One More Reason Patients Ask Doctors So Few Questions

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[tweetmeme source=”Healthmessaging” only_single=false]The most popular post on my blog is entitled Five Reasons Why People Do Not Ask Their Doctor Questions. Well it seems there is a sixth reason.

The Reason?

I am forever reminded of this when I see my retinal surgeon for follow-up for my surgery to fix a recently detached retina.   Every time I try and ask a question, I am told to wait until he’s finished with the exam…at which point I have forgotten the question.

Turns out today’s “medical exam” (aka medical interview) is actually a highly structured process which has changed little in many ways since its inception in the early 1900s.  Both the patient and physician have defined roles which have evolved over time.

The physician’s role is that of scientist and problem solver.  He or she listens, albeit often briefly, to the patient’s presenting complaints.  Next they examine the patient asking questions as they go along. Then comes a working diagnosis followed by tests (if needed), then a treatment plan is presented to the patient and viola…the physician is out the door.

The patient’s role in the medical exam is two-fold: 1) present their problems in a clear and concise fashion and 2) answer the physician’s questions when asked.  That’s it.  Remember it’s all about arriving at a diagnosis and treatment.  In fact the patient’s opening statement – describing their reason for the visit – is the only place in the medical exam where patients are supposed to talk freely.

Otherwise, if not explicitly asked by the physician, most patients, including “empowered patients,” are unlikely to bring up unvoiced concerns, expectations or questions.  After all who wants to interrupt their doctor.  There is just no place in the medical exam process formally designated for patient questions.  It isn’t that they are unimportant; they are just not needed by the physician to make a diagnosis.

All the talk about patient-centered care aside, the medical exam is a physician-directed affair.  Research shows that primary care physicians on average dominating 60% of available visit talk time.  The predominant communication style employed by the majority of primary care physicians is what is called biomedical.  This style relies on closed ended questions, evidence and hard science to arrive at a diagnosis and treatment plan.  In studies using conversational analysis (audio-recording and coding of physician-patient exchanges during the medical exam) patient questions are the least frequent form of patient verbal utterance during the typical office visit.

To be sure, the medical exam as taught in medical school over the last 5 years has taken on a more patient-centered orientation.   But physicians are busy people.  Like the rest of us, busy physicians gravitate to what will get us where we need to be in the least amount of time.  Unfortunately that means little time for unscripted patient questions.

That’s what I think.  What do you think?

Sources:

Kaplan CB, Siegel B, Madill JM, Epstein RM. Communication and the Medical Interview Strategies for Learning and Teaching.; 49-55.

Putnam SM, Stiles WB, Jacob MC, James S a. Patient exposition and physician explanation in initial medical interviews and outcomes of clinic visits. Medical Care. 1985;23(1):74-83.

Cegala DJ, Street RL, Clinch CR. The impact of patient participation on physiciansʼ information provision during a primary care medical interview. Health Communication. 2007;21(2):177-85.

16 Comments

  1. Verria Kelly says:

    The idea that exams are “physician directed affairs” is one of the problems with the medical system today. Misdiagnosed and undiagnosed conditions are on the rise because physicians are operating with their own knowledge, which, while highly specialized, isn’t the only information needed to make an accurate diagnosis. Patients, while obviously not medical doctors, are the experts when it comes to their own bodies and asking the right questions can help the right doctor determine an accurate diagnosis and effective treatment plan. If your doctor doesn’t allow you to ask questions, I say find another doctor.

  2. I agree 100% with you. Patients need room in the consultation for answers to their own questions.

    The problem is clearly that the consultation today is considered to be that defined period between the patient walking in and out of the door.

    Thankfully there are much more effective ways that are being adopted by some of the worlds best Doctors. The one that I am impressed most by is called Instant Medical History (check it out at http://www.medicalhistory.com) and it involves an interactive intelligent patient history gathering questionnaire and free text box.

    This online tool enables patients who can access the internet the ability to share their history AND any unscripted questions they may have BEFORE coming to the Doctor. It also enables Doctors to review this BEFORE they meet with the patient. It also effectively and securely documents the entire process.

    The tool can even help patients who can’t access/use the internet because it can be completed by a carer, in waiting room PC. Because it improves a Doctors effectiveness it can also help free up Doctors time so that they have more time available to dedicate to those patients who can’t use computers or mobile phones.

    As we’re using IMH as a part of our remote care service in the UK and Ireland you might want to check out this lecture given by Prof John Bachman MD, Professor of Medicine, Mayo Clinic College of Medicine, for a more independent vendor neutral perspective: http://bit.ly/dBQPgK

  3. Carolyn Thomas says:

    Thanks Stephen for this thought-provoking piece. Reminds me of what Dr. Jerome Groopman describes in his book “How Doctors Think” as “The 18-Second Rule”, which is how long he estimates a doctor will actually sit quietly and listen to a patient before interrupting with his/her first stab at diagnostics.

    Before I was sent home in mid-heart attack from the E.R. (with an acid reflux misdiagnosis, despite presenting with textbook heart attack symptoms like crushing chest pain and pain radiating down my left arm) the E.R. nurse had actually, unbelievably, told me NOT to “question the doctor. He is a very good doctor and does not like to be questioned!”

