Tai-Seale, McGuire, and Zhang,
HSR 2007
AcknowledgementNIMH (MH01935) , NIA (AG15737) for fundingComments from Margarita Alegria, John Z. Ayanian,
Howard Beckman, Richard Frankel, Richard Kravitz, Rachel Moser, Joseph Newhouse, Richard Street, Jr. and Suojin Wang
Editors Hal Luft, Jose Escarce, and two anonymous reviewers
Research assistants
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MotivationMedical office visit is the foundation of
medical care It is one of the most important professional
activities of primary care physicians Evidence continues to show a gap between
science and clinical practiceRacial minority patients fare even worse
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Realities of PracticeTime is scarce in primary care, 2,000 –
3,000 patients/physician, 15 min/visitCompeting demands aboundUnder pressure to be “productive” and have
short visitsQuality of care often falls short (McGlynn
2003)Proliferation of practice guidelinesAvailability of guidelines does not translate
into guideline concordant practice nor positive patient health outcome
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Some Physicians’ Analogies“Hamster” wheel (NYT)Doc on roller skatesPush the current patient
as quickly as possible so the next patient can be seen (Callahan 2006)
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Selected Literature Beckman and Frankel (1984)
Patients spoke for 18 seconds before interruption
Marvel et al (1999) Patients spoke for 23 seconds before interruption
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Our Main GoalCharacterize patient-physician relationship in a new way
Study how physicians and patients allocate the scarce resource of visit time to deal with complex issues in office visits
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Methodological RequirementsExaminations of complex reality require
suitable empirical research methodsHerbert Simon and Amos Tversky
advocated collecting data from observations of actual behavior
Lisa Cooper stressed the need for triangulating surveys with direct observation of the actual encounter
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Direct observation
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To Err is HumanThis is a very critical
way of studying physician behavior.
Humility and self-reflection are needed on the part of the researcher.
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Research QuestionsWhat was the length of primary care office
visitsWhat topics were discussed How many topics were discussed in each visitHow much time was devoted to each topicWhat factors influenced the length of
Discussion on topics Visits
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DataVideotapes
392 patient visits35 primary care physicians 3 types of practice settings1999-2000
Patient surveyPhysician survey
TimeEnd of VisitBeginning
Patient Talks
Physician TalksAnxiety aboutheart failure
Elevated blood pressure
Physician's haircut 0.28
Ibuprofen refill
Patient's church- related travel plan
Physician's home remodeling project
3.98
1.32
1.62
2.40
1.75
What does a visit look like
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Findings – Median LengthsTotal AMC MCG ICS
VisitPt talk 5.3 8.0 4.0** 1.8**MD talk 5.3 5.9 4.7** 2.6**Length 15.7 23.3 13.4** 9.7**Major topicPt talk 2.0 3.0 1.7** 0.9**MD talk 2.3 2.4 2.3 1.7Length 5.3 6.7 4.8** 3.2**
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Median Lengths of Time
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Duration AnalysisAnalyze the likelihood that the topic or visit
would end, given how much time had already been spent on it.
To test duration dependence, we use the Weibull proportional hazard function (Cleves 2004).
At the topic level:h(t|xi)=h0(t) exp(β'xi)
(1)
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Duration Analysis ResultsMajor Topics
Pt Talk MD Talk Topic Length
Mental Health .37** (85%) .52** (37%)
Psychosocial .48** (57%) 1.76** (-28%)
Pt initiation 2.53** (-22%)
MCG 1.58** (-26%) 1.60** (-20%)
ICS 2.93** (-54%) 1.98** (-28%)
Female Pt .73** (20%)
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Summary Six topics per visit, all competed for visit timeTime spent by patient and physician on a
topic responded to many factorsLength of the visit overall responded little to
the nature of topics in visits and to patient’s health status
Organizational/financial factors were dominant determinants of visit length
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Popular Press
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Tai-Seale, McGuire, Colenda, Rosen, CookJournal of American Geriatric Society 2007
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IntroductionLate-life mental disorders are common
(Charney et al. 2003)Elder suicide crisis (Kaplan 2001)PCPs deliver most mental health
treatment, esp. for elderly patients (Wang et al. 2006)
Practice guidelines call for a set number of office visits in which MH is discussed (Young et al 2001: 4v/5m)
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Study QuestionsWhat happens in a visit in which mental health problems are discussed?How much time is spent on addressing mental health issues?
How is that time spent?
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MethodsMixed Method ApproachQuantitative
How much timeQualitative
How is the time spentCritical discourse analysisConstant comparison
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0.0
5.1
.15
.2D
ens
ity
0 5 10 15 20t2
Median =1.9 min.Mean =3.9 min.
What Mattered?One Parameter Logit/Duration
Probability Topic Length
Patient’s Mental HealthSF36 MH <42 (50% of patients) 25 2.3SF36 MH ≥42 (control) 19 1.6
Practice SettingAMC (control) 28 2.6Managed Care Group Practice 20 2.0Inner-City FFS Solo Practices 9 1.6**
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What Mattered?One Parameter Logit/Duration
Probability Topic Length
White (control) .23 2.2
Non-White .16 1.7**
Female patient .27** 2.3
Male (patient) .12 1.2
Female Pt Male MD (control) .24 4.5
Female Pt female MD .32* 1.7
Male pt male MD .13** 1.2
Male pt female MD .07 2.5
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How Was the Time UsedTheme 1: biopsychosocial
Patient indicated emotional distress MD took the time to investigate the disease,
the person, and the lived lifeMD Recognized mental disorderInadequate treatment
Theme 2: narrowly biomedical Patient indicated emotional distressPhysician did not follow up
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D: (inaudible). What you been up to?P: I have just been crying my eyes out.D: Why?P: I don’t know. I can’t help it.D: Why?P: And then people ask me how I am, I just
cry.D: Oh, (pause.) Well I am not going to ask
you that anymore. (pause 2 seconds.) Why? Do you think you are puny?
P: No.D: No. Do they care, the people that ask?P: Yep.
Select ResponsesTwo U.S. Senate HearingsWA State Attorney General Media/Press coverage
News/Prof Org Press Date Circulation
New York Times Feb 07 40,000,000
New York Times Jan 08 40,000,000
American Medical News (AMA, front page)
Mar 07 251,000
Psychiatric News (APA) Nov 06 70,000
Good Housekeeping July 07 4,500,000
Lady’s Home Journal Dec 07 4,100,000
Prevention Magazine Jun 07 100,000AcademyHealth 2008 32
January 8, 2008Vital Signs
Aging: Mental Health Overlooked in Care of Elderly Patients
By ERIC NAGOURNEY
Depression and other mental illnesses are common among the elderly, and when they get treatment, it usually comes from their primary care doctors. But a new study suggests that those doctors may devote too little time to talking about those ailments.
When researchers reviewed videotapes of 385 appointments with elderly patients in three separate areas, they found the median time spent discussing mental health was just two minutes.
The study, which appeared in the December issue of The Journal of the American Geriatrics Society, was led by Ming Tai-Seale of the School of Rural Public Health at Texas A&M.
More than half the patients whose survey responses suggested they were depressed never spoke with their doctors at all about their emotional state. The subject came up in about a fifth of the visits over all.
But even when patients let their doctors know about their problems, the study found, the responses were often ineffective or worse.
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Fruits for ThoughtsThe busy car mechanicCome back in one week, two weeks, etc.You and your insurance, (employer, CMS,
etc.) pay each time you go, no matter how much good was done in each visitWonderfulAwful
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