Using a new contextual care model and contextual encounter checklist in a family practice residency program to investigate patient-physician interaction with the aid of videotaped resident encounters.

摘要

Patient-physician interaction dominates medical care and is a complex, dynamic intervention. High levels of physician skill combined with humanistic attitudes are necessary to maximize this tool. Continuing efforts to develop encounter models of care and teaching are vital. This dissertation examines medical interview literature and research. A Contextual Encounter Model (CEM) is introduced which offers a conceptual and structural approach to undergird a dynamic, patient-centered, culturally sensitive and family oriented relationship. Through shared meanings and mutually determined agendas, collaborative care promotes quality of life for both patient and physician. To aid in teaching and implementing contextual care, a 45-item Contextual Encounter Checklist was constructed and tested in a family practice residency clinic. Four observer pairs each evaluated 25 videotaped family practice resident encounters with variously aged patients during routine office visits. The raters agreed on observations for present and absent behaviors but showed more disagreement at higher levels of analysis. Mean scores for the subscale style were higher than for assessment, context, and management. Contextual subscale items were frequently rated not applicable and showed disagreement over the no and not applicable ratings. Overall, the encounters of male physicians exceeded those of female physicians in encounter rating scores of the full scale checklist. For female physicians, scores were higher in their work with female rather than male patients. In reference to patient gender, visits of male and female patients were comparably rated; however, visits with males showed less contextual content. There was no significant difference in the mean encounter ratings between the residents' levels of training. Behavioral scientists and physician ratings were similar; of 16 subscale mean scores, behavioral scientists rated lower nine times and higher seven times than physicians. More research is needed to understand the role of contextual care in patient encounters.