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Reducing Patients’ Unmet Concerns in Primary Care: the Difference One Word Can Make

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Abstract

Context

In primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed.

Objective

To test an intervention to reduce patients’ unmet concerns.

Design

Cross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys.

Setting

Twenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania.

Participants

A volunteer sample of 20 family physicians (participation rate = 80%) and 224 patients approached consecutively within physicians (participation rate = 73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition.

Intervention

After seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: “Is there anything else you want to address in the visit today?” (ANY condition) and “Is there something else you want to address in the visit today?” (SOME condition).

Main Outcome Measures

Patients’ unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys.

Results

Relative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR) = .154, p = .001). The ANY intervention could not be significantly distinguished from the control condition (p = .122). Neither intervention affected visit length, or patients’; expression of unanticipated concerns not listed in previsit surveys.

Conclusions

Patients’ unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form. Both the learning and implementation of the intervention require very little time.

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References

  1. Stewart M, Brown J, Levenstein J, McCracken E, McWhinney IR. The patient-centered clinical method, 3: changes in residents’ performance over two months of training. Fam Prac. 1986;3:164–7.

    Article  CAS  Google Scholar 

  2. Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision making style: results from the Medical Outcomes Study. Medical Care. 1995;33:1176–87.

    Article  PubMed  CAS  Google Scholar 

  3. Beckman H, Frankel R. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101:692–6.

    PubMed  CAS  Google Scholar 

  4. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: Have we improved? JAMA. 1999;281(3):283–7.

    Article  PubMed  CAS  Google Scholar 

  5. Callahan E, Stange K, Zyzanski S, Goodwin M, Flocke S, Bertakis K. Physician-elder interaction in community family practice. J Am Board Fam Pract. 2004;17(1):19–25.

    Article  PubMed  Google Scholar 

  6. White J, Levinson W, Roter D. “Oh, by the way ...”: the closing moments of the medical visit. J Gen Intern Med. 1994;9(1):24–8.

    Article  PubMed  CAS  Google Scholar 

  7. White JC, Rosson C, Christensen J, Hart R, Levinson W. Wrapping things up: a qualitative analysis of the closing moments of the medical visit. Patient Educ Couns. 1997;30:155–65.

    Article  PubMed  CAS  Google Scholar 

  8. Lipkin M, Putnam S, Lazare A, eds. The Medical Interview: Clinical Care, Education And Research. New York: Springer; 1995.

  9. Cohen-Cole SA. The medical interview: The three function approach. St. Louis: Mosby Year Book; 1991.

    Google Scholar 

  10. Lang F, McCord RS. Agenda setting in the patient-physician relationship. JAMA. 1999;282:942.

    Article  PubMed  CAS  Google Scholar 

  11. Lipkin M, Frankel R, Beckman H, Charon R, Fein O. Performing the interview. In: Lipkin M, Putnam S, Lazare A, eds. The Medical Interview: Clinical Care, Education and Research. New York: Springer; 1995:65–82.

    Google Scholar 

  12. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s guide to physical examination. 3rd edn. St. Louis: Mosby Year Book; 1995.

    Google Scholar 

  13. Swartz MH. Textbook of Physical Diagnosis: History and Examination. 4th edn. Philadelphia: W. B. Saunders; 1998.

    Google Scholar 

  14. Schuman H, Presser S. Questions and Answers in Attitude Surveys: Experiments on Questions Form, Wording and Context. Orlando FL: Academic; 1981.

    Google Scholar 

  15. Wellman FL. The Art of Cross-Examination. New York: Touchstone; 1997.

    Google Scholar 

  16. Loftus E. Eyewitness Testimony. Cambridge, MA: Harvard University Press; 1979.

    Google Scholar 

  17. Clayman S, Heritage J. The News Interview: Journalists and Public Figures on the Air. Cambridge: Cambridge University Press; 2002.

    Google Scholar 

  18. Boyd E, Heritage J. Taking the patient’s medical history: questioning during comprehensive history taking. In: Heritage J, Maynard D, eds. Communication in Medical Care: Interactions between Primary Care Physicians and Patients. Cambridge, England: Cambridge University Press; 2006.

