Patients' Perceptions of Omitted Examinations and Tests: A Qualitative Analysis

Physicians routinely use the physical examination, selected laboratory tests, and imaging studies in medical decision making.1 However, the use of these tools can be costly in terms of time and resources. Physicians are exhorted to employ only the most efficient diagnostic strategies and to avoid unnecessary examinations and tests.2–4 At the same time, broader public awareness of the benefits of medical technology and an increasingly strident consumerist ethos have raised the stakes for physicians committed to cost-effective care.5–7 Despite the gap in medical knowledge between physicians and laypersons, patients can identify specific interventions they consider necessary.8–12 Research suggests that visit satisfaction suffers8 and health-related worry increases13 when desired diagnostic interventions are not received. Nonetheless, uncritical compliance with patients' requests would be unprofessional and arguably unethical.14 Engaging patients in a clinical negotiation in which patients and physicians share their concerns, discuss areas of contention, and reach a mutually agreeable conclusion can enhance the patient-physician relationship and increase patients' participation in their own care.15,16 This process has itself been associated with improved physiological and functional outcomes.17,18 The clinician who is aware of the nature of patients' desires and the personal meaning patients ascribe to them will be in a better position to negotiate productively around visit content. A systematic study of patients' unmet expectations for diagnostic investigations would create a context for understanding this important aspect of the physician-patient relationship. The current study relies on the same data set as a previously published manuscript.19 In that article, we reported that patients had unmet expectations for care in about 20% of medical encounters and that these expectations could generally be traced to four sources: current somatic symptoms, perceived vulnerability to illness, past experiences, and acquired knowledge. However, that study was broadly focused on the entire spectrum of patients' expectations (ranging from history taking to counseling) and did not address the question that motivates this article: When patients seek investigation of their symptoms by hinting at, requesting, or demanding various diagnostic maneuvers, what are they really after? We framed the current investigation in terms of the following two research questions. First, what is the nature of patients' unmet expectations for the physical examination and for diagnostic testing in primary care? (In this context, we define “unmet expectations” as medical services patients deem necessary or possibly necessary but which are not received.) Second, what meaning do patients ascribe to these expectations and desires? What value do they place on the desired services and how do they interpret physicians' failure to provide them? Insights gained from pursuing these questions may be useful both to clinicians seeking more effective strategies for clinical negotiation and to administrators contemplating policies that affect delivery of diagnostic services.