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 dont 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 cant...I didnt wanna take a month out again (for surgical removal of pins and plates).
Patient: Like all summer long Ive been having fun with my ... uh, riding horses, and, course I still like to do that, but uh, that will be ... I, Ill 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 cant fix or cure the patients emotional concerns. Or, they may believe that the demands of the managed care environment doesnt 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 patients 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. Levinsons study are:
Acknowledgement. Physician names patients feelings or acknowledges life concerns. Example. Physician: "Im very frustrated, so Im 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 youll hang in there...."
Supportive. Physician is supportive of patients concerns. Example. Physician: "I think its really important you get second opinions for the complicated problems...you want the best for yourself."
Examples of missed opportunities in Dr. Levinsons study are:
Inadequate acknowledgement. Physician acknowledges clue, but does not respond to patients underlying concerns. Example. Patient: "Im 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 cant really tell you anymore, you know..."
Inappropriate humor. Physician jokes or laughs inappropriately. Example. Physician: "I guess, were gonna have to, you know...youre getting so old...were gonna have to shoot ya...thats all there is to it...."
Denial. Physician denies patients concerns. Example. Physician: "This
isnt a big deal."
Terminator. Physician terminates discussion of emotions. Example: Patient: "Hhhhh, Im a wimp, heh heh, Im imagining...." Physician: "All right...Well 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."