    My offending question had been: “But what about this pain down my arm? How is that a symptom of indigestion?”

    I now believe that, in the field of emergency medicine particularly, medical staff are pressured into making extremely rapid assessments and diagnoses of each patient. Not much tolerance for a patient asking those pesky questions, right?

    Regards,
    C.

    • “How Doctors Think” is a great book! With my wife’s lung cancer treatment, we finally had to reconcile ourselves to the fact that our doctors “was the supreme leader” of team. I can’t tell you how many times he would she or I who the team quarterback was. Since he was the top medical thoracic medical oncologists at MD Anderson and therefore the world…we eventually learned it was better to be alive than right…lol

      Take Care.. Steve

  4. @Carolyn Thomas Great example, do you think if YOU had written in YOUR electronic record “pain down my arm” and “How is this a symptom of indigestion?” your Doctor would have still sent you home without a proper examination?

    I bet his nurse would also be surprised by the amount of attention he would be willing to pay to the documented history patients provide him with.

    You can see this in lots of professions: documentation itself has a habit of making people behave in a much more accountable way.

  5. As a cancer patient, I have learned to demand time with my doctors. I fire a doctor who does not listen to my questions or talks down to me. I go the appointment prepared with a list of questions. I am conscious of when I ask my questions and try to do so when the time seems right. If my retinal specialist (and I do have one) treated me like yours treats you, I’d find another doctor. As a plain language and health literacy writer, I have worked as a patient advocate, and I find it very disappointing to hear about experiences like yours. Many patients will be too intimidated to ask for what they want and will walk away not getting what they need to heal and be healthy. Doctors learn from their patients.

    • Kristina,

      Since the detached retina was an emergency operation, I had just met my surgeon and had no inkling what his pe4rsonality was like. I will tell you that I believe that there is a direct relationship between the severity of any medical problem…and the degree to which you need to hand off certain decisions to the “expert.” In other words…its great to expect to have a collaborative relationship with a primary care doc as long as things are fine. But when you get real sick…it seems like we end up having to trade a little control for more expertise. It’s kinda like an atheist in foxhole under intense gunfire…you learn to pray real quick.

      Thanks for your thought!

  6. Robert Eikelboom says:

    How life has changed. My PhD supervisor in the early 1990s was/is an ophthalmologist, and I remember his Office Manager telling me that patients (usually elderly) would phone her as soon as they got home from an appointment, and ask her questions. When she asked why they did not ask the doctor when they were seeing him, the reply was “Oh… I could not do that! He’s far too busy.” It was the mindset of another generation: that doctors were the experts, and that we had to blindly follow their advice. Of course it was combined with a healthy respect for the professionals.
    Now I hear that doctors are at times fearful of patients having more information than them, often armed with more information (relevant and not relevant) than the doctor can deal with, and at times asking lots of irrelevant questions.
    However, my experience with my GP and a few times with specialists is that they are keen to glean an accurate clinical history. I come prepared with the facts, and throw in (hopefully) relevant questions which are answered appropriately.

    • Robert,
      Thanks for the comment. Great story about patients waiting until they get home to call with questions. I detected a bit of reticence on your part about whether you questions are “relevant’ to your doctor or not. No matter how empowered we are with information…we still put distance between ourselves and the “expert.”

      Steve Wilkins

  7. Lynn Nezin says:

    Thank you for a succinct description of the current disconnect occuring in offices every day. Sadly, the “empowered” patient is viewed with some measure of antagonism as the “entitled” patient, who is often seen to be inappropriately challenging a time-entrenched power structure.
    The situation of the office visit requires behavior change from both participants in the discussion — physicians will need to give themselves permission to listen a bit more attentively, and patients need to learn to present themselves with clarity and efficiency. Time remains of the essence, and the time must be used well by both parties.

  8. WarmSocks says:

    I type my questions in advance and give them to the doctor first thing. He can then determine the best sequence/timing to provide answers. That wouldn’t help in your emergency scenario, but another part of my solution would. I also have paper and pencil to take notes – if those questions are important enough to ask, then it’s important to write down the answer so I don’t forget. If you had pencil & paper, you could just jot down your question so that when the doctor does have time to answer, you have your question ready to ask.

  9. RuneStone says:

    I’m studying medicine in the Netherlands and we’re being trained to ask ‘do you have any questions?’ at the end of a consult… We’re supposed to reserve some time for getting to know what the patient thinks about your treatment plan. It’s a specific part of the entire history/exam process (and you’ll even lose points if you forget to ask it on a test).

    So, there is some effort to get patients to voice their concerns… but it will probably take years before it’s ‘common’. It’s very annoying, as a medical student, I expect my doctors to behave as I’m trained to do but apparently, all of them got the old-fashioned training…

  10. I agree with your premise that the medical appointment is a doctor driven affair. That is the way they were trained to manage the appointment. I have found that I have changed the dynamics of my appointments and made it a true partnership, co-leading and co-cordinating my appoinntments. Patients CAN change the process. Forgive the ad, but I did this using the concepts and processes described in my book, The Savvy Patient’s Toolkit.

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