The Unexpected in Primary Care: A Multicenter Study on the Emergence of Unvoiced Patient Agenda

I was invited to make comments on the articles by Peltenburg et al and by Griffen et al in this issue of the Annals. First I would like to express my appreciation for the important work of both sets of authors. Their research underscores the need for greater precision in how we train physicians to effectively communicate with their patients.

For several decades researchers and teachers of medical communication have wrestled with the challenge of helping physicians uncover the patient agenda. However, repeated studies show that physicians often miss identifying the full set of concerns that patients bring to the visit. In thinking about this challenge from the physician’s side we must appreciate the ever- present concern about time. For physicians to feel comfortable making the effort to fully identify patient concerns they must not fear losing control of time(1). Thus far, current efforts to promote full elicitation of patient concerns whether through patient activation or physician training, offers mixed results. Sometimes patients are more satisfied and sometimes they are less satisfied. Physicians can be effective in eliciting more concerns but often at the cost of extending the visit. The Euro Communication Study provides us two somewhat conflicting views of time use and agenda elicitation that seems to mirror the mixed results of the larger literature. In the current study, interviews where physicians addressed “emerging agendas” were not longer. In an earlier examination of their findings(2) Euro Communication Study researchers found that visits were longer when psychosocial concerns emerged but were not overtly stated by the patient as a topic of concern.

Primary care physicians have an incredibly difficult challenge in figuring out how to meet the needs of their patients. They are the front line mental health providers for many patients who often do not declare their emotional pain. Many symptoms are medically unexplained. Patients’ expectations are not always clear until a skilled physician helps the patient decipher the meaning of symptoms in the biopsychosocial context of their lives. Any measure of consistent physician success is most likely the product of focused training over an extended period of time as is required for mastering the more tangible skills of medical practice(3, 4). In the United States, communication training that includes the essential ingredients of direct observation and feedback is mostly absent during the clinical years of medical school and residency. Griffen et al’s findings that detailed descriptions of theory based interventions are mostly absent in the research runs parallel to this dearth of precision and emphasis on communication training in our pre-doctoral and graduate medical training programs. The recent Institute of Medicine report(5 )calling for improved teaching of social and behavioral science to medical trainees is aimed at educators. As Griffen et al and others(6) suggest, these efforts will be most useful if they can be linked to health outcomes.

1. Mauksch LB, Hillenburg L, Robins L. The Establishing Focus Protocol: Training for Collaborative Agenda Setting and Time Management in the Medical Interview. Families, Systems & Health. 2001;19(2):147-157.

2. Deveugele M, Derese A, van den Brink-Muinen A, Bensing J, De Maeseneer J. Consultation length in general practice: cross sectional study in six European countries. Bmj. Aug 31 2002;325(7362):472.

3. Cegala DJ, Lenzmeier Broz S. Physician communication skills training: a review of theoretical backgrounds, objectives and skills. Med Educ. Nov 2002;36(11):1004-1016.

4. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. Oct 2004;79(10 Suppl):S70-81.

5. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Institute of Medicine. Available at: http://www.iom.edu/report.asp?id=19413.

6. Chen FM, Bauchner H, Burstin H. A call for outcomes research in medical education. Acad Med. Oct 2004;79(10):955-960.

Competing interests:   None declared