Patients' perceptions of omitted examinations and tests - A qualitative analysis

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.