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Physicians Interrupt Patients After 11 Seconds

07/30/18 9:19 AM

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? 

Posted by Medical Justice | in Blog | 13 Comments »

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Mark williamsTom LeighBruce CampbellEasyEJoe Horton Recent comment authors
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Ari
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Ari

The answer is simple, but outside of concierge medicine, will not be adopted any time soon:

Charge by the minute. Lawyers do.

Lynne Pirie
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Lynne Pirie

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.

Mark williams
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Mark williams

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”,,… Read more »

Dr. Chim Richalds
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Dr. Chim Richalds

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.

Carla Schlissel
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Carla Schlissel

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.

Carla Schlissel
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Carla Schlissel

I believe we may have hit upon a difference in the way male and female practitioners work. 😉

David Stinson
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David Stinson

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.

Scott Nelson
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Scott Nelson

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.

retired
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retired

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… Read more »

Joe Horton
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Joe Horton

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… Read more »

EasyE
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EasyE

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… Read more »

Bruce Campbell
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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.

Tom Leigh
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Tom Leigh

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… Read more »