Stories From Frequent Attenders: A Qualitative Study in Primary Care

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Stories from Frequent Attenders:

A Qualitative Study in Primary Care


Paula Hodgson, Ph D , B S c [Hom)'
Patric ia S mith , M S c , M RCGP'
Trish B rown, LM S S A, M B B S '
Ch ristoph er D owric k, M D , FRCGP'
'LIniversity Liverpool, Merseyside, UK
^The Elms Medical Centre, Liverpool, UK
'Fazakerley Hospital, Liverpool, UK
"IT
MORE ONLINE
www.annfammed.org
ABSTRAa
PURPOSE Patients who make frequent office visits (frequent attenders) in primary
care are often considered a major burden on resources, yet we know little about
their perceptions and expectations. We wanted to explore how these patients
viewed their rates of consultation, what they expeaed from the consultation, and
how they perceived their relationship with the primary health care team.
METHODS Using a qualitative study design, we undertook in-depth semi-struc-
tured interviews with frequent attenders at 4 primary care practices of the Mersey
Primary Care R&D Consortium in the North West of England. Panicipants were
identified on the basis of office visits at least twice the mean standardized rate for
1 year and a medical assessment that these visits had no important clinical out-
come. Interviews with 30 patients aged 24 to 81 years (18 men) were audiotaped
and transcribed, and the text was methodically coded; data were analyzed by
generating common themes.
RESULTS Participants were unable or unwilling to quantify their consultation rates.
Despite the assertion by many participants that family doctors are caring, author-
ity figures, there was an underlying tension between such perceptions and the
apparent medical mismanagement of symptoms. Their expertations of the con-
sultation were complex and included the presentation of old and new symptoms
implicitly embedded within an illness framework. Gaining access to family doaors
was generally perceived as problematic.
CONCLUSION The criteria held by family doctors and researchers regarding the
appropriate rate of consultations in primary care may not be shared by patients
who attend frequently. Such patients require family doctors to acknowledge their
symptoms and to provide reassurance
/Inn Fam Med 2005:3:318-323. DOI: 10.1370/afm.311.
Conj lic ts of interest: none reported
CORRESPONDING AUTHOR
Paula Hodgson, PhD, BSc
Division of Primary Care
University Liverpool
Whelan Building
Brownlow Hill
Liverpool, Merseyside, UK L69 3GB
phodgson@liv.ac.uk
INTRODUaiON
T
he term j rei^uent attenders has 2 components within a medical arena. Its
overt meaning is numeric or statistical, referring to patients defined
simply by their number or rate of physician consultations.'"' It also
has a covert, pejorative meaning, referring to those patients who are per-
ceived by family doctors as taking up a disproportionate amount of con-
sultation time'"and being a burden on resources and workload." Propor-
tionally this group appears to be on the increase.'^ In the current climate
of increasing use of primary care services alongside constraints upon the
time allowed for a consultation, patients who attend frequently are often a
source of frustration to primary care clinicians."'"*
Researchers have adopted particular theories and methods" that tend
to disseminate a derogatory image of patients who attend frequently. For
example, they are reported to be more likely to suffer with psychological
and psychiatric problems, such as somatization, to have higher rates of
physical disease, and to have poorer health beliefs when compared with
those who are not frequent attenders. "'^'' Despite their heterogeneity.
ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 3, NO. 4 JULY/AUGUST 2005
FREQUENT ATTENDERS
there have been attempts to identify subgroups, such
as Katon's "distressed high utilizers,""" and Karlsson's 5
patient groups: patients with entirely physical illness,
patients with clear psychiatric illnesses, crisis patients,
chronically somatizing patients, and patients with mul-
tiple problems.''
We decided to approach frequent attendance from
another perspective, that is, what do patients them-
selves think about consulting a family doctor? Are they
aware that their consulting rates and their constellation
of symptoms are causing problems? Our research ques-
tions were influenced by work within the sociology of
health and illness that has explored individuals' percep-
tions and knowledge,^^^'' and science and technology
studies,*^''^' in which the taken-for-granted nature of
medical knowledge and its application in practice has
been questioned.
