[tweetmeme source=”Healthmessaging” only_single=false]I recently participated in a Twitter Chat about physician-patient communications. A common refrain from some of the providers in the group was that “there isn’t enough time” during the typical office visit for physicians to worry about communicating effectively. What’s up with that?
The goal of patient centered communications is to engage the patient in their own health care. While most physicians endorse the concept of patient centered communications, many seem reluctant to employ such techniques in their own practice. Why? I suspect that many fear that too much patient involvement will increase the length of the visit.
Take the patient’s opening statement aka “patient agenda” in patient centered lingo. This is where the doctor asks the patient why they are there. The resulting patient narrative is an opportunity for the physician to obtain valuable information to help assess the patient. Patient centered advocates recommend that physicians use open-ended questions like “what brings you in today” to solicit the patient’s concerns and agenda. Active listening by the physician and paying attention to the patient’s emotional cues are also hallmarks of patient centered communications.
The reality is that regardless of how they are asked, patients are often not able to complete their opening statement. That’s because many physicians (75% in one study of primary care physicians) interrupt their patients within the first 18-23 once they start talking. According to Jerome Groopman, MD, author of the book How Doctors Think, this is because doctors often have a hypothesis in mind regarding a diagnosis even before the patient says a word. When patients do speak, there is always the risk that physicians “take off” on the first concern mentioned on the assumption that it is the most important reason for the patient being there.
Here’s a personal example. Three times over the last several years my wife developed severe abdominal pain, nausea, vomiting and dehydration. Each time I took her into the emergency room as the problem always seemed to occur at night. The physician would come in and ask my wife what the problem was. No sooner did her opening words “I am a lung cancer survivor” get out of her mouth and the physician was off to the races apparently assuming that her being in the ER was due to her cancer. Chest X-rays were ordered…the whole works. Yet each time all she apparently needed was to get rehydrated (an IV) and given something to stop the nausea and vomiting. After 6 hours we would go home and she would be fine the next day.
My point is that a lot of time and resources can be misdirected when the patient is not allowed to say what they think is wrong. Not only is there a risk of wasting time, but physicians also risk losing the respect and trust of patients who feel they are not being listened to. Had my wife been allowed to fully explain what she thought she needed, based upon previous experience, she would have been quickly treated and out of the ER.
The Take Away – The use of patient-centered communications techniques like agenda setting and active listening can go a long way in: 1) obtaining useful diagnostic information, 2) giving patients a sense that they are being listened and that what they have to say is important and 3) building rapport between the physician and patient.
The Bottom Line – According to researchers, the use of open-ended questions and active listening during the patient’s opening statement added 6 seconds to the average visit length. In exchange, according to researchers, patients are more satisfied, adherent and report better outcomes. Not a bad investment for 6 seconds! What do you think?
Sources:
Beckman HB, Frankel, RM. The effect of physician behavior on the collection of data. Annals of Internal Medicine. 1984 Nov;101(5):692-6.
Marvel, K, Epstein, R, Flowers, K, Beckman H. Soliciting the Patient’s Agenda, Have We Improved? JAMA. 1999;281:283-287.
Groopman J. How Doctors Think. Houghton Mifflin. 2007.
Mind The Gap 
It seems to me that it’s only natural for an ER doc to assume that the first thing a patient says is why they’re in the ER. I agree that an awful lot of doctors need to listen better–and longer–to their patients, but the patient’s contribution to the problem is illustrated by your personal story: starting with irrelevant information.
Hi Haddie,
I can see your point. Being aware that that is the natural inclination of many doctors to “run with the first thing they hear” my wife is very careful to state what she thinks is going on..she is an RN and works with docs all the time. If she didn’t tell the doctor up front about her condition, it would show up in the meds list or on the X-rays..and it will then look like she’s holding back information. Kind of a Catch 22.
Steve
Very relevant. I would add that in our experience with patient communication, they also struggle with communicating their problem, at times; further adding to the complexity of this communication.
To drill down to the real problem it takes time. Patients who have found a medical doctor who still takes the time, really should hold on to him/her.
Today, consultation with a patient does not make a lot of money, thus, the more patients a doctor sees during a consultation day, the more money he/she makes. At least in a private practice setting, financials play a major factor why there is decreased communication…
Any thoughts?
http://premierhealth.wordpress.com/
Thanks, it’s usefully for me.
I am enjoying reading this blog. I agree completely with Olaf that there is a strong financial motivation on the part of the doctor to steer the conversation.
And I don’t blame the doctors, honestly. They’ve got a schedule to keep, and they need to move things along not only because income is at stake but also because given half the chance many patients are going to share great volumes of information that may or may not be relevant. The patient’s focus is on their health, their fears and worries, and all the data they’ve been gathering in the time leading up to the visit. We want to tell our doc what we found on the internet, etc. etc. etc. And the doctor is watching the clock. It’s a very out-of-balance situation.
I once left a doctor because I could not get answers. I kept trying to have a conversation about getting well. I had recently lost three family members to cancer and I wanted to know a) whether I had cancer and didn’t know it and b) how to prevent it. She was completely exasperated. My concerns were outside of her frame of reference which is about diagnosing people with symptoms of illness.
What finally occurred after a round of tests that proved negative and still did not get me out of her hair was this: She diagnosed me as having obsessive compulsive disorder and prescribed a medication.
