Abstract
BACKGROUND AND OBJECTIVES
Little is known about how patients and physicians perceive time and the extent to which they perceive the physician being rushed during encounters. One aim of this paper is to examine whether patient and physician characteristics and physician communication influence patient perception of the duration of the encounter and their perception of physicians being rushed. Another aim is to examine the relationship between patient and physician perceptions of physicians feeling rushed.
METHODS
We audiorecorded 461 encounters of overweight or obese patients with 40 primary care physicians and included 320 encounters in which weight was discussed. We calculated time spent with physician and coded all communication about weight using the Motivational Interview Treatment Integrity scale (MITI). Patients completed post-visit questionnaires in which they reported the estimated duration of the encounter and how rushed they thought the physician was during the encounter. Physicians reported how rushed they felt.
RESULTS
Patients estimated encounters to be longer than they actually were by an average of 2.6 minutes (SD=11.0). When physicians used reflective statements when discussing weight, patients estimated the encounter to be shorter than when physicians did not use reflective statements (1.17 versus 4.56 minutes more than actual duration). Whites perceived the encounter as shorter than African Americans (1.45 versus 4.28 minutes more than actual duration). Physicians felt rushed in 66% of visits; however, most patients did not perceive this. Internists were perceived to be more rushed than family physicians.
CONCLUSIONS
There is wide variation in patients’ ability to estimate the length of time they spend with their physician. Some physician and patient characteristics were related to patient perceptions of the length of the encounter. Reflective statements might lead patients to perceive encounters as shorter. Physicians, especially family physicians, appear able to conceal that they are feeling rushed.
Time is an important factor in health care settings as indicated by the double meaning of the word “patient.” A systematic review concludes that longer encounters are associated with lower prescription rates, more engagement in health promotion, and more patient empowerment.1 Many factors influence the actual duration of encounters. In a large European study, patient demographic factors explained 55% of the variance of encounter length.2
Encounter time can be represented either as actual or perceived time; these two do not always match. In two British studies, patient estimates were on average 7% shorter and 7% longer, respectively, than the actual duration. The standard deviations of the estimates were large.3,4
Actual and perceived time can influence patient satisfaction. In the United Kingdom, Cape found that the longer patients perceived the encounter to be, the more satisfied they were; the same was not true for actual duration of the encounter.4 In the United States, Lin et al found that neither the extent to which physicians felt rushed nor the patients’ perception of whether the physician was rushed influenced patient satisfaction.5
Thus, perception of the length of encounters is important. Besides patient demographics, it is unknown what might influence this perception. It is possible that physician communication could influence patient perception of time. A review suggested that positive physician communication could ameliorate the negative effects of time constraints.6 One aim of this paper is to explore whether patient and physician factors and physician communication influence patient perception of the duration of the encounter and their perception of physicians being rushed. Another aim is to examine the relationship between patient and physician perceptions of physicians feeling rushed. We used data from the CHAT (Communicating Health: Analyzing Talk) study, a large observational study of preventive and chronic care encounters between primary care physicians and their over-weight and obese patients.
Material and Methods
Recruitment: Physicians
Project CHAT was approved by the Duke University Medical Center Institutional Review Board. Forty physicians (74%) agreed to be in a study that examined how physicians discuss preventive health (not specifically about weight). Participating physicians gave written consent, completed a baseline questionnaire, provided an electronic signature for generating recruitment letters to their patients, and completed a post-visit survey after each audiorecorded encounter. Between 11–13 encounters with different patients were audiorecorded for each physician.
Recruitment: Patients
A letter introducing the study to patients included a toll-free number to refuse contact. One week later, patients were called to review eligibility and administer the baseline questionnaire. Eligible patients were at least 18 years of age, English speaking, cognitively competent, not pregnant, and had a body mass index (BMI)>25. Before the encounter, patients provided written consent. Immediately following the encounter, patients completed a post-encounter questionnaire.
