Physician Response to "By-the-Way” Syndrome in Primary Care

ABSTRACT: BACKGROUND/OBJECTIVE: "By-the-way” syndrome, a new problem raised by the patient at an encounter's closure, is common, but little is known about how physicians respond when it occurs. We analyzed the content of the syndrome, predictors of its appearance, and the physician response. DESIGN/PARTICIPANTS: Cross-sectional study of 92 videotaped encounters in an academic primary care clinic. RESULTS: The syndrome occurred in 39.1% of observed encounters. Its major content was bio-psychosocial (39%), psychosocial (36%), or biomedical (25%), whereas physician responses were mostly biomedical (44%). The physician response was concordant with the patient's question in 61% of encounters if the content of the question was psychosocial, 21% if bio-psychosocial, and 78% if biomedical; 32% of physicians solicited the patient's agenda two times or more in the group without, versus 11% in the group with, the syndrome (P = 0.02). In 22% of the encounters, physicians did not give any answer to the patient's question, particularly (38.5%) if it was of psychosocial content. CONCLUSIONS: "By-the-way” syndrome is mainly bio-psychosocial or psychosocial in content, whereas the physician response is usually biomedical. Asking about the patient's agenda twice or more during the office visit might decrease the appearance of this syndrom

Physician response to the "by-the-way" syndrome in primary care

BACKGROUND: Exploring all patient's requests during a medical encounter represents a difficult task. In some encounters, the patient raises a new problem just at the end of the visit, which has been called the ''by-the-way'' syndrome. Little is known about the content of the questions asked and physician response. We aimed to analyze this syndrome, physician response to it and the predictors of its apparition. METHODS: We videotaped a gender-stratified random sample of 24 encounters in a primary care outpatient clinic. Patients were aged 19-90 and 50% were women. We performed a qualitative and quantitative analysis of patient-physician encounters and examined the predictors of the apparition of the ''by-theway'' syndrome, defined as a new problem raised by the patient during the closure of the encounter. The content of the ''by-the-way'' syndrome and physician response were classified in three categories: biomedical, psychosocial and biopsychosocial by two independent investigators (kappa=0.82 and=1.0 for the category of the question and response respectively). RESULTS: The ''by-the-way'' syndrome occurred in 37.5% (9/24) of office visits. The content of this syndrome was biopsychosocial in 67% of encounters, psychosocial in 22% and biomedical in 11%, while physician responses were mostly biomedical (67%). In 78% of encounters, the content of physician response was not concordant with patient's question. To a patient who said he was ''anxious about an eventual positive response to an HIV test'' (biopsychosocial question), the physician did not give any response to the anxiety and added she ''never gives the results by phone'' (biomedical only answer). The visits with a syndrome were not shorter than those without (34 vs. 24 minutes; p=0.08). Questions about the patient's agenda at the beginning of the office visits was not significantly associated with the apparition of such a syndrome (44% in the group with the syndrome vs. 67%, p=0.29), but questions about patient's own agenda during the continuation of the encounter was (22% vs. 67%, p=0.04). CONCLUSIONS: The ''by-the-way'' syndrome is mainly of biopsychosocial or psychosocial content, while physician response is usually biomedical. Asking a question about the patient's own agenda during the continuation of the office visitmight decrease the apparition of this syndrome. Teaching should focus on a more appropriate physician response to the ''by-the-way'' syndrome

Physician Response to “By-the-Way” Syndrome in Primary Care

BACKGROUND/OBJECTIVE: "By-the-way" syndrome, a new problem raised by the patient at an encounter's closure, is common, but little is known about how physicians respond when it occurs. We analyzed the content of the syndrome, predictors of its appearance, and the physician response. DESIGN/PARTICIPANTS: Cross-sectional study of 92 videotaped encounters in an academic primary care clinic. RESULTS: The syndrome occurred in 39.1% of observed encounters. Its major content was bio-psychosocial (39%), psychosocial (36%), or biomedical (25%), whereas physician responses were mostly biomedical (44%). The physician response was concordant with the patient's question in 61% of encounters if the content of the question was psychosocial, 21% if bio-psychosocial, and 78% if biomedical; 32% of physicians solicited the patient's agenda two times or more in the group without, versus 11% in the group with, the syndrome (P = 0.02). In 22% of the encounters, physicians did not give any answer to the patient's question, particularly (38.5%) if it was of psychosocial content. CONCLUSIONS: "By-the-way" syndrome is mainly bio-psychosocial or psychosocial in content, whereas the physician response is usually biomedical. Asking about the patient's agenda twice or more during the office visit might decrease the appearance of this syndrome

Psychological transformations in kidney transplantation: A prospective qualitative study

The aim of this IRB-approved study was to prospectively analyze psychological transformations in ESRD patients before and after transplantation (KT). Semi-structured interviews were conducted in 30 patients (mean age = 53±10) after their inclusion on the waiting-list (Gr. A). Follow-up interviews were performed 6 months later in 15 patients still awaiting KT (Gr. B6), and in 15 patients 6 months (Gr. C6) and 12 months (Gr. C12) after KT. Qualitative analysis was performed. Gr: A:All patients underlined loss of freedom, 87% devoted much energy to maintain normality, 57% modified medical directives. All reported emotional fragility related to dialysis and loss of quality of life (QOL), negative (43%) or suicidal thoughts (20%). Professional stigma was underlined (26%). Gr: B6:40% reported no change, 60% mentioned increase of illness intrusiveness, 46% dialysis side-effects, 40% communication problems, 33% tension with medical staff and waiting list handling. Fear of emotional breakdown (40%), couple problems (47%) and worsened professional difficulties (20%) were reported. Gr: C6:All patients mentioned improved QOL and freedom recovery (87%). All expressed concerns about possible acute rejection, 73% were anxious about laboratory results, 93% experienced dependence to immunosuppressants, 47% reported difficulties in handling medication, 21% feared to forget them, 47% were concerned about side-effects, 67% had resumed work but medical constraints led to professional tension (40%). Gr: C12:All mentioned recovered QOL. Medical controls were accepted as a routine (87%) and adherence to medication was mandatory (100%). All mentioned the limited long-term graft survival and 47% were anxious about possible return to dialysis, especially younger patients (27%). Positive identity and existential changes were reported (60%). This prospective qualitative study identifies psychological modifications in the course of KT. It provides a basis to adequately address concerns, but it shows also that KT is clearly associated with positive psychological transformations