    Google Scholar 

  19. Bolinger D. Interrogative Structures of American English. University, Alabama: University of Alabama Press; 1957.

    Google Scholar 

  20. Borkin A. Polarity items in questions. Chicago Linguistic Society. 1971;7:53–62.

    Google Scholar 

  21. Horn LR. Some Aspects of Negation. In: Greenberg JH, Ferguson CA, Moravscik EA, eds. Universals of Human Language, Vol.4: Syntax. Stanford, CA: Stanford University Press; 1978:127–210.

    Google Scholar 

  22. Graubard BI, Korn EL. Predictive margins with survey data. Biometrics. 1999;55(2):652–9.

    Article  PubMed  CAS  Google Scholar 

  23. Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: Wiley; 1989.

    Google Scholar 

  24. StataCorp. Stata Statistical Software: Release 9.0. College Station, TX: Stata Corporation; 2005.

    Google Scholar 

  25. Williams RL. A note on robust variance estimation for cluster-correlated data. Biometrics. 2000;56:645–6.

    Article  PubMed  CAS  Google Scholar 

  26. White H. A heteroskedasticity-consistent covariance matrix estimator and a direct test for heteroskedasticity. Econometrica. 1980;48:817–30.

    Article  Google Scholar 

  27. Williams RL. A note on robust variance estimation for cluster-correlated data. Biometrics. 2000;56:645–6.

    Article  PubMed  CAS  Google Scholar 

  28. Cegala D, Broz L. Physician communication skills training: a review of theoretical backgrounds, objectives and skills. Med Educ. 2002;36:1004–6.

    Article  PubMed  Google Scholar 

  29. Ihler E. Patient-physician communication. JAMA. 2003;289:92.

    Article  PubMed  Google Scholar 

  30. Baile W, Lenzi R, Kudelka A, et al. Improving physician-patient communication in cancer care: outcome of a workshop for oncologists. J Cancer Educ. 1997;12:166–73.

    PubMed  CAS  Google Scholar 

  31. Stein T, Kwan J. Thriving in a busy practice: physician-patient communication training. J Eff Clin Prac. 1999;2:63–70.

    CAS  Google Scholar 

  32. Joos SK, Hickam DH, Gordon GH, Baker LH. Effects of a physician communication intervention on patient care outcomes. J Gen Intern Med. 1996;11(3):147–55.

    Article  PubMed  CAS  Google Scholar 

  33. Street RL, Gordon HS, Ward MM, Krupat E, Kravitz RL. Patient participation in medical consultations: why some patients are more involved than others. Medical Care. 2005;43(10):960–9.

    Article  PubMed  Google Scholar 

  34. Cassell E. Talking with Patients, Volume 2: Clinical Technique. Cambridge MA: MIT; 1985.

    Google Scholar 

  35. Heritage J, Maynard DW, eds. Communication in Medical Care: Interactions between Primary Care Physicians and Patients. Cambridge: Cambridge University Press; 2006.

  36. Stivers T. Prescribing Under Pressure: Parent-Physician Conversations and Antibiotics. New York: Oxford University Press; 2007.

    Google Scholar 

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Acknowledgments

Funding for this project was provided by the Agency for Healthcare Research and Quality, Grant no. R01 HS13343.

The authors wish to thank Jerome Hoffman MD for his assistance with the training video, and Iris Halldorsdottir, Erika Lamoureaux and Seung-Hee Lee for their assistance in data analysis. Marc Elliott is supported in part by the Centers for Disease Control and Prevention (CDC U48/DP000056). The contents of the publication are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

John Heritage had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conflicts of Interest

No author has a potential or actual financial conflict of interest regarding the research reported in this article.

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Correspondence to John Heritage PhD.

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Heritage, J., Robinson, J.D., Elliott, M.N. et al. Reducing Patients’ Unmet Concerns in Primary Care: the Difference One Word Can Make. J GEN INTERN MED 22, 1429–1433 (2007). https://doi.org/10.1007/s11606-007-0279-0

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  • DOI: https://doi.org/10.1007/s11606-007-0279-0

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