Today's health care consumers are expected to be proactive, self-managed and informed members of the health care team. One way for patients to become more involved in their care is to bring a list of questions to each visit. For example, the Agency for Healthcare Research and Quality advises patients to “Write down your questions before your visit. List the most important ones first to make sure they get asked and answered.”1
Although many health care quality and patient safety organizations have made similar recommendations that patients bring a list of questions to their office visits, few guidelines exist as to what should be on the list, how and when the list should be presented, and how much can realistically be discussed during a standard office visit. Many patients are confused about the best way to create and share lists, and many physicians dread them. How should we respond to these patients and their lists? How many questions can we cover in one visit? What should we do if the questions on the patient's list do not match what we want to talk about? This article explores these challenges and offers strategies for creating a shared agenda for the office visit while maintaining an efficient practice.
The challenges of patient lists
In a recent survey of 216 family physicians and internists at the University of Wisconsin, more than 60 percent of respondents said their patients bring in lists very often or sometimes.2 Given the increasing emphasis on consumer engagement in health care, this percentage is likely to increase over the coming years.
Patients' lists can often present challenges to physician practices because patients may have unrealistic expectations for what can be addressed during an office visit and may not list their most important issues first. For example, the patient who has a psychosocial concern may be inclined to put it at the end of the list or not list it at all, when in fact the psychosocial concern may be the patient's most serious problem.
Patients create lists for a variety of reasons. Lists may serve as memory tools, helping patients remember what they wanted to ask their doctor. Some patients bring in lists because they want to participate in setting the agenda for the visit. Patients may also bring in lists because they have been told to do so. Regardless of their reasons for making lists, patients understandably have the expectation that their doctor will answer all of their questions, and they may not think about time limitations.
Too often, patients do not get the opportunity to share their lists of concerns and questions. Physicians, perhaps worried that patient lists will result in longer visits or more issues than can be addressed at a single visit, tend to interrupt the patient to clarify the reason for the visit and do not get back to the patient's list. A study of more than 260 patient-physician interviews showed that the physician interrupted the patient's initial statement of concerns after a mean of 23.1 seconds, and patients rarely returned to completing their agenda for the visit.3
But responding to patients' lists may not be as time-consuming as feared. A study of outpatient visits found that when given the chance to speak uninterrupted at the beginning of the visit, patients required only 93 seconds on average. Eighty percent of all patients stopped talking after two minutes.4 Similarly, a randomized controlled trial of 900 patient encounters found that when patients brought in agenda forms and their physicians were educated about them, the visits were only slightly longer – 1.9 minutes on average.5 The number of problems addressed per visit increased by 0.5, and patient satisfaction increased.
Five steps for addressing patient lists
There are five main steps you can take to address the patient's list and begin the process of setting a shared agenda for the visit. This approach requires that you “invest in the beginning” of the visit, as recommended by the “four habits” model of health care developed by experts in physician-patient communication at Kaiser Permanente HMO.8
Acknowledge the patient's list of questions and concerns. The list shouldn't be viewed as a hassle but should actually be welcomed, as it saves you the step of having to elicit the patient's concerns. Writing down a list of issues means the patient took time to think about the visit and prepare for it, so it is important to acknowledge that effort. You can do this by saying simply, “I see you have a list of questions. Let's look at it together.”
Negotiate what to cover during the visit. If the patient's list is too long or does not match your priorities for the visit, you will need to negotiate which items you will address at the current visit. The key is to use positive language. For example, instead of saying, “We don't have time to cover all of your issues,” try saying, “I would like to cover as much as we can from your list, but I also want to take a few minutes to talk about your [diabetes, cholesterol, asthma, etc.].”
Be straightforward and honest with your patient about how much time you have allotted for the visit and plan jointly how to use that time. For example, you might say, “Since this visit is only scheduled for 15 minutes, let's decide on the three most important issues for today.”
The idea is to set realistic expectations at the beginning of the visit. If more time is required to tackle a patient's list, say, “I wish we had more time to focus on all of your other issues. Let's schedule additional appointments to discuss them.”
Most patients will accept this. For overly demanding patients, try explaining the risks of covering too many problems in a single visit (e.g., the patient's issues won't be discussed as thoroughly, mistakes are more likely and the information shared may be more difficult to retain).
Mutually set the agenda for the visit. After you've identified which issues are a priority for you and your patient, recap what you've agreed to address at the current visit. You might say, “Let's make sure we are on the same page. We are going to cover these three issues today … correct?”