Coding Audio Recordings: Quality
Motivational Interviewing (MI)
Two independent coders, each with 30 hours of training, assessed the extent to which physicians were using MI using the Motivational Interview Treatment Integrity scale (MITI)7 when discussing weight. The MITI has been shown to be a reliable and valid tool for assessing MI techniques.8,9 Inter-rater reliability was assessed using intraclass correlation coefficients (ICC) to account for differences in ratings for individual segments, along with the correlation between raters.10 Coders assessed global ratings of “Empathy” (1–5 scale, ICC=.70) and “MI Spirit” (1–5 scale, ICC=.81), which included three components: evocation (eliciting patients’ own reasons for change), collaboration (acting as partners), and autonomy (conveying that change comes only from patients).
Coders also identified six physician behaviors while discussing weight, including (1) closed questions (yes/no, ICC=.82), (2) open questions (ICC=.78), (3) simple reflections (conveys understanding but adds no new meaning, ICC=.45), (4) complex reflections (conveys understanding and adds substantial meaning, ICC=1.0), (5) MI consistent behaviors (asking permission, affirming, providing supportive statements, and emphasizing control, ICC=.70), and (6) MI inconsistent behaviors (advising without permission, confronting, and directing, ICC=.77).
Outcomes
Patients were asked after their encounter, “How much time did you spend with the doctor?” and prompted to give the answer in minutes. The actual time spent with the physician was calculated from the audio-recording of the visit. To create the time discrepancy outcome, the difference between patient reported time and the actual time was calculated.
Patient perception of the extent to which the physician was rushed was assessed by the patient's immediate post-encounter questionnaire. Patients rated “How rushed was the doctor?” (1=not at all rushed to 5= extremely rushed). As few patients reported that they perceived the physician to be rushed, this variable was dichotomized as “not rushed” if the score was 1 (n=257) and “rushed” if the score was >1 (n=63). Physicians answered a similar question about how rushed they felt on the survey administered immediately after the encounter. The distribution for this variable was different; thus the split for physicians was “not rushed” if scores were 1–3 (n=275) or “very rushed” as scores 4–5 (n=44).
Predictors
Predictor variables included: physician characteristics (gender, race [white, Asian or Pacific Islander versus African American]), years since medical school graduation, specialty [family versus internal medicine], and patient characteristics [gender, race (categorized as above), age]).
The relationships of five MI techniques were examined with the outcomes of time discrepancy and patient perception of physician being rushed. The MI techniques were (1) MI Spirit (score >1), (2) Empathy (score >1), (3) Open questions (any open questions), (4) Reflections (any simple and/or complex reflections), and (5) MI consistent and inconsistent behaviors (a score defined as MI inconsistent behaviors/[total MI consistent + inconsistent behaviors]).
Analysis
All analyses were performed using SAS 9.1 (SAS Institute, Inc, Cary, NC). For time discrepancy and the raw score (1–5) for patient perception of physician being rushed, an ICC was calculated to evaluate strength of association, within physician, between time discrepancy, and patient perception that physician was rushed.10
Linear mixed models (LMM) were fit to account for clustering of patients within physician.11 In the first set of analyses, PROC MIXED was used to examine the association of the time discrepancy with variables that were defined a priori at the patient (eg, age, gender, race), physician (eg, gender, race, specialty, years since medical school, actual time), and communication about weight (reflection) (Table 1). For the dichotomous outcome, PROC GENMOD was used to fit a generalized linear mixed model (GLMM) with a logit link to account for clustering of patients within physician to examine the relationship between patient perception of whether the physician was being rushed and variables defined a priori at the patient (eg, age, gender, race) and physician (eg, gender, race, specialty, years since medical school, actual time). We also examined whether there was an effect of race and gender concordance.
Table 1.
