The medical office visit is the foundation of medical care and one of the most important professional activities of primary care physicians who are often the only source of mental health services for older adults. Evidence continues to show that the gap between science and clinical practice remains wide: as many as one half of older adults with a recognized mental disorder fail to receive any mental health services, and even fewer receive evidence-based treatments. 

Direct observation of how patients and physicians interact has led to research findings that are straightforward and easily understood by the public and policymakers. It offers a new perspective to study physicians' work and patients' contributions with potentially important new insights. We plan to apply mixed methods approach and combine perspectives from mental health services research with behavioral economics, communication research, and statistics. 

We specifically aim to examine the productivity of physician-patient communication by linking elements of quality of communication on mental health in the context of busy clinics and competing demands from co-morbidities. We will assess the contribution of factors that are germane to the practice environment and malleable to policy. At the completion of the study, we seek to formulate concrete recommendations about specific organizational or clinical interventions that can address a national priority: translating evidence to practice.

Conclusion

Based on direct observation of primary care office visits, we examined the length of visits, and more importantly, the content of 385 visits in terms of units of clinical decision making, which we refer to as “topics.” We operationalized topics as clinical issues raised by either participant. We partitioned a visit into topics, and coded the amount of time spent on each topic. Our approach allowed us to examine how much time was dedicated to specific topics and the factors that influenced how clinical time was allocated.

We found that a very limited amount of time was dedicated to specific topics in office visits. The median visit length was 15.7 minutes, covering a median of 6 topics. We concluded that a highly regimented schedule might interfere with having sufficient time for patients with complex or multiple problems including mental health disorders.

We further studied the nature of mental health discussions and the time devoted to them. We found that more than 1/2 of patients who could have benefited from mental health treatment (suggested by their low SF36 mental health score) did not even have a discussion of mental health. The median time a physician and a patient spent on discussing mental health issues was 36 seconds and 69 seconds, respectively. Qualitative analysis showed wide variations in the quality of metal health care. Referrals to mental health specialists were rare even for severely depressed patients.

Other findings have been published.

Funder

National Institute of Mental Health