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When patients have more than one concern
Patient Education and Counseling 99 (2016) 671
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
From the Editor
When patients have more than one concern
The topic of solicitation of additional patient concerns is one of the quintessential issues in research on the doctor-patient relationship as well as in communication skills training in medical school and other contexts. We know that patients often have more than one concern, and that some of them remain unmet throughout the consultation. Beckman and Frankel’s classic study from 1984, quoted more than 500 times, showed that in two thirds of the consultations in their sample, patients were interrupted before they had finished their first sentence about their concerns for the visit [1]. Interruptions occurred at an average of 18 s into the patient’s story. When concerns are not elicited early in the consultation, they mainly remain undisclosed. Robinson and others have shown that additional concerns therefore often may occur towards the end of the consultation [2]. The so called door knob phenomenon is well known. When time is up and the patient is on the way out with his or her hand on the door knob, an additional concern may surface: “And then I kind of wonder . . . ”. This final concern may in some cases be the most important one. The doctor faces the choice of a prolonged consultation or letting the patient leave the room with an unmet concern. In another well-known study in the literature Heritage et al. showed that the way the doctor phrases his or her elicitation of additional concerns may have a major impact on patients’ presentations of concerns [3]. In their study, doctors were instructed to elicit additional concerns by asking if the patient had ANY more concerns in one intervention arm, while a question framed with the word SOME was applied in the other condition. Soliciting additional concerns by using the word SOME reduced the number of patients leaving the consultation with an unmet concern by 78%. The study illustrates how important the right choice of word is in elicitation of patient concerns. In the present issue of Patient Education and Counseling we publish two research papers on soliciting additional concerns in medical consultations. Robinson et al. performed a secondary analysis of videotapes/transcripts of more than 400 American primary care visits [4]. The authors found that physicians’ questions designed to solicit additional concerns occurred in only about one third of the visits. The study is based on three slightly dated data sets, but there is limited evidence that communication
http://dx.doi.org/10.1016/j.pec.2016.03.016 0738-3991/ ã 2016 Published by Elsevier Ireland Ltd.
behavior has changed dramatically during the last 10–15 years in American primary care. The study also showed that agenda setting in general was relatively infrequent. The second study on elicitation of additional concerns is a qualitative interview study by Summers et al. with general practitioners in Great Britain [5]. The GPs in this sample mostly perceived eliciting additional concerns as important to identify serious illnesses early, to increase patient as well as doctor satisfaction and to reduce the need for multiple visits. The GPs were also shown training videos in which additional concerns were solicited by using the words SOME and ANY as in the study by Heritage and Robinson [3]. Some GPs found these prompts to encourage additional concerns to be solicited early in the consultation useful, but soliciting additional concerns in every consultation was not supported by all GPs in the sample [5]. The two papers contribute to the literature on additional concerns by showing what doctors actually do, at least in the sample from American primary care, and what thoughts and reflections doctors have on the solicitations of additional concerns. By taking these two different perspectives, the two studies complement each other nicely. References [1] H.B. Beckman, R.M. Frankel, The effect of physician behavior on the collection of data, Ann. Intern. Med. 101 (1984) 692–696. [2] J.D. Robinson, Closing medical encounters: two physician practices and their implications for the expression of patients’ unstated concerns, Soc. Sci. Med. 53 (2001) 639–656. [3] J. Heritage, J.D. Robinson, M.N. Elliott, M. Beckett, M. Wilkes, Reducing patients’ unmet concerns in primary care: the difference one word can make, J. Gen. Intern. Med. 22 (2007) 1429–1433. [4] J.D. Robinson, A. Tate, J. Heritage, Agenda-setting revisited: when and how do primary-care physicians solicit patients’ additional concerns? Patient Educ. Couns. 99 (2016) 718–723. [5] R.H. Summers, M. Moore, S. Ekberg, C.A. Chew-Graham, P. Little, F. Stevenson, L. Brindle, G.M. Leydon, Soliciting additional concerns in the primary care consultation and the utility of a brief communication intervention to aid solicitation: a qualitative study, Patient Educ. Couns. 99 (2016) 724–732.
Arnstein Finset Patient Education and Counseling, Norway E-mail address: arnstein.fi[email protected] (A. Finset).
