A Taxonomy of Requests by Patients (TORP) - A new system for understandingclinical negotiation in office practice

BACKGROUND. The goal of our investigation was to facilitate research on cli nical negotiation between patients and physicians by developing a reliable and valid classification system for patients' requests in office practice. METHODS. We developed the Taxonomy of Requests by Patients (TORP) using inp ut from researchers, clinicians, and patient focus groups. To assess the sy stem's reliability and validity, we applied TORP to audiotaped encounters b etween 139 patients and 6 northern California internists, Reliability was a ssessed with the kappa statistic as a measure of interrater agreement. Face validity was assessed through expert and patient judgment of the coding sy stem. Content validity was examined by monitoring the incidence of unclassi fiable requests. Construct validity was evaluated by examining the relation ship between patient requests and patient health status; patient request fu lfillment and patient satisfaction; and patient requests and physician perc eptions of the visit. RESULTS. The 139 patients made 772 requests (619 requests for information a nd 153 requests for physician action). Average interrater agreement across a sample of 40 cases was 94% (kappa = 0.93; P < .001). Patients with better health status made fewer requests (r = -0.17; P = .048). Having more chron ic diseases was associated with more requests for physician action (r = 0.3 2; P = .0002). Patients with more unfulfilled requests had lower visit sati sfaction (r = -0.32; P < .001). More patient requests was also associated w ith physician reports of longer visit times (P = .016) and increased visit demands (P = .006). CONCLUSIONS, Our study provides evidence that TORP is a reliable and valid system for capturing and categorizing patients' requests in adult primary c are. Further research is needed to confirm the system's validity, expand it s applicability, and explore its usefulness as a tool for studying clinical negotiation.