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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.
The medical record was used to obtain patient age, whether patients were new or established, and the extent to which a family medical history was cited in the chart for the observed visit or during any visit over the past year. The presence of a genogram (family tree) was noted, as was whether the medical record contained sufficient information to assess a family history of breast cancer, colon cancer, or alcohol abuse.
The patient exit questionnaire was used to assess education level and health status as measured by the Medical Outcomes Study (MOS) General Health Survey.7 These items used a 5-point Likert-type scale for responses to questions about global health status, health limitations in everyday physical activities, emotional problems, limitations in work because of physical or emotional problems, and body pain during the 4 weeks before the visit. Patient satisfaction was assessed with the MOS 9-Item Visit Rating Scale.8 The questionnaire also assessed the patient’s report of a family history that was taken during the visit or within the past year and whether other family members were patients of the physician. Patients also were asked to rate on a 5-point Likert-type scale the degree to which they agreed with the following statement: “This doctor knows a lot about the rest of my family.” The patient exit questionnaire also assessed 4 components of the quality of primary care, using the previously validated Components of Primary Care Instrument (CPCI).9 The CPCI assesses the amount of interpersonal communication, coordination of care, physician’s in-depth knowledge of the patient, and how much the patient values continuity of care. Its domains have been found to be internally reliable,9 associated with patient satisfaction9 and preventive services delivery,5 and diminished by forced disruption in continuity of care.10
The physician questionnaire measured physicians’ age, sex, and residency training, and also asked them to rate how much they “focus on the family as the unit of care,” assessed with a 5-point Likert-type scale. Physicians also were asked to estimate the percentage of patients that they periodically counsel about familial or genetic diseases. The outcome measures of preventive services delivery, patient satisfaction with the visit, and patient perception of components of primary care were measured using the arithmetic mean and standard deviation of patient scores for each physician.
Development of Family Factors
A factor analysis was performed with physicians as the unit of analysis to determine whether a limited number of physician styles could be ascertained from the family items collected for this study. Data on all patients seen by a physician were represented by a mean for each physician. A detailed description of the resulting 3-factor solution has been published previously.1 Factor scores were computed for each physician on the basis of a sum of the standardized items defining each factor [Table 1].
Two of the 3 factors identified relate to the physician’s degree of focus on the family; the third assessed whether the physician performed prenatal care or deliveries. The first factor, the family-orientation factor, described those physicians who focused on the family as the unit of care. The second factor, the family-history factor, indicated an approach in which the physician obtained a considerable amount of contextual information about the patient and family and used that information to care for the individual patient. The specific items defining each of these factors have been described previously and are also shown in Table 1.1 Scores on these 2 factors were not found to be correlated (r =tion was found between the family-history style and this scale measuring in-depth knowledge of the patient and the family.
Time Use
Physicians who scored high on the family-orientation factor were significantly more likely than those who scored low to spend a greater percent of the visit time gathering family information and counseling and spend less time structuring the visit interaction (Figure 5). Physicians with a high score on the family-history factor had significantly longer visit times (average: ~ 1.5 minutes longer) and devoted a greater percentage of time to preventive services delivery, health promotion, exercise and nutrition advice, counseling, family information gathering, and history taking while spending less time on treatment planning.
After adjusting for multiple testing, only 2 of the clinical behaviors measured by the DOC showed a difference in magnitude of correlation between the 2 family focus styles. The family-orientation style was associated with a significantly greater percentage of time spent obtaining family information; the family-history style was associated with a greater percentage of time spent on preventive services delivery. The latter finding, based on direct observation of time spent for a specific visit, further validates the associations shown in Table 4.
