Primary Care

Primary care physicians interact differently with patients during initial and return visits

Patients appear to benefit from the continuity of seeing the same primary care physician over time, suggest two studies supported by the Agency for Health Care Policy and Research (HS06167) and led by Klea D. Bertakis, M.D., M.P.H., of the University of California, Davis. The first study demonstrates that return visits to the same doctor are shorter but more productive than the initial visit. The second study shows that physician practice style during the initial encounter along with other physician and patient factors influence the nature of return visits.

Bertakis, K.D., Azari, R., Callahan, E.J., and others. (1999, August). "Comparison of primary care resident physicians' practice styles during initial and return patient visits." Journal of General Internal Medicine 14, pp. 495-498.

This study found that return visits to the same primary care physician lasted only half as long (20 vs. 38 minutes) but were more work-intensive than the initial visit. Return visits were significantly less technically oriented, that is, the physician spent less time on history taking, physical examination, and treatment planning. Instead, there was more emphasis on health behaviors and the active involvement of patients in their own care. This difference between return and initial clinical visits suggests that physician-patient familiarity influences what happens during the medical visit, note the researchers.

They randomly assigned 212 nonpregnant adults to 58 senior resident physicians in either a family practice or general medicine clinic at a university medical center. Study patients returned for a median of four additional visits after their initial appointment from 1990 to 1993. All initial visits and 41 percent of return visits were videotaped to document physician practices during the visits. Despite the shorter length of return visits, they included an average of 1.84 clinically significant behaviors per 15-second interval versus only 1.71 per interval for initial visits, a significant difference. Also, in return visits, discussions concerning therapy centered less on evaluation feedback and planning treatment and more on treatment compliance. The interpersonal dynamics also changed, with the patient taking a more active role.

Bertakis, K.D., Robbins, J.A., Callahan, E.J., and others. (1999, March). "Physician practice style patterns with established patients: Determinants and differences between family practice and general internal medicine residents." Family Medicine 31(3), pp. 187-194.

Physician practice style during the initial patient visit is not the only factor affecting subsequent visits. Other physician and patient factors also play a role, finds this study. The researchers randomly assigned 509 new adult patients to family practice or internal medicine clinics at a university medical center and followed them for 1 year of care by resident physicians. They videotaped initial and return visits, and correlated factors associated with physician practice styles with established patients during return visits.

Both family physicians and internists spent more time on technical aspects of medical care (for example, medical exam and treatment) for patients in poorer health and for those patients whose initial visits had been characterized by more technical physician behaviors. Also, discussions of nutrition, exercise, and other health behaviors and discussions of treatment compliance during return visits were predicted by these issues being addressed during the first visit. Being male or having an addiction problem such as smoking was also predictive of these discussions in return visits. Physicians tended to encourage more active involvement with patients who were older, had higher incomes, and when they had used this approach the first time.

Women's return visits emphasized preventive services more than men's return visits. Also, higher initial health status, greater number of return visits, and more self-reported depressive symptoms all significantly influenced the amount of counseling services during return visits. The authors note that many factors influence the established practice style patterns of physicians, and that visits tend to consistently reflect a physician's personal style.

In addition, this study also found support for the hypothesis that there are measurable differences between the practice styles of family physicians and internists. For example, family practice residents gave greater attention to preventive services during return visits, while internal medicine residents spent more time using technical behavior during followup visits. These differences may have implications for patient outcomes, conclude the researchers.

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