IDENTIFYING AND ADDRESSING PATIENT CONCERNS: AGENDA SETTING

It is possible to adequately address a chief complaint but not identify or meet the patient’s concerns.

Agenda setting is defined as that process of the medical encounter where the doctor and patient agree on the plan for the visit. If agenda setting is not done, it defaults to whatever the doctor thinks is needed, and sometimes patients feel their concerns were not addressed.

Interpersonal skills are often portrayed as something we do in addition to our normal duties. The implication is that it would add time demands. But a group of researchers reported that certain interpersonal skills actually saved time.(Mauksch Arch Intern Med 2008) Those skills included rapport building, empathy, and agenda setting.

How do we conduct agenda setting? Here are two scripted phrases:

“What concerns you the most?” (addresses the patient’s fears)

“How can I be of most help to you?” (addresses the patient’s goals)

Another way of asking the second question is “what is your goal for this visit?” or “what would you most like to see accomplished?”

When we ask those sorts of questions we are identifying the patient’s concerns and needs, and setting the course for a more effective patient encounter.

Take home points:

-Set the agenda for the visit collaboratively with the patient

-“What concerns you the most?”

-“What would you most like to see accomplished today?”

MEDICAL INTERVIEW: HOW TO ELICIT ALL OF THE PATIENTS SYMPTOMS

Studies show that patients omit symptoms when explaining their history to the doctor. I see this in academics when I get a story that adds information compared to what the resident elicited. When I observe resident history taking directly, I sometimes can gain insight into optimal and suboptimal medical history taking.

Interruptions can be well-intentioned, but studies show they may prevent the patient from giving all the symptoms. Patients get off track and never finish. I recommend starting with a request for the whole story, or some such variant, and then listening without interruption. Facilitative questions are okay, like “tell me more” or “tell me more about the onset.” I usually don’t ask those until they are done talking.

At the end, I like to ask “what else?” Some patients, no doubt used to the medical system and perhaps also out of politeness, give very brief presentations. I want them to know they have permission to give more information.

A full account of symptoms in some cases is the most important factor in making the diagnosis. Patients often leave out key information, so taking a full and open history without interruption is key to medical diagnosis.

Take home points:
Start the medical history with an open invitation
Do not interrupt
Use facilitative questions to get more information “tell me more about…”
At the end ask “what else?”