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Have We Improved?

M. Kim Marvel, PhD; Ronald M. Epstein, MD; Kristine Flowers, MD; Howard B. Beckman, MD

JAMA. 1999;281:283-287.

Context  Previous research indicates physicians frequently choose a patient problem to explore before determining the patient's full spectrum of concerns.

Objective  To examine the extent to which experienced family physicians in various practice settings elicit the agenda of concerns patients bring to the office.

Design  A cross-sectional survey using linguistic analysis of a convenience sample of 264 patient-physician interviews.

Setting and Participants  Primary care offices of 29 board-certified family physicians practicing in rural Washington (n=1; 3%), semirural Colorado (n=20; 69%), and urban settings in the United States and Canada (n=8; 27%). Nine participants had fellowship training in communication skills and family counseling.

Main Outcome Measures  Patient-physician verbal interactions, including physician solicitations of patient concerns, rate of completion of patient responses, length of time for patient responses, and frequency of late-arising patient concerns.

Results  Physicians solicited patient concerns in 199 interviews (75.4%). Patients' initial statements of concerns were completed in 74 interviews (28.0%). Physicians redirected the patient's opening statement after a mean of 23.1 seconds. Patients allowed to complete their statement of concerns used only 6 seconds more on average than those who were redirected before completion of concerns. Late-arising concerns were more common when physicians did not solicit patient concerns during the interview (34.9% vs 14.9%). Fellowship-trained physicians were more likely to solicit patient concerns and allow patients to complete their initial statement of concerns (44% vs 22%).

Conclusions  Physicians often redirect patients' initial descriptions of their concerns. Once redirected, the descriptions are rarely completed. Consequences of incomplete initial descriptions include late-arising concerns and missed opportunities to gather potentially important patient data. Soliciting the patient's agenda takes little time and can improve interview efficiency and yield increased data.

Author Affiliations: Fort Collins Family Medicine Residency Program, Fort Collins, Colo (Dr Marvel); Primary Care Institute, Highland Hospital, Rochester, NY (Drs Epstein and Beckman); Departments of Family Medicine and Psychiatry (Dr Epstein) and Departments of Medicine and Family Medicine (Dr Beckman), University of Rochester, Rochester, NY; and the Institut d'Estudis de la Salut, Barcelona, Spain (Dr Epstein). Dr Flowers is in private practice in Antigo, Wis.

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