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?
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.