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
From the Editor
When patients have more than one concern
The topic of solicitation of additional patient concerns is one of the quintessential issues in research on the doctor-patient relationship as well as in communication skills training in medical school and other contexts. We know that patients often have more than one concern, and that some of them remain unmet throughout the consultation. Beckman and Frankel’s classic study from 1984, quoted more than 500 times, showed that in two thirds of the consultations in their sample, patients were interrupted before they had finished their first sentence about their concerns for the visit [1]. Interruptions occurred at an average of 18 s into the patient’s story. When concerns are not elicited early in the consultation, they mainly remain undisclosed. Robinson and others have shown that additional concerns therefore often may occur towards the end of the consultation [2]. The so called door knob phenomenon is well known. When time is up and the patient is on the way out with his or her hand on the door knob, an additional concern may surface: “And then I kind of wonder . . . ”. This final concern may in some cases be the most important one. The doctor faces the choice of a prolonged consultation or letting the patient leave the room with an unmet concern. In another well-known study in the literature Heritage et al. showed that the way the doctor phrases his or her elicitation of additional concerns may have a major impact on patients’ presentations of concerns [3]. In their study, doctors were instructed to elicit additional concerns by asking if the patient had ANY more concerns in one intervention arm, while a question framed with the word SOME was applied in the other condition. Soliciting additional concerns by using the word SOME reduced the number of patients leaving the consultation with an unmet concern by 78%. The study illustrates how important the right choice of word is in elicitation of patient concerns. In the present issue of Patient Education and Counseling we publish two research papers on soliciting additional concerns in medical consultations. Robinson et al. performed a secondary analysis of videotapes/transcripts of more than 400 American primary care visits [4]. The authors found that physicians’ questions designed to solicit additional concerns occurred in only about one third of the visits. The study is based on three slightly dated data sets, but there is limited evidence that communication
http://dx.doi.org/10.1016/j.pec.2016.03.016 0738-3991/ ã 2016 Published by Elsevier Ireland Ltd.
behavior has changed dramatically during the last 10–15 years in American primary care. The study also showed that agenda setting in general was relatively infrequent. The second study on elicitation of additional concerns is a qualitative interview study by Summers et al. with general practitioners in Great Britain [5]. The GPs in this sample mostly perceived eliciting additional concerns as important to identify serious illnesses early, to increase patient as well as doctor satisfaction and to reduce the need for multiple visits. The GPs were also shown training videos in which additional concerns were solicited by using the words SOME and ANY as in the study by Heritage and Robinson [3]. Some GPs found these prompts to encourage additional concerns to be solicited early in the consultation useful, but soliciting additional concerns in every consultation was not supported by all GPs in the sample [5]. The two papers contribute to the literature on additional concerns by showing what doctors actually do, at least in the sample from American primary care, and what thoughts and reflections doctors have on the solicitations of additional concerns. By taking these two different perspectives, the two studies complement each other nicely. References [1] H.B. Beckman, R.M. Frankel, The effect of physician behavior on the collection of data, Ann. Intern. Med. 101 (1984) 692–696. [2] J.D. Robinson, Closing medical encounters: two physician practices and their implications for the expression of patients’ unstated concerns, Soc. Sci. Med. 53 (2001) 639–656. [3] J. Heritage, J.D. Robinson, M.N. Elliott, M. Beckett, M. Wilkes, Reducing patients’ unmet concerns in primary care: the difference one word can make, J. Gen. Intern. Med. 22 (2007) 1429–1433. [4] J.D. Robinson, A. Tate, J. Heritage, Agenda-setting revisited: when and how do primary-care physicians solicit patients’ additional concerns? Patient Educ. Couns. 99 (2016) 718–723. [5] R.H. Summers, M. Moore, S. Ekberg, C.A. Chew-Graham, P. Little, F. Stevenson, L. Brindle, G.M. Leydon, Soliciting additional concerns in the primary care consultation and the utility of a brief communication intervention to aid solicitation: a qualitative study, Patient Educ. Couns. 99 (2016) 724–732.
Arnstein Finset Patient Education and Counseling, Norway E-mail address: arnstein.fi[email protected] (A. Finset).