From the Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (CPK, MH); Institute for Health Research, Kaiser Permanente Colorado, Denver, CO (DBM, EAB); Division of Research, Kaiser Permanente-Northern California, Oakland, CA (NC, AA, CSU, RWG); Center for Vulnerable Populations, University of California-San Francisco, San Francisco (CL); Department of Family Medicine, University of Colorado School of Medicine, Aurora (EAB); Department of Internal Medicine, University of Michigan, Ann Arbor (MH).
J Am Board Fam Med. 2018 Jan-Feb;31(1):29-37. doi: 10.3122/jabfm.2018.01.170167.
Choosing which issues to discuss in the limited time available during primary care visits is an important task for complex patients with chronic conditions.
DESIGN, SETTING, AND PARTICIPANTS: We conducted sequential interviews with complex patients (n = 40) and their primary care physicians (n = 17) from 3 different health systems to investigate how patients and physicians prepare for visits, how visit agendas are determined, and how discussion priorities are established during time-limited visits.
Visit flow and alignment were enhanced when both patients and physicians were effectively prepared before the visit, when the patient brought up highest-priority items first, the physician and patient worked together at the beginning of the visit to establish the visit agenda, and other team members contributed to agenda setting. A range of factors were identified that undermined the ability of patient and physicians to establish an efficient working agenda: the most prominent were time pressure and short visit lengths, but also included differing visit expectations, patient hesitancy to bring up embarrassing concerns, electronic medical record/documentation requirements, differences balancing current symptoms versus future medical risk, nonactionable items, differing philosophies about medications and lifestyle interventions, and difficulty by patients in prioritizing their top concerns.
Primary care patients and their physicians adopt a range of different strategies to address the time constraints during visits. The primary factor that supported well-aligned visits was the ability for patients and physicians to proactively negotiate the visit agenda at the beginning of the visit. Efforts to optimize care within time-constrained systems should focus on helping patients more effectively prepare for visits. Physicians should ask for the patient's agenda early, explain visit parameters, establish a reasonable number of concerns that can be discussed, and collaborate on a plan to deal with concerns that cannot be addressed during the visit.
在初级保健就诊时，选择在有限的时间内讨论哪些问题对患有慢性病的复杂患者来说是一项重要任务。
设计、设置和参与者：我们对来自 3 个不同医疗系统的 40 名复杂患者和 17 名初级保健医生进行了顺序访谈，以调查患者和医生如何为就诊做准备，如何确定就诊议程，以及在限时就诊期间如何确定讨论重点。
当患者和医生在就诊前都做好充分准备、患者首先提出最重要的问题、医生和患者在就诊开始时共同确定就诊议程、以及其他团队成员为议程制定做出贡献时，就诊流程和配合会得到改善。有一系列因素会破坏患者和医生建立高效工作议程的能力：最突出的是时间压力和就诊时间短，但也包括不同的就诊期望、患者不愿提出尴尬的问题、电子病历/文件要求、平衡当前症状与未来医疗风险、无法采取行动的项目、对药物和生活方式干预的不同看法、以及患者难以确定其首要问题的优先级。
初级保健患者及其医生采用了一系列不同的策略来应对就诊期间的时间限制。支持就诊配合良好的主要因素是患者和医生能够在就诊开始时主动协商就诊议程。在时间受限的系统中优化护理的努力应侧重于帮助患者更有效地为就诊做准备。医生应尽早询问患者的议程，解释就诊参数，确定可讨论的合理数量的问题，并共同制定计划，以处理无法在就诊期间解决的问题。