We know that consultation decisions by patients
who attend frequently are complex, including per-
ceptions of the medical role and past experiences of
symptoms.''^ Although these patients may have an
accurate recall of the number of consultations,'^* they
may believe their rates to be average or below aver-
age.' Yet the medical community knows little about
how these patients view the quality and importance of
their interactions with primary health care apart from
the suggestion that they may also find these encoun-
ters frustrating.^' Further exploration of the reasons
for consulting frequently may provide insights into
the expectations of this group of patients, enabling
clinicians to develop more appropriate management
strategies.
Our study was designed to answer 3 questions: (1)
What are the perceptions of people who attend fre-
quently of their rate of consultation? (2) What do they
expect of the consultation? (3) How do they view their
relationship with primary health care teams?
METHODS
Three family doctors and a social scientist developed
and undertook the study. The doctors were members of
the Mersey Primary Care R&D Consortium^ (the Con-
sortium) and had a particular interest in patients who
attend frequently.^"""
This study took place in 4 general practices within
the Consortium, in the North West of England. Three
practices were urban, and 1 was rural. One of the urban
practices was single-handed.* Ethical approval for this
study was given by Local Research Ethics Committees.
To encompass numeric and normative components
of frequent attendance, we used a 2-stage approach to
identify study participants. First we generated lists of
patients whose consultations rates were at least twice
the mean annual rate for each practice, stratified by sex
and 4 age ranges.^ Then we identified those patients
whose attendance was likely to be problematic for
their family doctors by sending each doctor a letter
outlining the research and asking them to assign each
listed patient to 1 of 3 categories: "'significant clinical
outcome"; "no significant clinical outcome",- and "other."
We used this process to exclude patients who were
consulting frequently for clearly recognized medical
problems ("significant clinical outcome") or time-spe-
cific events ("other"). Those patients who were judged
by a family doctor to have "no significant clinical out-
come" were classed as patients who, for the purposes
of this study, attend frequently. We contacted them
by letter, inviting them to take part in an interview,
and enclosed an information sheet and a consent form.
Patients who consented were contacted by telephone
to arrange a convenient time and location for interview.
The lead author carried out semi-structured interviews
with these patients during 2001 and 2002.
Analysis
The interview schedule can be found in the Supplemen-
tal Appendix, available online only at http://www.
annfammed.Org/cgi/content/full/3/4/318/DC1.
Interviews were audiotaped and transcribed. Analysis
was undertaken using NVIVO. All of the transcripts
were open coded by the lead author, and 10 transcripts
were open coded by a member of the team who was
a qualitative researcher. The next stage of analysis
involved generating themes that emerged from the
interviews through a review of the open codes. The
themes that emerged for the purposes of this report
included frequency of consulting, reasons for consult-
ing, bodily perceptions and reassurance, dissatisfaction
with consultations, and overcoming obstacles. All of the
interviews were included in the analysis,- there were no
disconfirming cases.
RESULTS
There were 496 patients who met the initial inclusion
criteria by consulting at least as twice as often as the
mean, by age and sex, for their practice. Of these, 75
(15%) were judged by their family doctors to have
* Science and technology studies have developed from work within medi-
cal sociology and the sociology of scientific knowledge. More recently,
there have been moves to work in medicine that have examined the
complex interplay between actors, medical knowledge, and medical
practices."
f The Mersey Primary Care Research and Development Consortium is
made up of 5 primary care practices. The aim of the Consortium is to
develop a research culture within primary care and is funded by the
Department of Health.
I The use of the term s/ng/e-handed in the UK refers to a primary care
practice that Is run by 1 family doctor
ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 3, NO. 4 JULY/AUGUST 2005
FREQUENT ATTENDERS
achieved "no significant clinical outcome" and were
therefore classified as patients who, for the purposes of
this study, were frequent attenders. All of these patients
were contacted, and 30 (40%) agreed to participate in
an interview. The 45 patients who were not interviewed
fell into several categories: 5 were not living at the last
known address,- 2 did not have a telephone,- 7 agreed
to be interviewed but were subsequently unavailable
when at the agreed time and location,- 16 declined to
be interviewed.
Eighteen (60%) participants were men and 12
(40%) were women. Their mean age was 54 years
(range 24 to 81 years). Their mean number of consulta-
tions was 28 (range 15 to 60) during the previous year.
Frequency of Consulting
There were 2 types of frequent attenders in this sample.
