OBJECTIVES: To understand the nature of patients' expectations for parts of
the physical examination and for diagnostic testing and the meaning patien
ts ascribe to their desires.
DESIGN: Qualitative inquiry based on patient interviews and focused on perc
eived diagnostic omissions as "critical incidents."
SETTING: Three general internal medicine practices (21 practitioners) in on
e mfd-sized northern California city.
PATIENTS: Of 687 patients visiting these practice shes and completing a det
ailed questionnaire, 125 reported one or more omissions of care and 90 comp
leted an in-depth telephone interview. This study focuses on the 56 patient
s interviewed who did not receive desired components of the physical examin
ation or diagnostic tests.
MEASUREMENTS: Qualitative analysis of key themes underlying patients' unmet
expectations for examinations and tests, as derived from verbatim transcri
pts of the 56 interviews, MAIN RESULTS: The 56 patients perceived a total o
f 113 investigative omissions falling into four broad categories: physical
examination (47 omissions), conventional tests (43), high-cost tests (10),
and unspecified investigations (13). patients considered omitted investigat
ions to have value along both pragmatic and symbolic dimensions. Diagnostic
maneuvers had pragmatic value when they were seen to advance the technical
aims of diagnosis, prognosis, or therapy. They had symbolic value when the
ir underlying purpose was to enrich the patient-physician relationship. Pat
ients in this study were often uncomfortable with clinical uncertainty, dis
trusted empiric therapy, endorsed early detection, and frequently interpret
ed failure to examine or test as failure to care.
CONCLUSIONS: When patients express disappointment at failing to receive tes
ts or examinations, they may actually be expressing concerns about the basi
s of their illness, the rationale for therapy, or the physician-patient rel
ationship.