Impact of Patient Requests on Provider-Perceived Visit Difficulty in Primary Care

Difficult visits are common in primary care and may contribute to primary care provider (PCP) career dissatisfaction and burnout. Patient requests occur in approximately half of primary care visits and may be a source of clinician-patient miscommunication or conflict, contributing to perceived visit difficulty. We aimed to determine associations between types of patient requests and PCP-perceived visit difficulty. This was an observational study, nested in a multicenter randomized trial of depression engagement interventions. We included 824 patient visits within 135 PCP practices in Northern California occurring from June 2010 to March 2012. PCP-perceived visit difficulty was quantified using a three-item scale (relative visit difficulty, amount of effort required, and amount of time required; Cronbach's alpha = 0.81). Using linear regression, the difficulty scale (score range 0-2 from least to most difficult) was modeled as a function of: patient requests for diagnostics tests, pain medications, and specialist referrals; PCP perception of likely depression or likely substance abuse; patient sociodemographics, comorbidity, depression; PCP characteristics and practice setting. Patients requested diagnostic tests, pain medications, and specialist referrals in 37.2, 20.0 and 30.0 % of visits, respectively. After adjustment for patient medical and psychiatric complexity, perceived difficulty was significantly higher when patients requested diagnostic tests [parameter estimate (PE) 0.11, (95 % CI: 0.03, 0.20)] but not when patients requested pain medications [PE -0.04 (95 % CI: -0.15, 0.08)] or referrals [PE 0.04 (95 % CI: -0.07, 0.25)]. PCP-perceived visit difficulty is associated with patient requests for diagnostic tests, but not requests for pain medications or specialist referrals. In this era of choosing wisely, PCPs may be challenged to respond to diagnostic test requests in an evidence-based manner, while maintaining the provider-patient relationship and PCP career satisfaction.