Most participants (27 of 30, 90%) were unable to give
a clear indication of their frequency of consultations.
Typical responses to the question on the frequency of
consultations included the following:
"Don't really know, depends what's wrong with me."
(Interview 09)
"Went to the doctor's last week." (Interview 22)
"Must be a couple of weeks ago now." (Interview 13)
"Quite a lot." (Interview 02)
"I've got to go up to the hospital on ... think it's Fri-
day, to see the doctor about my pains." (Interview 10)
"Well, it's just round the corner, only 5 minutes
away ... if it's nice I walk round, if it's bad, you know
raining, 1 go in the car." (Interview 14)
"Not sure really, can't really say, hard to remem-
ber how much ... not something I keep in my head."
(Interview 21)
The second group were crisis patients, with a clear
stressor that precipitated high rates of consultation for
a specific period.^" Three respondents reflected on their
high rates of consultation and offered explanations, for
example:
"I was going through a really bad patch ... went to
see Dr A, and he was really good." (Interview 04)
"Had lots of problems last year and couldn't cope."
(Interview 18)
Implicit here is the notion that, for these patients,
there were particular times when they were undergoing
specific life problems (work-related stress and marital
problems) and reported that their family doctors pro-
vided considerable support during these times. The
separation between acute periods, when they were
experiencing life problems, and other times, when they
did not need such support from their family doctor, is
illustrated by the following response
"Normally twice a year and that would be it."
(Interview 11)
Reasons for Consulting
Reasons for consulting a family doctor were based on
representations of family doctors as respected authority
figures who are the most appropriate to consult for the
distinctive and extensive physical sensations or symp-
toms that patients perceived to require medical care
and reassurance.
Representations of family doctors as having high
esteem and status is illustrated by the following quotes:
"They're like your mother and father, you can tell
them anything." (Interview 01)
"I suppose they're similar to a priest, somebody you
can trust." (Interview 14)
"I don't know ... they know lots, don't they?" (Inter-
view 05)
'They've had all that training and that, they have
those books they look things up in." (Interview 12)
"I tell my doctor things I wouldn't say to anybody
else, not even the wife. You know when you tell them
something, it's between you and him, you know it's not
going to get out." (Interview 24)
The belief that a family doctor was the most appro-
priate and obvious person to manage and treat their
symptoms is illustrated below:
"Doctor can sort it out." (Interview 03)
"Well, that's where you go when there's something
wrong with you, isn't it?" (Interview 25)
'They know what they're doing, don't they? They
know what to get for you, you know, the right drugs
and that." (Interview 20)
"They're the ones who tell you what's wrong, they
work it out." (Interview 10)
The ability of family doctors to be a part of an
individual's unique suffering was expressed by 1 inter-
viewee for whom there was overlap between experienc-
ing prolonged caring (and eventual bereavement for a
close family member) and increased contact with his
family doctor:
"It was all so difficult when John got ill. We couldn't
get any answers from all those doctors, they couldn't
do anything, and to make things even worse, I started
to get ill, had to give up work ... been there for 23
years. I was trying to cope with his [son's] terrible suf-
fering, and the wife was going out of her mind, know-
ing he could die at any time. And at the same time ...
he was so young, and we thought at first he'd be cured
... it just got worse and worse. When he died, our lives
fell apart. There was nothing ... and those doctor's,
they don't help me, I've been everywhere ... I'm still
waiting for test results." (Interview 26)
The interrelationship between periods of extreme
stress and illness are evident in this passage, along with
a sense of disappointment in the ability of clinician to
prevent this child's death. Furthermore, the extreme
ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 3, NO. 4 JULY/AUGUST 2005
FREQUENT ATTENDERS
and for this interviewee uniquecircumstances of his
suffering were perceived to be unnoticed by clinicians.
Bodily Perceptions and Reassurance
Some patients described experiencing a relatively high
number of physical sensations that were difficult for
them to endure and required reassurance from their
family doctor:
"I want to know what's wrong with me, there's
always something. Never seem to get clear. Think I'm
getting sorted, then something else pops up. Doctor
says I've got high blood pressure, you see, and have to
be careful. It could be to do with that." (Interview 29)
"Well, like the other morning, I woke up and I had
this terrible lump [points to throat]. I couldn't breathe,
it was really ... so had to phone the doctors. Couldn't
carry on with that, could I? What if I couldn't have
breathed? Don't want to wait around with that, do I?
