Do Unmet Expectations for Specific Tests, Referrals, and New Medications Reduce patients' Satisfaction?

BACKGROUND: Patient-centered care requires clinicians to recognize and act on patients' expectations. However, relatively little is known about the specific expectations patients bring to the primary care visit. OBJECTIVE: To describe the nature and prevalence of patients' specific expectations for tests, referrals, and new medications, and to examine the relationship between fulfillment of these expectations and patient satisfaction. DESIGN: Prospective cohort study. SETTING: VA general medicine clinic. PATIENTS/PARTICIPANTS: Two hundred fifty-three adult male outpatients seeing their primary care provider for a scheduled visit. MEASUREMENTS AND MAIN RESULTS: Fifty-six percent of patients reported at least 1 expectation for a test, referral, or new medication. Thirty-one percent had 1 expectation, while 25% had 2 or more expectations. Expectations were evenly distributed among tests, referrals, and new medications (37%, 30%, and 33%, respectively). Half of the patients who expressed an expectation did not receive one or more of the desired tests, referrals, or new medications. Nevertheless, satisfaction was very high (median of 1.5 for visit-specific satisfaction on a 1 to 5 scale, with 1 representing “excellent”). Satisfaction was not related to whether expectations were met or unmet, except that patients who did not receive desired medications reported lower satisfaction. CONCLUSIONS: patients' expectations are varied and often vague. Clinicians trying to implement the values of patient-centered care must be prepared to elicit, identify, and address many expectations

How Do Physicians Respond to Patients' Requests for Costly, Unindicated Services?

OBJECTIVE: To determine how physicians respond to a request for an expensive, unindicated test. DESIGN: Cross-sectional observational study. SETTING: Four sites of a group-model HMO. PARTICIPANTS: Thirty-nine internist volunteers. INTERVENTION: A standardized patient requesting magnetic resonance imaging (MRI) of the head to rule out multiple sclerosis (MS) was inserted unannounced into physicians’ regular schedules. The patient's only complaint was fatigue with no neurologic symptoms. MEASUREMENTS AND MAIN RESULTS: Physicians and standardized patients completed assessments after each visit. Thirty-five (90%) of 39 physicians “had no idea” that the patient they saw was the standardized patient, and the remaining four participants (10%) were only “somewhat suspicious.” Three (8%) of the physicians agreed to the MRI at the initial visit, and eight (22%) said they might order an MRI in the future. All doctors who refused the MRI told the patient this was based on lack of a medical indication for the test; seven (19%) also cited the test's expense. Twenty physicians (53%) of 38 agreed to a neurology referral. In response to the standardized patient's concerns, nine physicians (23%) verbalized that MS is scary, and four (10%) asked the patient about their friend's experience with MS. A few physicians appeared to dismiss the patient's concerns, such as by telling the patient they were being “paranoid.” CONCLUSIONS: Few physicians agreed to a standardized patient's request for a medically unindicated MRI, but more than half agreed to refer this patient to a specialist. As physicians practice cost-conscious medicine, they may need to focus on good communication to maintain patient satisfaction

Multisite phosphorylation networks as signal processors for Cdk1

The order and timing of cell cycle events is controlled by changing substrate specificity and different activity thresholds of cyclin-dependent kinases (CDK). However, it is not understood how a single protein kinase can trigger hundreds of switches in a sufficiently time-resolved fashion. We show that the cyclin-Cdk1-Cks1-dependent phosphorylation of multisite targets in Saccharomyces cerevisiae is controlled by key substrate parameters including distances between phosphorylation sites, the distribution of serines and threonines as phospho-acceptors, and the positioning of cyclin-docking motifs. The component mediating the key interactions in this process is Cks1, the phospho-adaptor subunit of the cyclin-Cdk1-Cks1 complex. We propose that variation of these parameters within the networks of phosphorylation sites in different targets provides a wide range of possibilities for the differential amplification of Cdk1 signals, providing a mechanism to generate a wide range of thresholds in the cell cycle