patients generally received what they asked for and altered physician behavior nearly half of the time.
authors.affiliation: Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA. sheri.keitz@duke.edu
authors.forename: Sheri A
authors.initials: SA
authors.lastname: Keitz
authors.forename: Karen M
authors.initials: KM
authors.lastname: Stechuchak
authors.forename: Steven C
authors.initials: SC
authors.lastname: Grambow
authors.forename: Celine M
authors.initials: CM
authors.lastname: Koropchak
authors.forename: James A
authors.initials: JA
authors.lastname: Tulsky
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D008297:Male; D008329:Managed Care Programs / Q000592:standards; D008875:Middle Aged; D009657:North Carolina; D017060:Patient Satisfaction; D010817:Physician-Patient Relations; D010821:Physicians, Family / Q000592:standards*; D011320:Primary Health Care / Q000592:standards*; D013023:South Dakota; D011795:Surveys and Questionnaires; D013637:Tape Recording; D014741:Video Recording