October 2000 Bulletin

Doctors overlook patients’ hidden clues

Failing to respond is a missed opportunity to show understanding, empathy

Patients may be hinting something important about the personal aspects of their lives or their emotions during an office visit, but physicians often don’t hear or respond to those hidden clues.

Yet, the clues represent opportunities for physicians to demonstrate understanding and empathy to the patients’ social and psychological concerns and, perhaps, to improve patient satisfaction.

A study published in the Aug. 23-30, 2000 issue of JAMA, the Journal of American Medical Association, found that 70 percent of the clues initiated by patients in a surgical setting were emotional in nature about their biomedical condition. Physicians responded positively in 38 percent of cases. The findings are based on an analysis of audiotapes of 116 randomly selected routine office visits to 54 primary care physicians and 62 surgeons in community-based practices in Oregon and Colorado in 1994.

Wendy Levinson, MD, and colleagues at the University of Chicago, who have previously mined a lot of important information from the tapes, present snippets of conversations in office visits. In one case, a patient tells his concerns about a future surgery, but the physician focuses on the details of where the surgery will be performed:

Patient: I always think of the stuff I wanna be doing, see, and I can’t...I didn’t wanna take a month out again (for surgical removal of pins and plates).

Physician: Yeah...

Patient: Like all summer long I’ve been having fun with my ... uh, riding horses, and, ‘course I still like to do that, but uh, that will be ... I, I’ll be out of that for a month.

Physician: Do you have to go to (X hospital)? You went (there) last time.

"In 25 interviews in which physicians missed opportunities, half of the patients brought up the same issue a second or third time," writes Dr. Levinson.

Dr. Levinson speculates that when physicians notice the clues they may not follow-up because they may believe they can’t fix or cure the patient’s emotional concerns. Or, they may believe that the demands of the managed care environment doesn’t give them the time to address anything but the biomedical concerns of the patients. However, the study found that when the physician responded to a patient’s clue visits tended to be shorter than those in which the physician did not respond.

The types of positive responses by physicians included in Dr. Levinson’s study are:

Acknowledgement. Physician names patient’s feelings or acknowledges life concerns. Example. Physician: "I’m very frustrated, so I’m sure that your frustration is much more than mine...."

Encouragement, praise, reassurance. Physician encourages, praises or offers reassurance. Example. Physician: "I think people like you, who care enough about your diabetes control, that you’ll hang in there...."

Supportive. Physician is supportive of patient’s concerns. Example. Physician: "I think it’s really important you get second opinions for the complicated problems...you want the best for yourself."

Examples of missed opportunities in Dr. Levinson’s study are:

Inadequate acknowledgement. Physician acknowledges clue, but does not respond to patient’s underlying concerns. Example. Patient: "I’m just so tired." Physician: "I would like you to do as much as you feel like doing...I used to encourage you to get out and walk, I can’t really tell you anymore, you know..."

Inappropriate humor. Physician jokes or laughs inappropriately. Example. Physician: "I guess, we’re gonna have to, you know...you’re getting so old...we’re gonna have to shoot ya...that’s all there is to it...."

Denial. Physician denies patient’s concerns. Example. Physician: "This
isn’t a big deal."

Terminator. Physician terminates discussion of emotions. Example: Patient: "Hhhhh, I’m a wimp, heh heh, I’m imagining...." Physician: "All right...We’ll see you Friday, do you have any questions?"

Dr. Levinson concludes that patient clues and physician responses "are interdependent and a key to building a trusting patient-physician relationship, thus ultimately improving the outcome of care."

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