A recent article evaluated 112 recorded clinical encounters. The rationale was testing of “shared decision-making tools.” I was confused by the findings and conclusions.
In 27 of the 40 (67%) encounters in which clinicians elicited patient concerns, the clinician interrupted the patient after a median of 11 seconds (interquartile range 7–22; range 3 to 234 s). Uninterrupted patients took a median of 6 s (interquartile range 3–19; range 2 to 108 s) to state their concern.
The headline adopted by the media was that physicians interrupt patients quickly. It was not intended as praise.
Interrupting may or may not be helpful in solving the problem at hand.
If the patient wants to meander for 5 minutes including details of no import to making a diagnosis, then why not interrupt? This issue is even more challenging when an office has booked patients solid and time is the single commodity in scarce supply. Further, third party payers and healthcare employers are pushing doctors to see more patients in shorter time slots. So, if one cannot get to the point quickly, no one benefits. The only obvious benefit to the meandering history would be the patient does not feel rushed; admittedly an important perk, but paling in significance to accuracy.
All professionals interrupt. It’s called asking questions. Lawyers interrupt. Accountants interrupt. It’s because they are developing an evolving hypothesis in their mind to solve the perceived problem at hand and are looking for confirming or refuting data. Plumbers and electricians do the same.
While I’m all for a relaxed doctor-patient encounter where there is unlimited time to have a back and forth discussion, there are other factors at play. Unless and until it is clear that the interruptions lead to less accurate diagnoses or failure to identify and solve problems, let’s call it something else: Questioning.
What do you think?
The answer is simple, but outside of concierge medicine, will not be adopted any time soon:
Charge by the minute. Lawyers do.
A wise, semi retired physician who was teaching part time once gave my class the following words of advice: ” If you listen to the patient long
enough, they will give you the diagnosis”. Or as Steve Covey the master of communication in business has stated “first seek to understand, then to be understood”. You will save a lot of time and aggravation by listening with both ears and both eyes focused on the patient, not your stupid laptop.
Lynne, you nailed it on the head. I, too, was trained treat if you give the patient just 2 minutes, TWO “tell me what ya got” minutes, the patient feels you listened, respected their issues and visit, and they reveal the “true story” and the doctor can take it from there. There are of course exceptions (manics, hysteria, drug seekers etc) but I am referring to 99% of patients we see.
I found by giving a patient a copy of the visit, their labs and telling them “don’t freak out by what you see , example your sodium say “LOW”,, and it’s 1 point low.
I educated my patients, I looked them in the eye and instead of a retrofitted room with my back to the patient, I had sears for the patient with their eye level higher than mine, much like how we kneel down and talk to our kids look UP at them to deescalate and diffuse and get past problem one…intimidation. I also put a 70 inch big ole tv screen on the wall so they could see AND CORRECT ANY ERROR I MAY BE PUTTING IN THEIR CHART! Example. Divorced x 4 now single . They can see the screen and if you get them to participate, they are more satisfied and not only ultimately improves their care, they see themselves as part of the PROCESS and I think less likely to sue or badmouth etc.
I still stand by my saying “they are Patients, not customers in this Walmart driven attitude that customers are always right”. Bull hockey. They aren’t always right. So get them involved. Maybe even have , if your space and budget do not allow, a tablet securely linked to what you are typing when , example I say, “I hate this part but if I can have a few minutes to focus on all the stuff insurance companies and government requires, that would be great, but once I log off it is a pain to log back in, somis there anything that we need to discuss at today’s visit, where we addressed the first few MAIN items of your issues and I am sure you are smart enough to know we can’t fix it all in one day!”
I am just telling anyone reading this , that this is HOW I approached things, and my patients became like a family.
I also educated my patients with some respectful tough love: IF YOU SHOW UP, we can keep this cattle farm running smoothly, patients NOT showing up is why many have to wait . If you will help me by showing up, on time or call if otherwise, things run much better for both of us. So help me help you by simply showing up: and come with a list of your concerns in order of importance, and bring all of your meds because do you know how many “man doc, it’s a little white round pill that is specialist gave me!”
I invite the spouse, because they keep each “honest” And if you are building a practice, that spouse who may not be your patient, may switch to you and become a PATIENT. But I set firm rules. They knew if I was running behind, it’s hard to insulate a Wall well enough to prevent thebaounds of example someone crying loudly “I miss him so much, the deer came out of nowhere and he swerved to miss and we rolled the car many times. We had just golfed that day”
When I walk in to see the next patient, them seeing it was obvious I had cried with my patient as well….the next patient room is silent: “Rough day for that lady it sounds Doc” and the patient asks me, “are YOU ok, I know your an hour behind but that woman i could hear… how do you do it “
I educate my patients as the above example, and thank them for their understanding because they know , THEY may need that extra time some day. Me and my “family group of patients” worked together . And if I knew I was running behind and not fair to patient , I would ask my nurse to triage anyone willing to reschedule due to some circumstances out of my control.
