The Patient-physician Relationship

DURING THE 1980S, RENEWED interest in the patientphysician relationship and the availability of more sophisticated audio and video technology allowed investigators to explore medical discourse in unprecedented detail. One of the most frequently quoted studies from this period (Beckman and Frankel) suggested that patients, asked to describe their concerns by a physician, were most often redirected after the first expressed concern and after a mean time of only 18 seconds. Additionally, in only 1 of 52 visits did redirected patients return to their agenda and complete their offering of concerns. As a result, the authors postulated that practitioners often pursued a concern without knowing what other issues the patient might wish to discuss or if the pursued concern was the most important one. Although Beckman and Frankel used the term interruption to describe this behavior, we prefer the term redirection to indicate verbal interventions that directed the focus of the interview before the patient had completed an initial statement of concerns. Since others had found that patients, if given the opportunity, have an average of 3 concerns per office visit, the chance of ignoring important issues and creating less efficient visits seemed realistic. Most texts on the medical interview have advocated an interviewing approach that solicits patients’ reasons for seeking care and encourages the practitioner to listen until all concerns have been elicited. This component of the medical interview, sometimes called the “survey of problems” or “agenda setting,” precedes more focused open-ended and closed-ended questions used to clarify further each concern. Although the original research by Beckman and Frankel found the agenda setting rarely completed, a number of concerns challenge whether the initial findings are generalizable. First, 81% (n = 60) of the visits were with internal medicine residents. Second, the sample size was small (n = 74 visits and patients). Third, the practitioners worked exclusively in an urban inner-city practice. To address these concerns, the current study was designed to extend the re-