Might have ended up in hospital. Then, like another
time had this funny breathing, and it just wouldn't stop.
I was getting worried so had to go to the doctor's for
that." (Interview 01)
"Doctor said, 'Come back if it happens again.'
And I'd had another one, felt really bad, didn't know
what was going on, just wouldn't go, this funny tin-
gling right the way down here [indicates back of leg],
couldn't walk hardly. Then it went here [points to
arm], could be something to do with my heart, heard
you get funny pains there, you know, before a heart
attack." (Interview 15)
"I'd been woken up by it, must've been 2 o'clock.
Didn't feel right at all, couldn't get back to sleep, tried
everything, thought of calling doctor out to come and
see me, but thought, best leave it to morning. And doc-
tor saw me and said I was all right. I was really worried,
just couldn't get right in myself. When it's that bad, you
have to go see him." (Interview 23)
Dissatisfaction wi th Consultations
Despite holding their doctors in high regard, slightly
more than 2 thirds of the interviewees (n = 22) expressed
some form of dissatisfaction with their treatment:
"I told her what was wrong and she said I had, it
was to do with my heart. It was my throat that were
wrong, so I don't know." (Interview 17)
"I keep telling them, 'What's up? I can't sleep.' They
don't seem to be able to do anything, they don't under-
stand." (Interview 21)
"It's a bit annoying, really. I keep saying there's
something draining behind my cheek, and then that
goes down my throat, some gloopy stuff, but he keeps
saying it's something to do with my teeth. I know it's
not, it's something behind there. I've been to the den-
tist, and he can't find anything." (Interview 11)
"I've been a few times to see her, and the last time
she said to get on with life, just enjoy it. How can I
when I've got this banging going on in my ear? It won't
go away by itself, I'm going to have to go back and get
it seen to." (Interview 09)
"You see, they can't find out what's wrong with me.
They keep saying one thing and giving me these pills.
They don't do any good, so I go back, they give me
others." (Interview 16)
"She gave me some cream, it didn't do any good, I
put it in the bath and had to go back." (Interview 12)
Overcoming Obstacles
Most interviewees (n = 23) reported obstacles to con-
sulting with their family doctor:
"You can never get through, and when you do,
they're so rude, you'd think they don't want you, and
you can never get the doctor you want ... you have to
take next week, but that's no good is it? I want to see
Dr B when I'm not well." (Interview 17)
"You have to be up early, get on the phone at quar-
ter past eight and keep ringing 'til you get through."
(Interview 13)
"It's a daft system, if you ask me. Used to be all
right. Can't see the doctor for 2 weeksdon't have any
appointments. I might not be ill then, and the girls say
if it's an emergency, then you have to call back, but try
getting throughit's always engaged." (Interview 30)
In spite of considerable logistical problems, such
as telephone systems and reception staff, there was a
sense from the interviews that a consultation with a
family doctor would be achieved.
A minority (n = 7) reported friendly relationships
with reception staff:
"I can go anytime, just phone up and they fit me in.
The girls on the telephone know me really well and
always sort me out." (Interview 07)
DISCUSSION
The term fretfuent attender has particular connotations
within a medical-research arena: it generally refers to
patients who are considered to be problematic within
primary care for the number of times they consult and
symptoms that are difficult to manage. A crucial find-
ing from this study was that most of our interviewees
were disinclined or unable to quantify their consulta-
tions. It may simply be that they were unable to recall
the number of visits they made to their family doctor,
or there may be a reluctance to disclose rates of con-
sultation, based on an awareness that their visits to
their family doctor are frequent and an unwillingness
to acknowledge inappropriate behavior. Their rates
of consulting might have become naturalized^'' and so
ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 3, NO. 4 JULY/AUGUST 2005
FREQUENT ATTENDERS
not considered to be worth quantifying, that is, visit-
ing the doctor has become commonplace and embed-
ded in their routines. Alternatively, these patients
might not perceive their consultations in terms of
numbers of visits,- they may be visiting their doctor
simply as a function of their symptoms, so the number
of times they consult is irrelevant. All of these inter-
pretations indicate qualitative differences between the
quantification of consultations by family doctors or
researchers and patients' perceptions of their atten-
dance rate. We conclude that the norms reported in
the literature about consultation rates do not apply to
this group of patients.
