Patients' perceptions of omitted examinations and tests : A qualitative analysis

To understand the nature of patients' expectations for parts of the physical examination and for diagnostic testing and the meaning patients ascribe to their desires. Qualitative inquiry based on patient interviews and focused on perceived diagnostic omissions as "critical incidents." Three general internal medicine practices (21 practitioners) in one mid-sized northern California city. Of 687 patients visiting these practice sites and completing a detailed questionnaire, 125 reported one or more omissions of care and 90 completed an in-depth telephone interview. This study focuses on the 56 patients interviewed who did not receive desired components of the physical examination or diagnostic tests. Qualitative analysis of key themes underlying patients' unmet expectations for examinations and tests, as derived from verbatim transcripts of the 56 interviews. The 56 patients perceived a total of 113 investigative omissions falling into four broad categories: physical examination (47 omissions), conventional tests (43), high-cost tests (10), and unspecified investigations (13). Patients considered omitted investigations to have value along both pragmatic and symbolic dimensions. Diagnostic maneuvers had pragmatic value when they were seen to advance the technical aims of diagnosis, prognosis, or therapy. They had symbolic value when their underlying purpose was to enrich the patient-physician relationship. Patients in this study were often uncomfortable with clinical uncertainty, distrusted empiric therapy, endorsed early detection, and frequently interpreted failure to examine or test as failure to care. When patients express disappointment at failing to receive tests or examinations, they may actually be expressing concerns about the basis of their illness, the rationale for therapy, or the physician-patient relationship.