Patient Agenda Setting: Complications, Consequences, & Coordination

 

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Why open the Floodgates?

When it comes to up-front or clinical agenda setting, why bother? Clinicians often fear that if allowed to share power and control, their patients will hijack consultations and clutter them with odd, unnecessary details and explanations, include long, emotionally laden information, voice too many concerns to be able to address within one visit, and extend already tight schedules. Let’s take a look at the origins of agenda setting, define up-front agenda setting, why the practice is so important, and how to manage it.

From Politics to Patients

Originating from political mass media studies, agenda-setting research focused on media networks’ roles in choosing and presenting stories to the public. They include

• which topics are newsworthy enough to present (e.g., political unrest versus climate change; heart disease versus skin cancer breakthroughs), the
• order of the stories presented (i.e., breaking news and headlines versus page two), and the
• amount of information allowed per story.

These choices influence public perceptions about what issues are most important at particular moments in time [1]. For example, leading stories about Zika virus can influence public awareness that the disease is the scariest and most important public health hazard of the day. Choosing which news stories lead and how much information, space, or time is allotted them influences public perceptions of which topics are most important, what topics a public thinks about, and what the public talks about (although not necessarily how to think or talk about them).

Clinical Up-Front Agenda Setting – It’s Complicated

Clinical agenda setting can have similar affects. The issues patients lead with are often assumed to be the chief or most important reasons for their medical visits. However, as health care professionals will quickly tell you, in many cases this is just not true. In addition to other factors, agendas are influenced by personalities, clinician-patient relationships, and the nature of the topics up for discussion. Let’s begin with a few basics.

Definitions

Agenda setting is “a process whereby patients and clinicians establish a joint focus for both their conversation and their working relationship” [2] (p. 822).

Up-front agenda setting is the strategy to solicit a complete list of patient concerns as quickly as possible [3]. As you already know, this approach can be easier said than done. However, we will describe methods that improve the likelihood for acquiring more comprehensive lists of patient concerns while keeping the allotted time scheduled for typical medical appointments in mind. As you will learn, additional time is usually not necessary.

Gobat et al. identified several core domains that encompass up-front agenda setting. This essay centers on the patient agenda domain, which examines clinician strategies to elicit patient concerns, expectations, and goals as efficiently and thoroughly as possible [2].

Significance

Patients  introduce an average of 3 concerns per primary care visit [3,4,5,6 ]. How practitioners communicate and react to patients during medical interviews can result in a variety of outcomes. We’ll begin with a list of some of the positive outcomes associated with implementing good agenda setting strategies, then explain why some patients delay disclosures, and finally, describe methods that promote successful agenda setting.

Why bother? Because effective agenda setting can . . .

• facilitate patient engagement and involvement
• help patients provide more complete descriptions of their concerns
• improve acquisition and more thorough understandings of problems
• improve the gathering of potentially relevant information from patients for diagnosis and treatment
• reduce unmet concerns (i.e., those topics patients plan but fail to raise during their medical visits)
• allow more efficient management of visits due to identifying and prioritizing problems earlier
• positively influence patients’ beliefs and attitudes that their clinicians are listening to them, that they understand them, and care about them
• improve patient adherence to treatment recommendations
• facilitate positive relationship development between clinicians and their patients
• improve the potential for decision making collaborations between clinicians and patients
• improve patient satisfaction and loyalty
• reduce doorknob disclosures (i.e., late-arising concerns) that are frequently the “real reasons” for medical visits. These declarations are revealed just as an office visit is coming to a close (e.g., when the clinician’s hand is on the doorknob and about to leave).

Why do some patients wait to state their real reasons for office visits?

Disclosures are delayed because problems are intimate, difficult to admit or explain, and/or embarrassing. Patients also delay disclosing based on how they view their relationships with their clinicians as well as their clinicians’ management of medical interviews. Bringing up personal and embarrassing topics is challenging for most of us. Here are some other reasons patients delay expressing concerns to their clinicians [5].