What do we make of this? My belief now, years later, is that there is an enormous missed opportunity in the medical world. I left that doctor and went on a quest for health, which was not found in the world of “health care.” I am someone who fell through because there was no wellness resource that could redirect my questions and concerns into something mutually beneficial for both me and the health practice. Had there been an RN, nutritionist or wellness consultant on staff that was trained in coaching patients who do not present very specific symptoms of illness, my needs would have been served and they still would have made money. Win win.
There are millions of people walking around with declining health who could benefit from a simple addition of a wellness component in medical clinics. Someone should be talking to them about diet, exercise, science based supplementation, and prevention. People want these services and are willing to pay for them, as evidenced by the economics of the wellness industry. Instead of cutting the patients off when they begin their long tirade about everything from minor aches and pains to digestion, fatigue, sleep deprivation, anxiety and occasional headaches, the doctor could simply say, “John, it sounds to me like you would benefit from a consultation with Suzy. She consults with patients about better health. For now, let’s talk about your most pressing concerns.”
This may be a bit of a diversion from your topic. When a patient does have specific symptoms of illness, the doctor should completely hear them out. Get the full list, not just the top one or two in order to make a fully informed decision about care. But if the process of routing a patient through the system includes redirecting those with minor health concerns and health enhancement questions to a wellness resource, the doctor can take the needed time with those who are very sick. And the clinic still makes money.
Jayna
I am a nurse practitioner and since my role is very similar to a doctor’s, and many of the same experiences, so it interests me when people complain of not being listened to. You and Jayne are trying to make the same point with two totally dissimilar stories, which only go to show how challenging it can be to be a diagnostician faced with different problems, different personalities, different expectations, and many times in a day.
It appears your wife was in severe pain and other symptoms of an acute abdomen; and with a history of cancer, very sorry to agree with the ER doctor, but severe pain is cancer until it is ruled out. Think how much more you would have been upset/outraged if metastatic cancer had been missed. This was an emergency room and the worst case scenario has to be ruled out. I’m glad in this case that it was. I wasn’t there of course, but the fact that your wife mentioned cancer right off the bat seems like a tip-off that that was in the back of her mind despite what you say. Perhaps you were not cognizant of it.
And Jayne appears to have be well and merely worried. Perhaps she should have allowed herself, after a reasonable lab/imaging evaluation, to be reassured, and taken advantage of the many fine educational websites on the Internet to find information about cancer detection and screenings. This might be the best use of resources since a physician’s skills are best used in diagnosis and treatment.
Perhaps the problem is a lack of congruence between the patient’s expectations and what may have been an appropriate evaluation.
My experience is that patients’ communication skills run the gamut. Fortunately the garrulous people who don’t allow you to even start a line of questioning are rare. The other difficult type of patient is the one who “knows their body” – sounds like a harmless phrase, but on continuing to hear them out, often turns out to be synonymous with “I’ve figured out my diagnosis and now please write me a prescription for [medication].” This visit is going to take a long time since the person has to be talked out of their preconceived idea, if it turns out after evaluating the problem, they were on the wrong track. Very often it IS the case, since diagnosis is a systematic step by step process.
In figuring out what the patient’s problem is, the patient contributes to the “history” (first step) only. The clinician does the “exam,” the “diagnosis” and the “plan” (treatment), which is an multi-step internal process the patient doesn’t participate in. A lot of people who would like to be proactive in their own care identify a symptom and then want to jump to a diagnosis without realizing there are intervening steps of data collection for the clinician.
I think this may be why certain patients will use up the entire consultation time talking about their symptoms if not interrupted, and then be surprised that I have questions to ask and actually expect to examine them too, plus expect to use up at least 5 minutes discussing treatment options followed by further discussion about what I will do and what the patient will do : )
Time management is a 2 way street!
I appreciate forums like this one, which enables us all to see how the other half lives. I understand the individual’s need to be listened to, but I think it also helps if patients learn a little more about the diagnostic process, not so they can do it themselves–they can’t–but so they can better utilize their time with their clinician.
Stephanie,
Thanks for your thoughtful comments! Check out the previous post entitle “One More Reason Why Patients Don’t Ask Questions” in which I discuss the patient and providers roles during the ?medical interview.” Most people are not aware that what they see as a conversation with their doctors is often anything but…because it was never intended to be a ‘two-way reciprocal conversation. Provider-directed medical interviews are no where near as productive or effective than a patient-centered approach, at least according to the evidence. I would argue that any lack of congruence between patient and physician, i.e., expectations, beliefs, etc.) is a failure on the provider’s. part. Why? It is the provider’s job to understand the whole patient, their attitudes, beliefs, expectations, etc. rather than the other way around.
Thanks – where is article source?
Communication is important. As an ED nurse, I would often accompany the MD when he did his initial eval and many times would agree the MD would cut the patient off as they might not have been getting to the point quick enough. I would stay after the MD left and talk to the patient and many time glean other important points and then relay them to the MD. This is called team work. The MD/NP are one member of the team, Nurses, case managers, social workers and others also have a role to ensuring patients are listened to and that their care is patient centered.
When it works it is a beautiful experience; yet when it does not…you know the outcome…everyone loses…..