Discussion
To our knowledge, this is the first study to assess the effect of different approaches to family care on patient outcomes and time use during patient visits. Our study indicates that different styles of family focus have implications for the process and outcomes of patient care. Furthermore, physicians with the 2 different family practice styles tend to differ in physician characteristics and to see different patient populations. It is interesting to note that patients of family-oriented physicians whose practice style included greater emphasis on certain familial psychosocial aspects of care tended to report better overall health status (P <.10). This is of practice experience? One hypothesis about the possible etiology of these styles is that new residency graduates use their training to gather family histories as a context for screening and health habit advice for the individual patient. However, as they gain more practice experience they tend to become more relationship centered—pay more attention to family problems and less to screening and preventive services delivery. This process could be part of the developmental life cycle of a family physician; it may also be fueled by the complementary attitudes of patients. Younger patients often choose younger physicians, while older, patients and those with family problems may go to older more experienced physicians. In addition, our findings indicate that physicians who practice with a family-history stylemay benefit from a lower threshold for referring patients for family counseling. Alternatively, these physicians might work to hone their own skills to meet these needs while they perform preventive and physical examination procedures.16 In contrast, physicians who use a family-orientation style need to make certain that they or someone in the health care team will monitor and maintain the appropriate preventive services delivery.
Limitations
One limitation of our study was that the 2 family focus styles were developed on the basis of a small number of items related to family focus. There may be other styles that could be captured with a broader assessment. In addition, the sample represents only one geographical area (northeast Ohio). Our study, however, clearly benefited from the intensive multimethod examination of the process and outcome of care. Our findings advance previous work1 that reported a high level of family care and identified 2 distinct styles of family care in real world community practices.
1. Medalie JH, Zyzanski SJ, Langa D, Stange KC. The family in family practice: is it a reality? J Fam Pract 1998;46:390-6.
2. Stange KC, Zyzanski SJ, Flocke SA, et al. Illuminating the ‘black box’: a description of 4454 patient visits to 138 family physicians. J Fam Pract 1998;46:377-89.
3. Stange KC, Zyzanski SJ, Smith TF, et al. How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patient visits. Med Care 1998;36:851-67.
4. US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore, Md: Williams and Wilkins; 1996.
5. Flocke SA, Stange KC, Zyzanski SJ. The association of attributes of primary care with preventive services delivery. Med Care 1998;36 (suppl):A521-30.
6. Callahan EJ, Bertakis KD. Development and validation of the Davis Observation Code. Fam Med 1991;23:19-24.
7. Ware J, Nelson E, Sherbourne C, Stewart A. Preliminary tests of a 6-item general health survey: a patient application. In: Ware ASJ, ed. Measuring functioning and well being. Durham, NC: Duke University Press; 1992;291-307.
8. Rubin HR, Gandek B, Rogers WH, et al. Patient’s ratings of outpatient visits in different practice settings. JAMA 1993;270:835-40.
9. Flocke SA. Measuring attributes of primary care: development of a new instrument. J Fam Pract 1997;45:64-74.
10. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract 1997;45:129-35.
11. Kelly TL. The selection of upper and lower groups for the validation of test items. J Edu Psychol 1939;30:17-24.
12. American Academy of Family Physicians. Facts about family practice. Kansas City, Mo: American Academy of Family Physicians; 1996.
13. Bertakis KD, Callahan EJ, Helms J, et al. Physician practice style and patient outcomes: differences between family practice and general internal medicine. Med Care 1998;36:879-91.
14. Jaén CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166-71.
15. Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF, Zyzanski SJ. The value of a family physician. J Fam Pract 1998;46:363-8.
16. Cole-Kelly K, Yanoshik MK, Campbell J, Flynn SP. Integrating the family into routine patient care: a qualitative study. J Fam Pract 1998;47:440-5.
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.
The medical record was used to obtain patient age, whether patients were new or established, and the extent to which a family medical history was cited in the chart for the observed visit or during any visit over the past year. The presence of a genogram (family tree) was noted, as was whether the medical record contained sufficient information to assess a family history of breast cancer, colon cancer, or alcohol abuse.