It is entirely appropriate to consult a family doc-
tor when experiencing physical symptoms that are
perceived to be related to some form of illness: 90% of
initial contacts with health professionals are located in
primary care." Family doctors are generally perceived
as situated within an illness framework and can diag-
nose conditions and manage symptoms. The multiplic-
ity of complaints and symptoms reported during our
interviews, however, suggests a high degree of medi-
calization^^ by patients and family doctors, which is in
agreement with the finding that patients who consult
frequently have a much higher rate (40% to 50%) of.
physical disease than does the average attender.'^'*
The apparent inability of these patients to accom-
modate physical sensations or symptoms and to consis-
tently seek out medical advice (despite such obstacles
as reception staff and practice systems) suggests several
possibilities. Their physical feedback mechanisms may
be amplified, leading to a heightened experience of their
bodies and an inability to distinguish between normal
and abnormal sensations.'^ They lack the ability to reas-
sure themselves that they are not ill or to accommodate
bodily changes. There are underlying problems (includ-
ing mental health and social issues) that are consistently
unresolved and are expresed as physical symptoms.^'^^
Respondents' perception that doctors misunder-
stood their symptoms led to the associated belief that
their doctors were managing their illnesses inappro-
priately. Such tension can be understood in a number
of ways. There may be poor communication between
frequent attenders and family doctors that reflects a
dysfunctional relationship.^' Family doctors may not
communicate adequately their diagnosis and manage-
ment of symptoms, and patients who attend frequently
may be selective about the information that they
choose to give and to receive. As long as these patients
perceive and represent their symptoms and illnesses as
managed inappropriately by family doctors, there will
always be a justifiable reason to frequently visit their
family doctor.
We suggest at least 2 levels of need among patients
who attend frequently. First, their apparent high levels
of physical symptoms have to be acknowledged by a
significant other, such as a family doctor. Second, their
symptoms require legitimization by being situated
within an illness framework. The dissatisfaction with
family doctors expressed by some interviewees, how-
ever, indicates a third component to their needs, that
is, their particular suffering is considered unique and
cannot be fully understood, even by an authority on
illness, such as a family doctor.
Strengths and Limitations of the Study
We used a novel method to determine which patients
family doctors consider to frequent attenders.
Although, similar to other research,'" we used quantita-
tive definitions of frequent attendance to generate lists
of patients who had office visits at twice the mean rate
for the practice and age ranges, the rating of these lists
of patients was undertaken by family doctors for whom
"no significant clinical outcome" was used as an identi-
fier for patients who frequently attend. There may
have been differences between doctors in their use of
the criteria (which would require further refinement),
as evidenced by the 3 interviewees in this study who
could be considered to be crisis patients rather than
frequent attenders. We believe, however, that using
family doctors to identify those patients who they con-
sider attend frequently is a useful strategy that can be
fijrther developed.
It was difficult to find patients who would agree
to an interview for this study. Ethical considerations,
however, constrained us from determining whether the
potential participants who were not interviewed (60%)
are the more challenging for family doctors in terms of
their consultation rates and symptoms.
Implications for Future Research
and Clinical Practice
Clinical management of patients who attend frequently
is characterized by mutual frustration and a lack of
reciprocity.''' Frequent attenders require consistent
acknowledgment and legitimization of their perceived
unique suffering. An increased awareness by physi-
cians of their patients' perceptions and expectations
is essential. Instead of giving patients medications for
their symptoms, clinicians might find it more helpful
to focus on reassurance techniques using explanations
that relate to the patient's conceptual framework and
exempt the patient from blame." To design effective
. educational interventions, we need future research that
examines clinicians' interactions with patients who
attend frequently.
To read or post commentaries in response to this article, see it
online at http://www.annfammed.Org/cgi/content/full/3/4/318.
ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 3, NO. 4 JULY/AUGUST 2005
FREQUENT ATTENDERS
Key words: Frequent attendance; primary care; patient perceptions;
medically unexplained symptoms (MUS)
Submitted July 26, 2005; submitted, revised, February 2, 2005; accepted
February 7, 2005.
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