One of the most common yet difficult dilemmas in office practice is how to handle the unexpected add-on problem at the end of a patient visit. Sometimes, the problem the patient mentions to the scheduler as the reason for the visit is not the “real” problem; it is simply a means for getting into the exam room, where the patient slowly gathers the courage to raise his or her actual concerns. Most of us have been confronted with this situation hundreds, possibly even thousands, of times. The doctor must choose between the possibility of missing a serious problem or getting behind schedule. Cutting the visit short may even alienate the patient.
A corollary problem is the patient who brings an impossibly long written list of complaints, hoping to cover all of them in a single office visit. Long lists are often greeted with exasperation by the doctor; however, all patients have lists, the vast majority of which are simply unwritten. In my experience, patients bring an average of about three concerns to their visits. Patients with written lists may have a number of reasons for making them. They may fear they will not remember to ask about specific health care concerns. They may believe this is how they will get the most out of their visit financially. Or they may actually be trying to save their busy doctor some time by covering everything in one visit.
Of course, long lists cannot be addressed sufficiently during an average-length office visit. Even if there were enough time to discuss each item on the list, it would be difficult for the patient to retain all of the doctor's advice regarding each problem.
The best approach for managing patients' lists and add-on concerns is through skillful agenda setting. Here's how.
The exhaustive “What else?”
The “exhaustive ‘What else?’” technique, taught by the American Academy on Physician and Patient, can help you discern the patient's real agenda and then negotiate what will be covered in the current visit. In general, after a brief introduction, the physician uses the “What else?” to extract all the concerns the patient may have.
The conversation might go like this:
Doctor: “Hello, Mrs. Jones. My assistant tells me you are here about your cold.”
Mrs. Jones: “Yes, that's right.”
Doctor: “I want to cover that in detail; however, I was wondering if you were hoping to cover any other concerns today?”
Mrs. Jones: “Yes, Doctor, I wanted to mention my sore shoulder.”
Doctor: “I see. Your shoulder hurts. Anything else?”
Mrs. Jones: “My blood pressure has been acting up.”
Doctor: “OK. Any other concerns?”
Mrs. Jones: “Well, I was a little concerned that the pressure in my chest might be from my heart and not only this cold.”
Doctor: “I can see how that might be a worry for you! We definitely need to discuss that. What else?”
Mrs. Jones: “I think that is everything.”
At this point, the list is complete and negotiation can begin: “So, you have a cold with some chest pain that you have been worried about. Your shoulder has been hurting too. And your blood pressure is of concern to both of us. I recommend we deal with the cold symptoms, the chest pain and the blood pressure today. I'm concerned about the shoulder too, but do you think we could work on that at a follow-up appointment?”
The “What else?” technique uncovers pertinent fears and anxieties up front and prevents an “Oh, by the way, I have been having some chest pain,” from surfacing at the end of a visit. Any additional problems that come up later in the visit, despite the doctor's best efforts to uncover them early, are highly likely to be small ones that can comfortably be deferred.
There are some pitfalls to avoid. After the greeting, it takes the physician, on average, about 18 seconds to interrupt the patient.1 Without interruption, patients spontaneously complete their stories in under 2.5 minutes. That two minutes is rich in history, and it is best to simply listen. After the patient has finished speaking, then summarize and use the exhaustive “What else?” technique.
Occasionally, the technique may be seen as an invitation for a long list; however, I have found that only rarely does the patient actually expect to cover every concern raised. Instead, the technique helps you uncover the patient's real agenda and then kindly and gently re-orient expectations, if needed. “In our time allotted today, I would like to cover the most important items. That way, I will be confident that we have dealt with them completely and that you understand them fully. I am concerned about these other items. Would you consider another appointment in the near future to cover them?”
Field Guide to the Difficult Patient Interview. Platt FW, Gordon GH. Philadelphia: Lippincott Williams and Wilkins; 1999.
Soliciting the Patient's Agenda: Have We Improved? Marvel MK, Epstein RM, Flowers C, Beckman HB. Journal of the American Medical Association. 1999; 281:283–287.
Skills for Communicating With Patients. Silverman J, Kurtz SM, Draper J. Oxon, England: Radcliffe Medical Press Ltd; 1998.
Medical Interview: Clinical Care, Education and Research. Lipkin M, Putnam SM, Lazare A, et al, eds. New York: Springer-Verlag; 1995.
The dreaded list
Although we all dread long written lists, they do have a number of advantages. First, they are testimony that the patient is engaged in his or her health care and in the visit, since the patient has taken some time to think ahead and write down his or her concerns. Second, a list makes it easier to negotiate what is reasonable to cover at this particular visit. You don't have to spend time uncovering the patient's agenda because the patient has penned it out for you. In my personal experience, people with written lists rarely fail to identify otherwise hidden concerns. Finally, the list provides an opportunity to compliment the patient on his or her efforts, which helps build your relationship.
The conversation could start this way: “I see you have a list today. I'm pleased you have thought ahead about what we might cover at our appointment. Let's take a minute to look at the list together and make sure we cover the most important items today.” This technique gives the doctor the opportunity to mentally note the relative importance of the patient's agenda items so minor ones do not usurp the time.
Be careful, however, that you do not trivialize any items on your patient's list. Although we, as physicians, may see each visit as a small portion of our day, to a patient with concerns, it is a big event. We want to help our patients with their illnesses and concerns, but due to time and other pressures, it is easy to lose sight of the fact that it is the patient's visit, not ours. What we may believe is trivial, such as the common complaint of chest pain with a simple cold, may have been the driving force in the patient making an appointment. Be sensitive to your patients' concerns while guiding them toward an appropriate plan of care.
Add-on concerns and lists are common occurrences in office practice. Agenda setting invites the patient to participate in a plan and establishes a mutually agreed-upon approach to the visit. Eliciting and negotiating a patient's agenda is an essential, learnable skill for office efficiency. Such skills also enhance relationship building, which is central to patient adherence and to satisfaction for patients and doctors alike.