Running Out of Time: Physician Management of Behavioral Health Concerns in Rural Pediatric Primary Care

Abstract

The purpose of this work was to examine pediatricians' responses to behavioral health concerns raised in the context of rural primary care visits with particular focus on time spent. Research assistants directly observed 302 patient visits in 2 rural pediatric primary care offices. The length of the visit, concerns raised, and physicians' responses were recorded. Interrater reliability, scored for 25% of observed visits, was strong. Behavioral, emotional, or developmental concerns were raised by either the parent or physician in 23.6% of all primary care visits observed. Approximately 9% of all visits were identified as a psychological consultation before the visit and lasted approximately 7 minutes longer than visits for other reasons. Behavioral concerns were raised during approximately 18% of visits not originally identified as a psychological consultation. In these cases, visit length increased by >5 minutes on average, a statistically significant difference. In addition, during these visits, discussion of behavioral concerns often consumed more than half of the visit. Data suggested that physicians were responsive to behavioral, developmental, or emotional concerns, engaging in further assessment, supportive statements, treatment, or referral in approximately 97% of the visits when such concerns were raised. Findings converge with previous research, showing that approximately one quarter of all primary care visits involve a discussion of behavioral, developmental, or emotional concerns. Moreover, this study is the first to document the specific impact of such concerns on pediatricians' time, often sited as a key reason why they struggle to effectively identify and treat behavioral concerns presenting in primary care. These data provide a starting point for controlled studies, including comparisons of rural versus urban samples and the impact of various collaborative models of care.