Characteristics for Patients Counseled (n=320)
| M (SD) or % (n) | |
|---|---|
| Patients | |
| Race | |
| White/ Asian /Pacific Islander | 61% (196) |
| African American | 39% (124) |
| Male | 34% (108) |
| Age | 58.4 (13.3) |
| Patient perception of duration of visit (minutes) | 22.9 (12.4) |
| Patient feeling physician being rushed | |
| Not at all rushed (1) | 80% (257) |
| 2 | 13% (41) |
| 3 | 5% (15) |
| 4 | 1% (3) |
| Extremely rushed (5) | 1% (4) |
| Physician (n=40) | |
| Race | |
| White/Asian/Pacific Islander | 85 % (34) |
| African American | 15% (6) |
| Male | 40% (16) |
| Years since medical school graduation | 22.1 (8.0) |
| Specialty | |
| Family physician | 48% (19) |
| Internist | 53% (21) |
| Visits | |
| Actual visit time (minutes) | 20.3 (7.6) |
| Physician report of being rushed | |
| Not at all rushed (1) | 34% (109) |
| 2 | 24% (78) |
| 3 | 28% (88) |
| 4 | 12% (38) |
| Extremely rushed (5) | 2% (6) |
| Duration of talk about weight (minutes) | 3.3 (3.3) |
| Communication during talk about weight | |
| Motivational interviewing spirit present | 12% (37) |
| Empathic statements present | 6% (18) |
| Open-ended questions present | 38% (121) |
| Reflection present | 38% (122) |
Results
Data from 320 encounters were available for the analyses. The actual duration of the visit and patients’ estimate were both normally distributed. Actual encounter lengths with African American physicians were longer than those with white physicians (mean (SD)=23.0 (8.9) minutes versus 19.7 (7.1) minutes, P=.004). Encounters with family physicians were not significantly longer than encounters with internists (21.1 (8.0) minutes versus 19.4 (7.0) minutes, P=.055). Encounter length was not significantly different between African American and white patients (20.4 (7.6) minutes versus 20.1 (7.9) minutes, P=.77). Of the patients, 80% did not feel that the physician was rushed at all, while physicians reported feeling rushed to some degree during 66% of the visits.
Relationship Between Actual and Estimated Length
The average patient estimated duration was 2.6 (SD=11.0) minutes longer than the actual duration (Table 1). White patients estimated their visit to be shorter than African American patients (Table 2). When physicians used reflective statements when discussing weight, patients estimated the visit to be shorter than when physicians did not use reflective statements.
Table 2.
Discrepancy Between Patient Estimated and Actual Duration of Visit, by Characteristics of Patients, Physicians, and Communication in Visits
| Characteristics | Mean* (Minutes) | 95% CI | P Value |
|---|---|---|---|
| Patients | |||
| Gender | .62 | ||
| Female | 2.53 | 0.47, 4.58 | |
| Male | 3.20 | 0.71, 5.70 | |
| Race | .04 | ||
| White/Pacific Islander | 1.45 | -0.84, 3.73 | |
| African American | 4.28 | 1.99, 6.58 | |
| Age (mean for age 60) | 0.03 | -0.07, 0.12 | .54 |
| Physicians | |||
| Gender | .30 | ||
| Female | 3.71 | 1.46, 5.95 | |
| Male | 2.02 | -0.65, 4.69 | |
| Race | .49 | ||
| White/Pacific Islander | 2.22 | 0.59, 3.85 | |
| African American | 3.51 | 0.12, 6.90 | |
| Specialty | .95 | ||
| Family medicine | 2.82 | 0.33, 5.31 | |
| Internal medicine | 2.91 | 0.81, 5.01 | |
| Years since residency (mean for 10 years) | 0.08 | -0.11, 0.27 | .41 |
| Actual visit time (mean for 10 minutes) | -0.21 | -0.37, -0.04 | .02 |
| Communication during talk about weight | |||
| Reflective communication (15 missing) | .01 | ||
| No | 4.56 | 2.42; 6.69 | |
| Yes | 1.17 | -1.19; 3.53 |
CI—confidence intervsl
Adjusted means ( 95% CI) are presented for categorical data. Parameter estimates (95% CI) are presented for continuous data (age, years since residency, and actual visit time).
Predictors of Physician Being Rushed
Even when physicians reported feeling very rushed, less than half of the patients perceived the physician to be rushed. When the actual duration of the visit was shorter, patients were more likely to perceive physicians as rushed. Patients were less likely to perceive family physicians as rushed than internists (Table 3). Communication variables and race or gender concordance were unrelated to perceptions that physicians were rushed (data not shown).
Table 3.