The patient exit questionnaire was used to assess education level and health status as measured by the Medical Outcomes Study (MOS) General Health Survey.7 These items used a 5-point Likert-type scale for responses to questions about global health status, health limitations in everyday physical activities, emotional problems, limitations in work because of physical or emotional problems, and body pain during the 4 weeks before the visit. Patient satisfaction was assessed with the MOS 9-Item Visit Rating Scale.8 The questionnaire also assessed the patient’s report of a family history that was taken during the visit or within the past year and whether other family members were patients of the physician. Patients also were asked to rate on a 5-point Likert-type scale the degree to which they agreed with the following statement: “This doctor knows a lot about the rest of my family.” The patient exit questionnaire also assessed 4 components of the quality of primary care, using the previously validated Components of Primary Care Instrument (CPCI).9 The CPCI assesses the amount of interpersonal communication, coordination of care, physician’s in-depth knowledge of the patient, and how much the patient values continuity of care. Its domains have been found to be internally reliable,9 associated with patient satisfaction9 and preventive services delivery,5 and diminished by forced disruption in continuity of care.10
The physician questionnaire measured physicians’ age, sex, and residency training, and also asked them to rate how much they “focus on the family as the unit of care,” assessed with a 5-point Likert-type scale. Physicians also were asked to estimate the percentage of patients that they periodically counsel about familial or genetic diseases. The outcome measures of preventive services delivery, patient satisfaction with the visit, and patient perception of components of primary care were measured using the arithmetic mean and standard deviation of patient scores for each physician.
Development of Family Factors
A factor analysis was performed with physicians as the unit of analysis to determine whether a limited number of physician styles could be ascertained from the family items collected for this study. Data on all patients seen by a physician were represented by a mean for each physician. A detailed description of the resulting 3-factor solution has been published previously.1 Factor scores were computed for each physician on the basis of a sum of the standardized items defining each factor [Table 1].
Two of the 3 factors identified relate to the physician’s degree of focus on the family; the third assessed whether the physician performed prenatal care or deliveries. The first factor, the family-orientation factor, described those physicians who focused on the family as the unit of care. The second factor, the family-history factor, indicated an approach in which the physician obtained a considerable amount of contextual information about the patient and family and used that information to care for the individual patient. The specific items defining each of these factors have been described previously and are also shown in Table 1.1 Scores on these 2 factors were not found to be correlated (r =tion was found between the family-history style and this scale measuring in-depth knowledge of the patient and the family.
Time Use
Physicians who scored high on the family-orientation factor were significantly more likely than those who scored low to spend a greater percent of the visit time gathering family information and counseling and spend less time structuring the visit interaction (Figure 5). Physicians with a high score on the family-history factor had significantly longer visit times (average: ~ 1.5 minutes longer) and devoted a greater percentage of time to preventive services delivery, health promotion, exercise and nutrition advice, counseling, family information gathering, and history taking while spending less time on treatment planning.
After adjusting for multiple testing, only 2 of the clinical behaviors measured by the DOC showed a difference in magnitude of correlation between the 2 family focus styles. The family-orientation style was associated with a significantly greater percentage of time spent obtaining family information; the family-history style was associated with a greater percentage of time spent on preventive services delivery. The latter finding, based on direct observation of time spent for a specific visit, further validates the associations shown in Table 4.
Discussion
To our knowledge, this is the first study to assess the effect of different approaches to family care on patient outcomes and time use during patient visits. Our study indicates that different styles of family focus have implications for the process and outcomes of patient care. Furthermore, physicians with the 2 different family practice styles tend to differ in physician characteristics and to see different patient populations. It is interesting to note that patients of family-oriented physicians whose practice style included greater emphasis on certain familial psychosocial aspects of care tended to report better overall health status (P <.10). This is of practice experience? One hypothesis about the possible etiology of these styles is that new residency graduates use their training to gather family histories as a context for screening and health habit advice for the individual patient. However, as they gain more practice experience they tend to become more relationship centered—pay more attention to family problems and less to screening and preventive services delivery. This process could be part of the developmental life cycle of a family physician; it may also be fueled by the complementary attitudes of patients. Younger patients often choose younger physicians, while older, patients and those with family problems may go to older more experienced physicians. In addition, our findings indicate that physicians who practice with a family-history stylemay benefit from a lower threshold for referring patients for family counseling. Alternatively, these physicians might work to hone their own skills to meet these needs while they perform preventive and physical examination procedures.16 In contrast, physicians who use a family-orientation style need to make certain that they or someone in the health care team will monitor and maintain the appropriate preventive services delivery.