• Patients delay disclosures until they believe they can trust their clinicians.
• Patients prefer that their clinicians bring up the uncomfortable topics.
• Patients wait due to gender differences and/or cultural norms.
• Patients wait due to their clinicians’ interviewing styles.

Applications: The following strategies improve initial and followup solicitations of concerns.

Initial solicitation techniques: Verbal and nonverbal behaviors influence patient participation during up-front agenda setting and ongoing medical consultations.

Verbal communication involves linguistic choices we make when we speak, write, or sign (i.e., American Sign Language). Words, grammar, and sentence structure make up our verbal communication.

Nonverbal communication involves the many other means that we use to communicate along with or without words. Examples of nonverbal behaviors include our tone of voice, speed of speech, facial expressions, eye contact, posture and body orientation, gestures, timing, silence, touch, and personal space.

1. Question format: Use open-ended questions. Patients prefer responding to open-ended questions (e.g., What brings you here today?. What can I do for you today?) as opposed to questions involving simple yes, no, and short answers, or that confirm clinicians’ prior knowledge of their concerns (e.g., So, your knee hurts?). Patients want to describe their conditions in their our own words, in their own time, and on their terms when establishing agendas with their practitioners [7].

2.  Avoid interrupting patients.  In a well-known and a follow-up study investigators found practitioners interrupted and redirected patients immediately after describing their first reasons for office visits. The time allowed for patients to speak before being interrupted averaged only 18 and 23 seconds respectively [8,5]. Once redirected, few patients returned to complete their list of problems. Those patients permitted to complete their thoughts only needed an average of 6 additional seconds. That extra time translated to more efficient patient information gathering and fewer doorknob disclosures [5]!

Followup solicitations

Strategies used for effective solicitation of other issues may be more subtle than initial requests. Patients’ understandings and reactions to further appeals can vary as a result of clinician word selection and by how patients view their relationships with their clinicians. Here are tips that encourage greater patient participation and less confusion based on misinterpretations of requests.

Nuance – word-choices & relationships matter.

3.  Positively frame rather than negatively frame questions. After obtaining initial responses, follow-up questions can elicit additional patient concerns. Patients can react positively or negatively by the words clinicians choose when making requests. For example, clinicians using words associated with negative polarity often sway patients to “no” responses.

e.g., “Is there anything else you want to address in this visit today?”

However, using words that embody positive polarity when making requests for more information tend to favor “yes” responses.

e.g., “Is there something else you would like to address in this visit today?”

More patients respond positively to questions using the word something. Implementing this word encourages patients to reveal additional topics, earlier in their visits, and reduces the number of unmet concerns patients list in their pre-visit questionnaires. These outcomes are accomplished without lengthening appointment durations [6]. Alternative phrases which can improve list completion related to positive polarity include “Are there some other topics you would like to discuss?”, “Do you have additional concerns you would like to talk about?” and  “Are there other things on your mind?”

4.  Formulate questions using more inclusive/neutral wording. Asking patients if they have other “problems” they would like to discuss can leave out other important reasons for patient visits. “Problems” can suggest physical, medical, diagnosable, and treatable concerns. Patients visiting to renew prescriptions, review test results, or for annual checkups can feel awkward when responding to this type of question. What inclusive wording can replace the word “problems” in the phrase “Do you have additional ______ that you would like to discuss?” Neutral terms which can be perceived as more comprehensive forms of solicitation include “issues,” “concerns,” “things,” “topics,” “matters,” “items,” and “reasons [3].”

Patients’ reactions can vary as a result of relationship status. Familiarity can influence patient responses to solicitations.

Returning patients make up about half of the reasons why patients visit primary-care physicians [9]. These patients may interpret agenda setting questions differently than new patients. The common wording used when questioning returning patients can lead to confusion based on their understandings of various phrasing for “other issues.” Patients can interpret “Do you have some ‘other issues’ that you would like to discuss today?” as requests for only those things considered “new,” “which are either totally new or ‘new since last visit’ [3] (p.435).” So, chronic and previously diagnosed, treated, and recurring problems may not be regarded as new, triggering returning patients to answer “no” to this type of questioning because answering “yes” about conditions their clinicians are already aware of seems awkward. After responding “no” to this type of request, some patients will feel the need to circle back, rephrase the question, then answer it in a way consistent with their objectives. Others however, may delay repairing their answers until their office visits are nearly concluded or not mention their intentions at all.

