American College of Physicians: Internal Medicine — Doctors for Adults ®

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Listening and prioritizing help keep the visit on track

Tips for finding out what’s really wrong with your patients before they have their hand on the doorknob

From the October ACP Observer, copyright 2006 by the American College of Physicians.

By Yasmine Iqbal

The patient had told the medical assistant that he was suffering from upper respiratory problems. So, after some initial chitchat, Francesca C. Dwamena, ACP member, associate professor of medicine at Michigan State University in East Lansing, Mich., delved into the symptoms and potential causes. Just as she thought they were finishing up the 20-minute visit, however, the patient told her, somewhat sheepishly, that he had actually come to see her for another problem – an ulcer in his genital area.

It wasn’t the first time Dr. Dwamena had been blindsided by a “hand-on-the-doorknob” issue. “We tend to pick up on whatever the patient tells us first and go with it, following one track for the entire visit,” she said. “But the problem with launching into diagnosis-seeking questions is that, in many cases, we haven’t heard 95% of what’s really bothering the patient.”


Francesca C. Dwamena, ACP Member: “Start the visit off with open-ended questions.”



“Most doctors think that they’re saving time by jumping right in and asking questions, but data suggests that this is anti-therapeutic,” agreed Frederic W. Platt, FACP, a general internist in Denver and regional consultant for the Bayer Institute on Health Care Communications. “You can’t start solving problems before you know what all the problems are. And it’s a mistake to assume that patients will start with the most important issue – if it’s a psychosocial problem, for example, 90% of the time, patients won’t bring it up first.”

By taking just a minute or so to elicit a list of issues and prioritize them, experts say, you can ensure better care for your patients and keep your schedule on track. Here are some tips.

Ask open-ended questions. Having the patient write down the reasons for the visit or go over them beforehand with a medical assistant might be helpful, but even so, start the visit with open-ended questions to make sure that you’re addressing everything.

“Don’t assume that the list is complete,” said Dr. Dwamena. “Many times, lists only give the details about one problem.” She suggested starting the visit by acknowledging the list (“I see you’ve come in to talk about your respiratory symptoms and your prescription refills”), but then following up by saying something like “What else would you like us to discuss today?” or “Is there anything else that is concerning you?”

“Some physicians despise it when patients bring in long, disorganized lists of complaints – the French call this ‘the disease of the little paper’,” added Dr. Platt. He asks his regular patients to feel free to bring a list, on two conditions: they must prioritize the list beforehand, and they must make two copies (or he must be able to look at the entire list with the patient), so he can scan all the concerns and reprioritize them, if necessary.

Set the timeframe. “Most doctors are afraid to mention time limits,” said Howard B. Beckman, FACP, medical director of the Rochester Individual Practice Association in Rochester, N.Y. “What they don’t realize is that they’re going to implicitly signal this anyway if they appear rushed or start cutting the patient off as time starts running out. This is much more insulting than explicitly stating the timeframe at the beginning.” Dr. Dwamena suggested saying something like “We have 20 minutes together today and I’ll need about five minutes to examine you. I want to make sure we cover what’s important to you, so why don’t you tell me what you’d like to discuss?” Also, be upfront about how much you can cover in one visit, and let patients know beforehand if they might have to schedule a follow-up appointment for less-pressing issues.

Don’t interrupt. “Once we’ve asked ‘What else?’ we need to practice being quiet for longer than we’re used to,” said Dr. Beckman. “But it’s counterintuitive for most doctors to just listen.”

He suggested using simple phrases such as “Uh-huh,” “Go on,” or “Tell me more,” to encourage the patient to get all the issues out into the open. “Doctors are afraid of wasting time by allowing patients to ramble on, but most patients won’t talk continuously for more than a minute and a half,” he said.

In fact, research Dr. Beckman conducted with colleague Kim Marvel, PhD, and others, published in the Jan. 20, 1999, Journal of the American Medical Association, has suggested that patients rarely get the opportunity to speak this long. His study found that doctors interrupt patients an average of 23 seconds after asking them to describe their concerns.

Prioritize the agenda items. Once you’re sure you’ve heard all the patient’s issues, bring up any agenda items of your own, such as discussing the results of lab tests. Then, negotiate the order in which you’ll tackle the issues. “Most patients won’t hesitate to re-prioritize their lists if they understand why certain things take precedence,” said Dr. Dwamena.

But exceptions do occur, she noted, recalling one case in which a patient insisted on focusing on her back pain instead of talking about why she wasn’t taking the medication she had prescribed to treat blood clots in her lungs. “In that case, I sought the support of the patient’s family members, who had come with her to the appointment, to help her understand why we needed to address the medication issue first,” she said.

If the patient insists on focusing on something you believe is a minor issue, such as having you check out a mole before addressing the cause of chest pains, you need to probe a little deeper, suggested Dr. Beckman. “Get to the root of the issue by asking ‘Why is this concerning you?’” he said. “It might turn out, for example, that the patient had a brother who died of skin cancer.”

Finally, keep the conversation going as the visit progresses to avoid last-minute issues, said Wendy S. Levinson, FACP, professor of medicine at the University of Toronto. “Keep asking patients how they feel about tests and treatments,” she said. They might have heard, for example, that a medication you’re prescribing has unwanted side effects, and they may hesitate to bring up this concern until you’re on your way out the door. “To avoid this, you have to continue to tap into their inner dialogue throughout the visit.”

Yasmine Iqbal is a freelance writer in Philadelphia.

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