What would a consultation look like if a patient were able to voice all of their concerns? Asked in a different way, how can we quantitatively demonstrate the benefits of a consultation where a patient is allowed to simply speak freely?
Writing in The Journal of the American Medical Association, Dr. M. Kim Marvel et al. give some rich detail and answers. They use a slightly different approach to “agenda” than Barry et al. did in their work on unexpressed patient agenda items. This paper, though, comes to the same general conclusion: that being intentional about hearing all that a patient has to say makes healthcare more effective, not less.
Barry et al. explicitly define “agenda” in their paper. Although Marvel et al. don’t, it seems to be synonymous with a patient’s “concern”, mentioning research that
others [have] found that patients, if given the opportunity, have an average of 3 concerns per office visit.1
What they do define is the term “redirection”, citing Beckman and Frankel’s now (in)famous work that physicians interrupt their patients after 18 seconds:
Although Beckman and Frankel used the term interruption to describe this behavior, we prefer the term redirection to indicate verbal interventions that directed the focus of the interview before the patient had completed an initial statement of concerns.
The author’s method, then, is fairly straightforward: they timed and counted the ways that physicians talked about what they wanted to talk about instead of what the patient wanted to talk about. This “redirection” included everything outside of letting the patient talk or asking “Anything else?” in the most general way.
At first glance, the coding system, which the authors inherited from Beckman and Frankel, seems a little draconian. Even open-ended questions like “Tell me more about your pain” are coded as a “redirection”. The authors call this an “Elaborator”, which
are often focused, open-ended questions. Although designed to facilitate patient disclosure, they have the effect of directing the discussion toward a particular concern. The point of this method is to find out how free the patient really is to express everything they want to.
The other important data point was the “solicitation”:
an open-ended request for the patient’s problems or reason for visit. Both the timing and frequency of the solicitation were recorded.
The data that Marvel at al. produced is rich and worth reading through in depth. A few highlights:
completed their statement of concern(s)in only 28% of the consults studied
- A majority of physicians solicited concerns only once, and at the beginning of the consultation (47% did this, as compared with almost 25% who didn’t solicit their patient’s concerns at all)
- The more the physician solicits the patient’s concerns, the more information the physician gets: the mean number of concerns was 0.83 when the physician did not solicit concerns, and 1.3 when the physician did
Completed and noncompleted statements took approximately the same time (23.8 vs 27.7 seconds, P=.14). In other words, just let ’em talk.
- After the first time the physician redirected the conversation,
the patient went on to state 1 or more additional concerns in 33%of consultations.
- After the traditional “history-taking” portion of the visit, patients
initiated a new concernin just over 20% of cases
- There was no significant correlation between the likelihood a physician would allow a concern to be completed and any demographic or quality (e.g., physician experience, the sex of the patient, number of patients the physician sees per day) except one:
Fellowship-trainied physicians [
in family therapy and communication skills] solicited a complete listing of concerns more frequently.
When we talk about the sequence of events in a physician-patient meeting, there’s an interesting tension, which Marvel et al. do a wonderful job of discussing.
Looking at the sequence of a story, one of the things that makes stories effective (even “efficient”) at presenting information is that a story starts with a problem and doesn’t stop until there’s some kind of solution. Paralleling this, it makes sense that every concern should come out at the beginning of a doctor’s visit, and the discussion should proceed from there and work towards any necessary treatments:
Given the relatively small proportion of the interview needed to clarify the patient’s concerns, the related decreased likelihood of late-arising concerns and the difficulty of exploring new concerns late in the visit, our data support complete agenda setting as an efficient manner to open the medical encounter.
Multiple solicitations early in the visit may enhance the efficient of the interview by…allowing the physician and patient to prioritize problems at the outset…
This model of efficiency isn’t everything, though. There are a lot of assumptions behind this idea of getting everything out at once. There are plenty of reasons a patient would wait to bring up an issue until later in the consultation. Not least among them is that patients
may defer emotionally laden topics until the trustworthiness of the physician is better known or until the physician brings up the topic.2
Stories are both linear and cyclical. They move from a beginning to an end. Inside of every story of any length, though, there are smaller, dependent stories that make up the large one. The easiest way to express this is a trilogy. There are three plays, novels, or films that make up one whole, moving from beginning to end. The entire, overarching story, though, is made up of three smaller works, and each has smaller stories inside of it.
Without knowing it, the authors advocate for this principle in medical encounters:
One style that seemed useful was to follow each open-ended solicitation with a focused open-ended question (eg, “Tell me more about the leg pain”) then revert back to another open-ended solicitation (eg, “Anything else?”) before moving into closed-ended questioning and the examination.
This approach allows the physician to explore each individual concern and build trust. After hearing all the patient has to say about this concern, it also allows the physician to continue asking what else the patient’s concerns are in the broadest way. This is a little like each seperate work in a trilogy: whatever topic each film, novel, etc. explores can be investigated, but after that investigation is done, it’s time to move on to the next topic.
Marvel et al. mention “flexibility” in medical interviewing. Flexibility is good both for the style and personality of the physician and the needs of the patient. In this method of cyclical interviewing, the patient can present information in whatever order they wish, and the concern will be heard and investigated. The physician can decide exactly how much information is sufficient before returning to a more general “Anything else?”
The other interesting data from this paper is that physicians trained in communication skills interviewed differently. Stories and storytelling can be taught. If the advantages of looking at medical communication as a story can be articulated, they can be implemented.
The article reviewed: Marvel, M. Kim, Ronald M. Epstein, Kristine Flowers, and Howard B. Beckman. “Soliciting the Patient’s Agenda: Have We Improved?” JAMA 281, no. 3 (1999): 3–7.
1 Levenstein, J. H., E. C. McCracken, I. R. McWhinney, M. A. Stewart, and J. B. Brown. “The Patient-Centred Clinical Method. 1: A Model for the Doctor-Patient Interaction in Family Medicine.” Family Practice 3, no. 1 (March 1986): 24–30. ↑
2 Epstein, R. M., D. S. Morse, R. M. Frankel, L. Frarey, K. Anderson, and H. B. Beckman. “Awkward Moments in Patient-Physician Communication about HIV Risk.” Annals of Internal Medicine 128, no. 6 (March 15, 1998): 435–42. ↑