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Thursday Review: “The Effect of Physician Behavior on the Collection of Data”

I love patient stories, and know how important they are to good care. The fact remains that patients are usually going to tell stories… badly. Physicians and other providers need to let them tell those ineffective stories, and be prepared for it.

Dr. Howard B. Beckman and Dr. Richard M. Frankel wrote an article in the Annals of Internal Medicine on how physicians’ verbal cues influence how and how much medical information is collected.

Beckman and Frankel help us realize how much control providers have over the patient encounter, and why narrative competence is so important.

Discussing the context of their article, the authors describe work focusing on barriers to patient-provider communication. This largely focuses on patients’ “hidden agenda”,1 in other words, that patients deliberately decide to withhold or delay sharing relevant information.

The data shows that that simply isn’t the case. This article focuses on how the physician’s speech controls the flow of information almost exclusively.

I’ve written about other researchers who have used Beckman and Frankel’s work to talk about how patients’ concerns can go unvoiced and different techniques for getting more of patients’ agendas out into the open. It’s worth diving in a little to this article, which set the precedent.

A story is a way of organizing information that states a problem first, then tells about a series of obstacles in the way of solving that problem, and that ends with some sort of solution.

Interestingly enough, the authors suggest that this is how medical students are taught information is collected: Students are taught that the clinical encounter may be segmented into a set of discrete tasks. The first is to identify the chief complaint.2

Beckman and Frankel point out that this has less to do with narrative and more to do with scientific method. The first phase of a medical encounter finds a question to ask, and a provider immediately moves into hypothesis testing.

Allowing a patient to simply talk until they feel they have every problem or concern out in the open is the same thing as knowing all the elements available to form a question for research.

If a physician asks, “What seems to be the trouble?” it sounds straightforward. The patient presents the most pressing issue first and presents it completely, and the conversation moves from there. It doesn’t happen that way: there is no empirical evidence that supports the hypothesis that the ordering of concerns is positively related to medical importance or severity.

The trouble is that patients, however, are not medically trained and are (usually) talking off the cuff. The other issue, one that the authors don’t mention explicitly, is that a healthcare provider is an authority figure, and is shown a large amount of deference in a discussion.

Put together, it’s important that the patient is allowed to stumble through their concerns, vomit out whatever related bits come to mind, and move through a fuzzy mental checklist of what they want to talk about. The authors name the goal of a patient’s opening remarks to be a spontaneous flow of information.

The main method of control that physicians (and other providers) exert over the conversation is the question. A closed-ended question (one that limits the number of responses) quickly “redirects” the conversation, as Marvel et al. say. Surprisingly, even an open-ended question (“Tell me more about…”) or a “recompleter” (simply re-stating what the patient has said) is enough to derail the flow of a patient’s thoughts. These are signals to the patient that what was just said is more important than anything else.

Almost anything said by a physician during the opening moments of a medical encounter takes control of the conversation:

  • In another paper, Frankel3 found that 94% of all interruptions concluded with the physician obtaining the floor.
  • In two studies,4, 5 physicians were found to control 91% and 99% of the questions asked in routine office visits…

The solution to get all that information out into the open is surprisingly low-tech and wonderfully simple:

…physician responses such as “mmh hmh,” “go on,” and “I see,” known linguistically as continuers, were found to facilitate completion [of a patient’s opening statement]. Although generally considered to be inert, these types of neutral utterances produced open-ended patient continuation that included new topics and concerns. Far from being inert, these linguistic devices appear to play a major role in facilitating all patient concerns at the beginning of a visit.

Narrative competency is important, then, because the patient probably isn’t going to tell a very well-organized story. It’s important that professionals are able to know how to listen as if it were one.


The article reviewed: Beckman, Howard B., and Richard M. Frankel. “The Effect of Physician Behaviour on the Collection of Data.” Annals of Internal Medicine 101, no. 5 (1984): 692–96.

1 Barsky, Arthur J. III. “Hidden Reasons Some Patients Visit Doctors.” Annals of Internal Medicine 94, no. 4 Part 1 (April 1, 1981): 492–98.

2 Kraytman, Maurice. The Complete Patient History. McGraw-Hill, 1979.

3 Frankel, Richard M. “From Sentence to Sequence: Understanding the Medical Encounter through Microinteractional Analysis.” Discourse Processes 7, no. 2 (April 11, 1984): 135–70.

4 Frankel, Richard M. “Talking in Interviews: A Dispreference for Patient-Initiated Questions in Physician-Patient Encounters.” In Interaction Competence, edited by George Psathas. Norwood, NJ: Ablex Publishing, 1986.

5 West, Candace. “Ask Me No Questions…” In The Social Organization of Doctor-Patient Communication, edited by Sue Fisher and Alexandra Dundas Todd, 75–106. Washington, DC: Center for Applied Linguistics, 1983.

Featured Image: detail from Design: Facial Anatomy from Encyclopédie by A. J. Defehrt, from the collection of the Art Institute of Chicago, reference 1941.133.58. This work is in the public domain.