I like that saying “God gave us Two eats and One mouth for a good reason”
Sorry for the novel, but this topic is one dear to my heart because I had partners that saw their patients as numbers. Sad. Wait until they get sick someday as i did, deathly sick, and they will see what being a number feels like. But I hope not. I chose Mayo Clinic in Arizona and was never made to feel like a number:
I will shut up here.
If the patient doesn’t give me their chief complaint within the first few seconds of talking, I’m interrupting and asking for it. Too often, patients want to tell their story like a mystery novel unfolding, with a grand reveal at the end. That’s not how history-taking works. Through the filter of the chief complaint, different details of the patient’s story rise and fall in importance. It makes no sense to wait for the “punchline” and then try and work backwards to get the relevant details.
Thank you, Lynne. Unfortunately, medicine was forced into electronic recording of everything, so if the physician is looking at the patient, they may not record something of import. On the other hand…1. A lot can be learned by the simple act of Observing the patient and 2. 11 seconds is not long enough to learn much of consequence.Too many physicians, and dentists, are too abrupt, too curt.Their chairside/bedside manner leaves much to be desired, and that includes the way way they interrupt, excuse me, ask questions.
I believe we may have hit upon a difference in the way male and female practitioners work. 😉
We are timed – literally- and do not have the time to tag along on somebody else’s verbal meandering. The conversation has to be guided toward fruitful exchange if information. There are consequences of being perceived as too slow. If you have read the patient history, you can focus on the gaps in your knowledge.
I’m with Pirie. 11 seconds is not verbal meandering. I was given the same advice as she, by a med school professor, and I believe that having taken that seriously is a major reason for my having a zero-loss malpractice record after 36 years of practice, including 21 years of high-risk emergency medicine. The patient’s story often clarifies atypical presentations of illnesses and injuries.
I used to allow patients to tell me a story about what lead up to them being in front of me. But if after a couple of minutes of rambling if I was not getting some gist of where they were going with the story, I would interrupt. There has to be a balance between the patient telling a story leading to a diagnosis and some directed questioning. Sometimes patient’s would in fact lose their way and forget the point of their story.
This is not a male versus female issue. This is the difference between building rapport with a patient and being a compassionate physician versus being a time obsessed physician under time pressure from a hospital employer and squeezed by the EHR to put checks in boxes as opposed to extracting a meaningful patient narrative.
I never timed myself, but I’m pretty sure I gave patients several minutes to get to the point. After that, I’d interrupt and say, “OK–my turn,” and proceed from there. I only recall one patient–actually one relative of a patient–who was offended by that–at least openly offended.
Even more pernicious and the-wastefuil is the problem of patients answering questions that are a little different from the ones I was asking. That derails the dialog in a major way and is something I never allowed. Not even for 11 seconds after I recognized that I wasn’t getting an answer to the question. “How long has this been going on?” “I bought this old car….” “Um, that’s nice, but how long has this physical problem been going on? Days, weeks, months, or years?” “Oh–about 6 months.” Thanks.
All this can be done in a friendly way, maybe even amusing to both the patient and to me, but the bottom line is that in order to help the patient, I need the information I need, and so do you–male, female, or otherwise doesn’t matter, No info = no correct diagnosis.
We had a different prof in medical school, a rather direct, if somewhat aloof neurologist. His dictum was to take a history from the patient. If the patient couldn’t give you a history, don’t bother talking with the spouse, proceed directly to the neurological exam. Reason? “Nuts marry nuts and idiots marry idiots.” His advice proved correct–and saved me and many of my colleagues a lot of time–over the years. I’m sure he got the data painfully.
During my oral exam for board certification in ENT 20 years ago, we had to get through several vignettes in an hour, and if you had expected the examiner to ramble on, you would have been left in uncomfortable silence. As physicians, we’re like detectives trying to solve the patient’s problem expeditiously. When we have a chief complaint of vertigo, there are less than half a dozen possible diagnoses. I don’t think anyone takes offense if an engaged doctor leads the dialogue while taking a history, since 90% of making the correct diagnosis depends on the history. Taking a history is an art – it should be as short as possible. Interrupting is not perceived as rude if it’s done in a way where it’s clearly in the patient’s best interest. Thank you.
As Steven Covey wrote (and this applies to physicians as much as anyone), ““Most people do not listen with the intent to understand; they listen with the intent to reply.” If you are preparing to interrupt, you are not listening.
The goal of the encounter is to heal as much as it is to cure. I have been seeing patients for 35 years. Paying heed to the patient’s narratives has kept me sane and healthy. Let the patient tell their story. You will both benefit.
In the ED, if I waited for the responses to open ended questions, like we were taught to do, most people would be dead by the time I had some idea about how to work them up. Most people don’t have a clue about what is important and what is not. Many of them have some kind of silly hypothesis about what is wrong with them. If I didn’t interrupt, the ED would grind to a halt. I’m sure the pressure to see hordes of clinic patients makes open ended questions and prolonged listening impractical as well, especially since documentation and administrative hassles are so overwhelming. Not many docs now have the luxury of listening without interrupting. What drives me nuts is patients who interrupt me and start talking when I’ve spoken only about 5 words, while I’m trying to convey something important. It would be nice if a few of them had some listening skills.