Limitations
One limitation of our study was that the 2 family focus styles were developed on the basis of a small number of items related to family focus. There may be other styles that could be captured with a broader assessment. In addition, the sample represents only one geographical area (northeast Ohio). Our study, however, clearly benefited from the intensive multimethod examination of the process and outcome of care. Our findings advance previous work1 that reported a high level of family care and identified 2 distinct styles of family care in real world community practices.
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.
The medical record was used to obtain patient age, whether patients were new or established, and the extent to which a family medical history was cited in the chart for the observed visit or during any visit over the past year. The presence of a genogram (family tree) was noted, as was whether the medical record contained sufficient information to assess a family history of breast cancer, colon cancer, or alcohol abuse.
The patient exit questionnaire was used to assess education level and health status as measured by the Medical Outcomes Study (MOS) General Health Survey.7 These items used a 5-point Likert-type scale for responses to questions about global health status, health limitations in everyday physical activities, emotional problems, limitations in work because of physical or emotional problems, and body pain during the 4 weeks before the visit. Patient satisfaction was assessed with the MOS 9-Item Visit Rating Scale.8 The questionnaire also assessed the patient’s report of a family history that was taken during the visit or within the past year and whether other family members were patients of the physician. Patients also were asked to rate on a 5-point Likert-type scale the degree to which they agreed with the following statement: “This doctor knows a lot about the rest of my family.” The patient exit questionnaire also assessed 4 components of the quality of primary care, using the previously validated Components of Primary Care Instrument (CPCI).9 The CPCI assesses the amount of interpersonal communication, coordination of care, physician’s in-depth knowledge of the patient, and how much the patient values continuity of care. Its domains have been found to be internally reliable,9 associated with patient satisfaction9 and preventive services delivery,5 and diminished by forced disruption in continuity of care.10
The physician questionnaire measured physicians’ age, sex, and residency training, and also asked them to rate how much they “focus on the family as the unit of care,” assessed with a 5-point Likert-type scale. Physicians also were asked to estimate the percentage of patients that they periodically counsel about familial or genetic diseases. The outcome measures of preventive services delivery, patient satisfaction with the visit, and patient perception of components of primary care were measured using the arithmetic mean and standard deviation of patient scores for each physician.
Development of Family Factors
A factor analysis was performed with physicians as the unit of analysis to determine whether a limited number of physician styles could be ascertained from the family items collected for this study. Data on all patients seen by a physician were represented by a mean for each physician. A detailed description of the resulting 3-factor solution has been published previously.1 Factor scores were computed for each physician on the basis of a sum of the standardized items defining each factor [Table 1].
Two of the 3 factors identified relate to the physician’s degree of focus on the family; the third assessed whether the physician performed prenatal care or deliveries. The first factor, the family-orientation factor, described those physicians who focused on the family as the unit of care. The second factor, the family-history factor, indicated an approach in which the physician obtained a considerable amount of contextual information about the patient and family and used that information to care for the individual patient. The specific items defining each of these factors have been described previously and are also shown in Table 1.1 Scores on these 2 factors were not found to be correlated (r =tion was found between the family-history style and this scale measuring in-depth knowledge of the patient and the family.
Time Use
Physicians who scored high on the family-orientation factor were significantly more likely than those who scored low to spend a greater percent of the visit time gathering family information and counseling and spend less time structuring the visit interaction (Figure 5). Physicians with a high score on the family-history factor had significantly longer visit times (average: ~ 1.5 minutes longer) and devoted a greater percentage of time to preventive services delivery, health promotion, exercise and nutrition advice, counseling, family information gathering, and history taking while spending less time on treatment planning.
