BACKGROUND: Previous research has identified 2 styles of family physicians’ focus on the patient’s family: (1) using the family history as the context of care of the patient; and (2) maintaining a family orientation with the family as the unit of care. The purpose of our study was to determine whether these styles affect patient outcomes and time use during outpatient visits.
METHODS: In a cross-sectional study, data on 4454 outpatient visits to 138 community family physicians were collected using direct observation, patient and physician questionnaires, and medical record review. We computed partial correlations between the physician’s family practice style score and patient outcomes for delivery of preventive services, patient visit satisfaction, and patient-reported delivery of specific components of primary care. We controlled for relevant patient characteristics.
RESULTS: The patients of the physicians using either practice style had similar levels of satisfaction with coordination of care and interpersonal communication, and their value of continuity of care was comparable. Patients of physicians with a family-history style, however, rated their physicians lower on a measure of in-depth knowledge of the patient and family but higher on preventive services delivery. Differences in time use during the visit reflected how these styles were manifested during the outpatient visit.
CONCLUSIONS: The different styles physicians use to focus on the family affect the process and outcomes of patient care. This difference may be explained by the developmental life cycle of family physicians, as younger physicians may be more focused on family history and older physicians may have a more family-oriented focus. Physicians may need to find alternate ways of meeting those patient needs not well met by their predominant practice style.
In a previous report1 we found the majority of family physicians who practice in the community include the patient’s family as part of their clinical work. Family physicians exhibited 2 styles of focusing on the patient’s family. One style used family information primarily as contextual data for caring for the individual patient. We labeled this the family-history style. Other physicians focused on family problems and used the family as the unit of care. We called this the family-orientation style [Table 1].
Although this distinction is interesting, it remained unclear whether the 2 styles affect the process and outcome of patient care. This paper addresses the question: Do patients of physicians with a family-history style have different outcomes than patients of physicians with a family-orientation style? The specific outcomes we examined included delivery of preventive services, patient visit satisfaction, and patients’ perception of the delivery of specific components of primary care. In addition, we looked at the association of these 2 styles of family focus with physician characteristics, the type of patients seen, and the process of care.
Methods
Study Design and Sample
Our research was part of the multimethod cross-sectional Direct Observation of Primary Care (DOPC) study of the content and context of outpatient visits to family physicians in northeast Ohio. The reliability and validity of the methods, instruments, and sampling techniques have been described in detail elsewhere.2,3 Briefly, 138 community family physicians were visited on 2 separate days by nurses trained in observational research methods while providing outpatient care. The patient sample consisted of consecutive patients seen during the 2 days of observation (89% of patients participated).
Data Collection and Measures
The research nurses collected data using multiple methods including direct observation of the patient visit, medical record review, patient exit questionnaire, physician questionnaire, billing data, and a practice environment checklist.2 The data used to assess a physician’s family focus were derived from each of these sources [Table 1].
Those nurses directly observing the patient visit completed a practice environment checklist to record whether a family history was taken and whether another family member’s problem was discussed. The checklist also recorded the patient’s sex and race and whether the physician used family charts. Family charts typically include individual medical records for family members held together in a single folder. The degree to which patients were up-to-date on any preventive services for which they were eligible, according to age- and sex-based recommendations from the United States Preventive Services Task Force (USPSTF),4 was calculated from the direct observation of the physician-patient encounter for services delivered during the visit and review of medical records for services recorded as delivered in the time frame recommended by the USPSTF.4,5
How time was spent during the face-to-face encounter portion of the visit was measured with a modified version2 of the Davis Observation Code (DOC).6 The DOC categorizes time use into 20 behavioral categories during 15-second observation and 5-second recording intervals.6 These data were used to determine the length of the visit and the proportion of visit time spent in each of 20 categories.