A framework for understanding visits by frequent attenders in family practice

OBJECTIVE: Our purpose was to develop a typology of outpatient visits between family physicians and adult "frequent attender" patients. STUDY DESIGN: This was a cross-sectional observational study using qualitative analysis of family physician visits. Three family physician researchers reviewed detailed field notes for each patient based on direct observation of a single office visit to determine major themes and characteristics of physician-patient encounters. POPULATION: Non-pregnant adults in the top 5% for visit frequency, and age- and sex-matched non-frequent attenders were identified from among 1194 adult patients in 18 Midwestern family practice offices as part of The Prevention and Competing Demands in Primary Care Study. RESULTS: Visits by 62 patients who had made at least 25 visits in the previous 2 years were selected (frequent attender visits). Three major dimensions emerged to distinguish different encounter types: (1) biomedical complexity, (2) psychosocial complexity, and (3) the degree of dissonance between the patient and the physician. These 3 dimensions were used in a descriptive framework to characterize visit types as: simple medical, ritual visit, complicated medical, the tango, simple frustration, psychosocial disconnect, medical disharmony, and the heartsink visit. CONCLUSIONS: The discovery of a wide variation of encounter types among adult frequent attenders and the resulting descriptive framework laid a foundation for defining the appropriateness of outpatient health care utilization, for designing interventions to reduce inappropriate utilization, and for educating physicians regarding effective management of frequent-attender patients.