After adjusting for multiple testing, only 2 of the clinical behaviors measured by the DOC showed a difference in magnitude of correlation between the 2 family focus styles. The family-orientation style was associated with a significantly greater percentage of time spent obtaining family information; the family-history style was associated with a greater percentage of time spent on preventive services delivery. The latter finding, based on direct observation of time spent for a specific visit, further validates the associations shown in Table 4.
Discussion
To our knowledge, this is the first study to assess the effect of different approaches to family care on patient outcomes and time use during patient visits. Our study indicates that different styles of family focus have implications for the process and outcomes of patient care. Furthermore, physicians with the 2 different family practice styles tend to differ in physician characteristics and to see different patient populations. It is interesting to note that patients of family-oriented physicians whose practice style included greater emphasis on certain familial psychosocial aspects of care tended to report better overall health status (P <.10). This is of practice experience? One hypothesis about the possible etiology of these styles is that new residency graduates use their training to gather family histories as a context for screening and health habit advice for the individual patient. However, as they gain more practice experience they tend to become more relationship centered—pay more attention to family problems and less to screening and preventive services delivery. This process could be part of the developmental life cycle of a family physician; it may also be fueled by the complementary attitudes of patients. Younger patients often choose younger physicians, while older, patients and those with family problems may go to older more experienced physicians. In addition, our findings indicate that physicians who practice with a family-history stylemay benefit from a lower threshold for referring patients for family counseling. Alternatively, these physicians might work to hone their own skills to meet these needs while they perform preventive and physical examination procedures.16 In contrast, physicians who use a family-orientation style need to make certain that they or someone in the health care team will monitor and maintain the appropriate preventive services delivery.
Limitations
One limitation of our study was that the 2 family focus styles were developed on the basis of a small number of items related to family focus. There may be other styles that could be captured with a broader assessment. In addition, the sample represents only one geographical area (northeast Ohio). Our study, however, clearly benefited from the intensive multimethod examination of the process and outcome of care. Our findings advance previous work1 that reported a high level of family care and identified 2 distinct styles of family care in real world community practices.
1. Medalie JH, Zyzanski SJ, Langa D, Stange KC. The family in family practice: is it a reality? J Fam Pract 1998;46:390-6.
2. Stange KC, Zyzanski SJ, Flocke SA, et al. Illuminating the ‘black box’: a description of 4454 patient visits to 138 family physicians. J Fam Pract 1998;46:377-89.
3. Stange KC, Zyzanski SJ, Smith TF, et al. How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patient visits. Med Care 1998;36:851-67.
4. US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore, Md: Williams and Wilkins; 1996.
5. Flocke SA, Stange KC, Zyzanski SJ. The association of attributes of primary care with preventive services delivery. Med Care 1998;36 (suppl):A521-30.
6. Callahan EJ, Bertakis KD. Development and validation of the Davis Observation Code. Fam Med 1991;23:19-24.
7. Ware J, Nelson E, Sherbourne C, Stewart A. Preliminary tests of a 6-item general health survey: a patient application. In: Ware ASJ, ed. Measuring functioning and well being. Durham, NC: Duke University Press; 1992;291-307.
8. Rubin HR, Gandek B, Rogers WH, et al. Patient’s ratings of outpatient visits in different practice settings. JAMA 1993;270:835-40.
9. Flocke SA. Measuring attributes of primary care: development of a new instrument. J Fam Pract 1997;45:64-74.
10. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract 1997;45:129-35.
11. Kelly TL. The selection of upper and lower groups for the validation of test items. J Edu Psychol 1939;30:17-24.
12. American Academy of Family Physicians. Facts about family practice. Kansas City, Mo: American Academy of Family Physicians; 1996.
13. Bertakis KD, Callahan EJ, Helms J, et al. Physician practice style and patient outcomes: differences between family practice and general internal medicine. Med Care 1998;36:879-91.
14. Jaén CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166-71.
15. Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF, Zyzanski SJ. The value of a family physician. J Fam Pract 1998;46:363-8.
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