We admit it. We’ve fallen into the same trap in our columns that we fall into every day in the office or hospital. All our columns on the impact of interruptions and distractions have focused on interruptions to healthcare workers. Now a new “Piece of My Mind” in JAMA reminds us about the impact of interruptions on our patients (Mauksch 2017).
For several decades now, when teaching students and residents about listening skills, we have quoted from a study by Beckman and Frankel that physicians interrupt their patients on an average of 18 seconds (Beckman 1984). Actually, the timeframe might be even shorter. A study of resident interactions with patients showed the interruption occurred on an average of 12 seconds (Rhoades 2001).
But in the recent piece Larry Mauksch points out that the interruptions are not always negative and provides some great examples of how to interrupt your patient tactfully so that you do not appear rude yet help focus on things that are important to the patient. He notes that some interruptions may build rapport, offer support, and express cooperation.
He suggests adhering to “The Triple E” when interrupting patients:
Mauksch suggests the following script for redirecting patients who have a tendency to jump from one symptom/topic to another: “Excuse me, your back pain sounds distressing, but we were only part way through addressing your asthma. How about we finish the asthma and then see if there is time for your back pain?”
We all have a few patients who tend to move from topic to topic and are difficult to get to focus on key points. Most of us have learned that, to be fair to both those patients and other patients we are seeing the same day, thoughtful scheduling is important. If we schedule such patients early in an office/clinic session we will always be pressured by time and workload and all patients get short-changed. So we tend to schedule the more “loquacious” patients toward the end of an office/clinic session.
But what if you are a patient? When we do our patient safety for patients courses we tell our audience they should have a checklist of the symptoms/topics they hope to discuss with their physician or other healthcare provider. The items should be roughly prioritized with those the patient considers most important near the top of the list. Giving the physician a copy of the checklist at the beginning of the session may also help him/her get an idea about time allocation.
Mauksch also points out that the physician can also do agenda setting early in a session to help avoid late “oh, by the way” issues. For example, he suggests the following script: “Excuse me for a moment. Your knee has been painful. Before we talk further about this pain, I’d like to know if you have something else important to address today. This way you and I can figure out how to make the best use of our time.”
Read Mauksch’s article. It’s short but to the point. And his suggestions are valuable not only for your patient interactions but apply equally to many of the everyday interactions you have with multiple other people! They are an important part of treating individuals with respect and you’ll find in the long run that will make your life easier.
Actually, another group of clinicians recently took agenda setting to a new level: collaborative agenda setting in the electronic visit note. Anderson et al. (Anderson 2017) had patients attending a large primary care safety-net clinic type their agendas into the electronic visit note before seeing their clinicians. Patients and clinicians agreed that the agendas improved patient-clinician communication (patients 79%, clinician 74%), and wanted to continue having patients type agendas in the future (73%, 82%).
Are there implications for patient safety? You bet! One of the examples provided by Anderson et al. was a patient typing on his agenda “lumps on my lungs”. The clinician explained that a pulmonary nodule had been identified on a CT scan on an ER visit that the clinician might have missed if the patient had not put it on his agenda.
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
Mauksch LB. Questioning a Taboo. Physicians’ Interruptions During Interactions With Patients. JAMA 2017; 317(10): 1021-1022
Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med 1984; 101(5): 692-696
Rhoades DR, McFarland KF, Finch WH, Johnson AO. Speaking and interruptions during primary care office visits. Fam Med 2001; 33(7): 528-532
Anderson MO, Jackson SL, Oster NV, et al. Patients Typing Their Own Visit Agendas Into an Electronic Medical Record: Pilot in a Safety-Net Clinic. Ann Fam Med 2017; 15(2): 158-161