Surface any remaining concerns. The best way to do this is to ask, “Is there something else?” This simple question gives the patient a final opportunity to mention any concerns, instead of waiting until the end of the visit when it's too late to address them.9
Plan for the next visit. At the end of the visit, show that you haven't forgotten about the additional issues on the patient's list, and commit to tackling them at future visits. You can do this by saying, “Since we were unable to finish talking about all the items on your list today, let's schedule another visit.”
What would you do?
The following vignettes illustrate how shared agenda setting and negotiation could work.
Vignette 1: You are 45 minutes behind on a busy afternoon and walk into an exam room. As if in slow motion, your patient unfurls a scroll of questions to cover during the visit. What should you do?
A. Tell the patient, “There is no way we have enough time to cover all 12 of your complaints.”
B. Review the list with your patient and decide what is reasonable to cover at the current visit.
C. Call your baby sitter and tell her to put the kids to bed because you won't be home until 10:00 p.m.
The correct answer is B. In this situation, spending a few minutes reviewing the list will signal that you respect your patient's efforts to compile a list of health concerns and become an active participant in the visit. Discussing the list will also help you begin to structure the visit appropriately, according to the amount of time given, and will allow you to provide some patient education in a direct, supportive way about how many issues you can realistically cover in a single visit. You may be able to look at the list and address a few items quickly, before focusing on the more serious health concerns.
Vignette 2: On a bright and sunny Monday morning, you see a long-time patient of yours with a complex medical history of coronary artery disease, renal failure, hypertension and diabetes. He pulls out a list of six issues to cover today that does not include any of his chronic medical issues. What should you do?
A. Focus on the six complaints on his list and have him schedule another appointment to talk about his chronic medical problems.
B. Postpone talking about the issues on his list, and instead talk about his chronic medical issues.
C. Spend a few minutes with the patient negotiating which issues are most important to discuss at today's visit.
The correct answer is C. In this situation, the patient's complaints are important to him, but you can't ignore his chronic medical issues, so you'll need to look at his problem list and his list of complaints and jointly agree on an agenda for the visit. It is likely that one or two of his chronic medical issues are stable and don't need much attention, so you should have time to address something on the patient's list of concerns. Again, this is a great opportunity for patient education: “Every time I see you, I'd like to review your chronic medical problems. So, make sure to include at least your diabetes on every list you bring in.”
Vignette 3: You enter the exam room to see a relatively new patient. You have met him twice before, and he has depression, migraine headaches and back pain. You ask him, “So, what can I do for you today?” He stares at you blankly and says, “I don't know. I just had this appointment on my calendar.” What should you do?
A. Ask a few open-ended questions about his medical problems and how he has been feeling, until you develop a viable list of topics to cover.
B. Instruct him to make a list every time he comes to see you.
C. Spend your 15 minutes talking about family, hobbies, etc., so you can get to know the patient better.
The correct answer is A. In this situation, where the patient has no list, it is the clinician's responsibility to elicit complaints and then to prioritize them with the patient. Some patients may be shy or have low literacy levels and may not feel comfortable writing down a list or presenting it to their physician, but the visit will be much more effective if the clinician engages the patient in developing the agenda.
THE FIVE STEPS SUMMARIZED
When patients present with a list of questions or concerns, follow these five steps:
1. Acknowledge the list.
- “I see you have a list of questions. Let's look at it together.”
- “Do you have a list of what you want to talk about today?”
2. Negotiate what to cover.
- “I would like to cover as much as we can from your list, but I also want to take a few minutes to talk about your [diabetes, cholesterol, asthma, etc.].”
- “There are a couple of issues on your list that we can cover quickly. Would you like to talk about those issues first so we have enough time to discuss your [diabetes, cholesterol, asthma, etc.]?”
- “You have a lot of issues on your list, and this visit is only scheduled for 15 minutes. Let's look at it together and decide on the three most important issues for today. We can schedule a follow-up appointment to discuss the remaining issues.”
3. Set the agenda for the visit.
- “Let's make sure we are on the same page. We are going to cover these three issues today … correct?”
- “Are you okay with our plan for today's visit? I want to make sure that we are covering the most important issues.”
4. Surface any remaining concerns.
- “Is there something else?”
5. Plan for the next visit.
- “Since we were unable to finish talking about all the items on your list today, let's schedule another visit.”
Stop dreading the list
The best response to patient lists is not to dread them but to use them as a starting point for negotiating and jointly developing a prioritized, realistic list of topics to cover during the visit. The visit length may increase slightly, by 1.9 minutes according to the study mentioned earlier, but the time spent will be more focused and constructive. In order to get to that place, however, clinicians and patients must be educated on the appropriate use of lists. The above strategies may be a way to achieve patient-centered communication while maintaining an efficient practice.