Why Patients Don’t Ask Their Physicians Questions – Additional Thoughts

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Many of my readers are curious about patient question asking behavior during a trip to the doctor. The fact that most of us ask few “important” questions during a routine (or not-so-routine) physician visit seems very counter intuitive.   After all, conventional wisdom (and TV drug ads) are forever telling us to “ask your doctor” or “talk to your doctor.”  It seems like a very logical thing to do.   But you would be wrong.

You see most people are not aware that the “visit with the doctor” is a highly structured, time honored affair.   Physician office visits typically are not like normal conversations. It is not that they can’t be a conversation…it is just that typically they are not.   In a conversation there is a natural flow between participants, e.g., someone talks, and some listens, and then someone talks. During the office visit, patients generally have a very limited “window of opportunity“for telling their story to the doctor.

For more information on patient question asking behavior check out my earlier post.

The structure of the physician visit goes back to the early 1900’s and the advent of the “physician as scientific expert” role.   Consistent with the scientific method, there has to be a process to everything.

In the case of the physician-patient interaction, the process involves the physician guiding the patient through the following 5 steps:

  1. Identify the patient’s presenting problem – this phase is important because it is the only time patients are asked to describe their illness in their own terms and in pursuit of their own agenda.   Problem presentation is normally initiated by physicians’ opening questions and ends when the physician begins the medical history and exam.
  2. Conduct the medical interview (history and physical examination) – In this phase the physician asks the questions and the patient answers.
  3. Diagnose the problem – Here the physician tells the patient what he/she thinks is wrong, including recommending any necessary tests.
  4. Treatment of the problem – This is where the physician recommends a course of treatment, including medications, referrals, etc. to the patients.
  5. Closing – This is where the physician tells the patient when they should schedule the next appointment and then out the exam room door.

The patient’s window of opportunity for “speaking up” during the office visit is often limited even further by the physician interrupting the patient’s opening statement (problem presentation) with a question…which invariable segues into the medical interview without the patient being allowed to finish.

The truth is that most of us are pretty adept at knowing when to speak up and when to keep quite in social situations.   The physician visit is no exception.   A look, a comment or a gesture let us know when the other party (in this case our physician) is interested in what we have to say.   Social norms, i.e., physicians are busy and I shouldn’t waste their time with my trivial question, my doctor will probably think I am dumb if I ask my question, etc. also silence even the most empowered patients among us.

Implications for Patients

As the side bar points out, 28% of medical errors in one physician study were attributable to cognitive errors on the part of physicians including:

  • Incomplete/faulty history and physical examination
  • Failure to consider the correct candidate diagnosis
  • Premature closure (of the visit).

 

There are steps patients can take to avoid such medical errors.  They include: 1) understanding the process of the office visit from the physician’s perspective and 2) knowing when and how to speak up in a way that will get their thoughts, concerns and desires across in a productive, satisfying fashion.

For more information on patient question asking behavior check out my earlier post.

5 Comments

  1. Ellen says:

    Something that has been helpful for me is writing questions down and giving them to the physician as soon as possible. If they use an assistant to screen patients before they conduct the exam give your questions to the assistant and have them put in the holder outside the exam room. If they don’t use an assistant have them ready to give to the physician right away. Also, have a copy of the questions with you to write down their answers. Using this approach has helped me in dealing with a chronic illness over the past few years.

  2. Sheba Muturi says:

    You make the very important point that it is easy to tell patients to talk to their doctors but in reality, “During the office visit, patients generally have a very limited “window of opportunity“for telling their story to the doctor.”
    Ellen makes a good point about preparing questions ahead of time. I recently came across excellent work by the UBC Division of Health Communication. http://www.chd.ubc.ca/dhcc/ourwork/ttyd/community

    They have developed a workshop to equip patients with the skills to successfully engage with their health professionals. They emphasize a shared decision-making approach which goes beyond patients simply asking questions to providing active input that contributes to the decision. The workshops are based on the PACE framework which stands for: Presenting detailed information about how they feel; Asking questions if desired information is not provided; Checking understanding of information that is given to you; and Expressing concerns about the recommended treatment. This approach has been proven to work and patient advocacy groups could use this to enhance patients’ skills, which are becoming more important as overworked physicans allot less and less consultation time to patients.

  3. Ellen,

    Thanks for the great comments. Turns out that I am familiar with the PACE system and the work of very interesting work of Don Cegala, PhD.

    Best,
    Steve Wilkins

  4. This is a great blog. A lot of the problem may stem from many patients’ and families’ expectation that effective physician-patient communication is up to the physician. Communication is a two-way street, and both sides should come to the conversation reasonably prepared. Writing down questions in advance is a great practice. Three other steps that help some people are: actually practicing saying the questions out loud; having a friend accompany you to help you articulate concerns and remember what has been said; and telling the physician at the beginning of the exam that you will have a couple of questions to ask when the doctor is ready to hear them.

    • Neil,

      Thanks for you comments and kind words. Frankly I believe that if we as an industry were able to get the patient more involved in the office visit in meaningful and focused ways, they could make physician better communicators which would be good for everyone.

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