ILLUMINATING THE BLACK-BOX - A DESCRIPTION OF 4454 PATIENT VISITS TO 138 FAMILY PHYSICIANS

BACKGROUND. The content and context of family practice outpatient visi ts have never been fully described, leaving many aspects of family pra ctice in a ''black box,'' unseen by policymakers and understood only i n isolation. This article describes community family practices, physic ians, patients, and outpatient visits. METHODS. Practicing family phys icians in northeast Ohio were invited to participate in a multimethod study of the content of primary care practice. Research nurses directl y observed consecutive patient visits, and collected additional data u sing medical record reviews, patient and physician questionnaires, bil ling data, practice environment checklists, and ethnographic fieldnote s. RESULTS. Visits by 4454 patients seeing 138 physicians in 84 practi ces were observed. Outpatient visits to family physicians encompassed a wide variety of patients, problems, and levels of complexity. The av erage patient paid 4.3 visits to the practice within the past year. Th e mean visit duration was 10 minutes. Fifty-eight percent of visits we re for acute illness, 24% for chronic illness, and 12% for well care. The most common uses of time were history-taking, planning treatment, physical examination, health education, feedback, family information, chatting, structuring the interaction, and patient questions. CONCLUSI ONS. Family practice and patient visits are complex, with competing de mands and opportunities to address a wide range of problems of individ uals and families over time and at various stages of health and illnes s. Multimethod research in practice settings can identify ways to enha nce the competing opportunities of family practice to improve the heal th of their patients.