PREVALENCE AND SOURCES OF PATIENTS UNMET EXPECTATIONS FOR CARE

Background: Patients' expectations and the role they play in medical c are are increasingly considered to be important, but the factors that influence these expectations have not been well studied. Objective: To examine the factors that influence patients' expectations for care in office practice. Design: Qualitative inquiry nested within a large cl inical survey. Setting: Three general internal medicine practices in o ne mid-sized city in northern California. Patients: 688 patients visit ing their internists' offices were surveyed (response rate, 86%); 88 p atients who reported one or more omissions of care on a post-visit que stionnaire and were available for a telephone interview 1 to 7 days af ter the visit were included in the qualitative inquiry. Measurements: Proportion of surveyed patients who reported one or more omissions of care, and qualitative analysis of the sources of patients' expectation s, as determined from the telephone interviews. Interviews focused on the sources of expectations and perceptions of omission. Using an iter ative process and working by consensus, investigators developed coding categories on a randomly selected 50% of the transcripts. The other 5 0% of the sample was used for validation. Results: The 125 patients wh o had unmet expectations perceived omissions that were related to phys ician preparation for the visit (23%), history taking (26%), physical examination (30%), diagnostic testing (28%), prescription of medicatio n (19%), referral to specialists (26%), and physician-patient communic ation (15%). Unmet expectations were shaped by patients' current somat ic symptoms (intensity of symptoms, functional impairment, duration of symptoms, and perceived seriousness of symptoms) (74%); perceived vul nerability to illness (related to age, family history, personal lifest yle, or previously diagnosed conditions) (50%); past experiences (pers onal or familial) with similar illnesses (42%); and knowledge acquired from physicians, friends, family, or the media (54%). Conclusions: Pa tients' expectations for care are derived from multiple sources; their complexity should discourage simple schemes for ''demand management.' ' Nevertheless, the results of this study may help physicians to take a more empathetic stance toward their patients' requests and to devise more successful strategies for clinical negotiation.