Patient, Physician, and Visit Characteristics Predicting the Probability of Patient Feeling of Physician Being Rushed During the Visit (OR) and (95% CI))(n=320)*
| Characteristics | OR | 95°% CI | P Value |
|---|---|---|---|
| Patients | |||
| Female versus male | 0.70 | 0.33, 1.50 | .36 |
| Age—20-year increments | 1.34 | 0.96, 1.87 | .10 |
| White versus African American | 0.98 | 0.44, 2.17 | .96 |
| Physicians | |||
| Female versus male | 1.46 | 0.59, 3.62 | .43 |
| White/Pacific Islander versus African American | 4.39 | 0.92, 21.01 | .05 |
| Internal medicine versus family medicine | 2.23 | 1.26, 3.93 | .01 |
| Years since residency—10-year increments | 1.22 | 0.71, 2.10 | .43 |
| Visits | |||
| Physician report of being rushed | .54 | ||
| Very rushed (5,4) versus Not at all (1) | 1.71 | 0.74, 3.90 | |
| Somewhat rushed (3) versus Not at all (1) | 0.80 | 0.33, 1.94 | |
| A little rushed (2) versus Not at all (1) | 0.82 | 0.40, 1.66 | |
| Actual visit time—10-minute increments | 0.60 | 0.39, 0.93 | .03 |
Outcome variable was dichotomized (0=Not at all rushed [n=257], 1=rushed [any degree of perception of rush] [n=63])
OR—odds ratio
CI—confidence interval
Discussion
This is the first study to link direct observation of physician communication to patient perceptions of time and patient perceptions of physicians being rushed. We found that patients on average estimated the duration of their encounter to be 2.5 minutes longer than it actually was and, notably, that there was large variability among patients. This discrepancy was larger than that found in the United Kingdom studies.3,4 Reflective statements were associated with patients perceiving the encounter as shorter. Even when physicians were very rushed, they seemed able to conceal this feeling of being rushed. Although we measured many patient variables, few explained the discrepancy between the estimated and actual time.
As patient satisfaction appears to be related to the perception of time in the encounter,4,5 longer perceived encounters are desirable. Patients might feel the encounter is longer when physicians allow them to talk more; however, our findings do not support this notion. Reflective statements encourage patients to speak more but seem to have the opposite effect. Perhaps patients viewed the encounters as more efficient, and thus quicker, when physicians talked less. Retrospective perception of time increases with the amount of information processed.12 An active patient probably processes more information than a passive listener. Also, it may be that patients viewed that the encounters are more enjoyable when physicians showed they were listening, and as the saying goes, “Time flies when you are having fun,” they might have viewed the encounter as shorter.
Whites viewed their encounters as shorter than did African Americans, inconsistent with previous studies in which African Americans report spending less time with their physicians than whites13 and with our observation that there was no difference in actual duration of the encounter. In contrast to a previous study,14 there was no race concordance effect. Therefore, even though African American physicians had longer encounters than white physicians, this actual longer length was not associated with patients, African American patients included, perceiving a longer length.
Family physicians may do a better job of hiding their feeling of being rushed as patients were less likely to perceive them as rushed when compared to patients of internists. Family physicians may have more theoretical training on communication and more practical training in outpatient clinics than inter-nists. Family physicians may also pay more attention to socio-emotional factors than internists, which might make patients feel they are less rushed.15
It makes sense that patients feel the physicians to be more rushed as encounter duration is shorter. We were encouraged that physicians seemed able to conceal that they were feeling rushed from their patients. This was also found by Lin et al, although they used a cruder measure of perception of feeling rushed.5 Another possible explanation is that patients usually expect physicians to be in a hurry and thus, hurried has become the new “normal.”
The strength of the study is the large sample size and the detailed information on communication about weight. A limitation is that our observation of reflective statements was limited to utterances about weight, and this might not pertain to the whole encounter. However, it is unlikely that communication during weight-related discussions differs significantly from other communication throughout the encounter. Another limitation is that we might not have measured the most important behaviors or other aspects of communication that are important for the perception of time.
In conclusion, we found that reflective statements might have influenced patients to view encounters as shorter. Some patient and physician factors were related to perceptions of encounter length and physician being rushed. Feeling rushed may have become the standard for physicians, yet they do not behave in a way that makes patients feel rushed or patients have become accustomed to physicians acting rushed. The findings, while intriguing, should be confirmed by other studies before inferences are made.
ACKNOWLEDGMENTS
Support was received from the National Institutes of Health (R01CA114392); Dr Alexander is supported by Health Services Research Career Development Award RCD 07-006 from the Department of Veterans Affairs. Early preliminary results were presented at the 2010 International Conference on Communication in Healthcare, Verona, Italy.
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