Joseph Scherger, MD, MPH
Ever notice a patient wince when interrupted describing his or her problem? It is well known that physicians interrupt their patients much of the time and usually within 30 seconds of the start of the visit. One study in Family Medicine showed that residents interrupted patients 12 seconds into a visit 25% of the time (article pdf). We even teach interruptions as part of “controlling the conversation” and “limiting the agenda” for the visit.
In a practice where there is ample time for visits, there is rarely if ever a need to interrupt a patient. I’m now in such a setting after more than 30 years of brief office visits, and I had to train myself to not interrupt patients. What a great feeling that is! At our practice, we sit back and let every patient finish what he or she has to say. Patients notice this, too, saying they have never had a physician listen to them like we do. We learn things about patients they have not had the chance to share with physicians before.
Since we have an hour for every new patient visit, early in the encounter I ask the patient to tell me his or her story. The patient often asks, “Which story?” I say, “Where were you born and what happened after that?” It is amazing to me how most patients finish this story in about 5 minutes. As a matter of fact, I’m impressed with how brief most patients are when giving their narratives uninterrupted.
Our physicians are now demonstrating an uninterrupted communication style to medical students in their family medicine clerkships. By the time they arrive at our practice, they have already been taught to interrupt patients, so we teach them otherwise. Often, this helps them love family medicine. We look forward to training residents in uninterrupted narrative next year when our residency program starts.
Interrupting patients is a part of the paternalistic culture of medicine where the physician’s time is more important than the patient’s, and the physician knows better than the patient what the problem is. Such paternalism is unprofessional and even dangerous and should not be a part of patient-centered care.
I admire professionals who let people have their say completely. Counselors are very good at this and so are good lawyers, realtors, designers, and many others. Interruptions seem to be mainly a physician behavior.
Visits with patient can be efficient without interruptions. When patients have been given the chance to say everything they want during the visit, they are more receptive to hearing our assessment and recommendations for managing their problems. After all, patients are in charge of their care. Our job is to serve them, respectfully and without interruption.
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Kudos for not interrupting your patients and for teaching the next generation of physicians in family practice how to un-learn the habit. As a foundation dedicated to promoting humanism in medicine we applaud your efforts. We know your patients applaud them too!
I also like the concept of not interrupting patients. I’ve found that if I can TRULY let a patient just talk, they give me a much better sense of what the story (and backstory!) are, than if I jump in with a checklist of questions.
Having said that, when schedules are busy, it seems SOME form of time management is needed. We’re a rural clinic, so staying busy is not JUST because we want to maintain a solid bottom line – we also want to be able to be available to patients with urgent needs.
The implicit balancing act there in that is balancing availability for all vs lots of time for each individual – and I’ll freely admit that there are times I’ve shortened one visit, in order to squeeze in someone else and save that someone else a long and expensive trip to the ER a half hour away.
So – I see value in both the open “we don’t interrupt” approach, AND the “agenda-setting” approach. Both have something to offer, both have their place – and my question is whether there is any comparative research between the two styles in terms of patient satisfaction, health outcomes, or office efficiency and productivity.
Challenging research to do, but it would be very informative if done!
To answer my own question, I did find this – it’s a review, not a study, but helpful:
Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med. 2008 Jul 14;168(13):1387-95
http://archinte.jamanetwork.com/article.aspx?articleid=414377
As a method to help me and to teach resdents and medical students about interruptions, I have employed the following mantra: “Consider the first 60 seconds of the encounter to be sacred.” In this way, we tune ourselves to listening and being aware of patients needs.
Joe, I couldn’t agree more. As a resident in the 70’s I was taught to control the conversation. When I became a faculty member and began video taping residents I say what we were teaching and was appalled. We immediatley retrained ourselves not to interupt. I think this note say more about the power of videotaping than anything else, but programs continue to teach “active listening” and guided interviewing, mainly as a by product of having to see more patients.
I’m with Kieth only I would say, “the opening statement” rather than the first 60 seconds. If we can just let the patients tell us in their own words (no matter how many of them there are) why they have come in, we can honor their preeminence in the encounter but also manage our time efficiently. If we interrupt them and then fail to ask “what else,” we only invite longer visits because of “doorknob” issues. I do not have the luxury of Dr. Scherger’s 60 min visits but I am consistently praise by patients and students for my ability to allow patients to express their “story” in their own words, without interruption (and even to encourage them to elaborate when I feel they are not really finished). Since I teach interviewing to students, I am helping to create a new generation of physicians who understand how important this is.
Full, mindful and generous attention at the beginning and at the end of the encounter go a long way to patient and doctor satisfaction, and better health outcomes! I find it helpful to round out visits with an inquiry such as “We’ve talked a lot. I wonder if you could tell me what you understand to be our plan. Is there anything else I can help you with today?”
The lesson of the first day of economics 1: Wants are infinite, resources finite. To pretend otherwise is disingenious. To teach otherwise is a disservice to our students and creates a cognitive dissonance that is pathologic. Providers no longer have infinite time, nor do they control their time. We are factory workers in a system that we do not control. Stop idealic dreaming.