With regard to this dilemma, here are suggestions for addressing returning patients.

5.  Formulate questions so that patients can backtrack, revisit, elaborate, or incorporate new, past, or existing concerns.

e.g., “Do you have concerns regarding new topics, or questions about the things we’ve recently discussed that you would like to ask about?”

6.  Consider beginning appointments by generating a list at the outset of an office visit.

e.g., “Let’s begin our visit by listing the things you’d like to discuss today.”

Keep in mind when applying point 6, that patients may nevertheless have reasons to delay stating certain topics until later. Consider the list generated as a good start.

7.  Partnership-building behaviors increase patient involvement and assertiveness [10].

• Solicit – Clinicians often find that first complaints are not the chief complaints [5]. As already stated, more frequent solicitations increase the chances of meeting your patients’ needs and earlier in the process.

• Encourage involvement, Affirm, Accommodate

Avoid speaking too quickly or appearing rushed.

Acknowledge and show interest.

Allow patients to talk about their feelings, express their opinions, make requests, change topics, and provide detail.

When possible and appropriate, agree with patients.

Use continuers & nonverbal paralinguistics. These are facilitative and nondirective utterances which allow and encourage patients to express themselves (e.g., “Uh-huh,” “Yeah,” “What else?,” “Mm hmm”).

Consider nonverbal strategies (see point 9 described below).

8.  Supportive talk behaviors validate patients’ emotional and/or motivational states (e.g., expressions of concern) [10]. These behaviors can be performed throughout medical visits.

• Reassure, encourage, and praise – Indicate that observations and thoughts are valued. Show approval.

e.g., “You are providing important and helpful details.”

• Empathize and express concern – Identify with patients’ discomfort.

e.g., “I know that this is not easy to talk about.” “That must have been scary for you.”

• Comfort – Console patients when they experience frustration, sadness, and embarrassment.

e.g., “Let’s see what we can do to help you feel better as quickly as possible.”

9.  Like verbal behaviors, nonverbal behaviors can influence patients’ willingness to participate in clinical settings and increase their satisfaction with their clinical experiences.

Here are nonverbal behaviors to consider when interacting with patients that increase their involvement. These behaviors need to be performed within a reasonable range of acceptability. As mentioned elsewhere, don’t be weird!

Immediacy behaviors are verbal and nonverbal actions that can communicate both psychological and physical closeness. Those who appropriately perform these actions are perceived as more likeable, approachable, open, warm, friendly, and involved.

Body orientation – Face your patients, stand relatively close, use an open relaxed position (i.e., uncrossed arms & legs), and slight forward lean.

Avoid standing too far away and facing away from your patients for long periods of time, or using closed, stiff (i.e., tightly crossed arms), and backward leaning positions.

Eye contact – Look at your patient while speaking and listening to them (but avoid staring them down).

Head nodding – Perceived as a form of approval, show your patients that you are listening, paying attention, interested, and supportive.

Facial expressiveness – Be engaged. Smile when appropriate and show concern.

Tone of voice – Use friendly, soft, less aggressive, and less hyper-formal tones.

References

1. McCombs, M. E., & Shaw, D. (1972). The agenda-setting function of mass media. Public Opinion Quarterly, 36, 176-187. doi: 10.1086/267990
2. Gobat, N., Kinnersley, P., Gregory, J. W., & Robling, M. (2015). What is agenda setting in the clinical encounter? Consensus from literature review and expert consultation. Patient Education and Counseling, 98, 822-829.
3. Robinson, J. D., & Heritage, J. (2016). How patients understand physicians’ solicitations of additional concerns: Implications for up-front agenda setting in primary care. Health Communication, 31, 434-444. doi: 10.1080/10410236.2014.960060
4. Braddock, C. H., III, Edwards, K. A., Hasenberg, N. M., Laidley, T. L., & Levinson, W. (1999). Informed decision making in outpatient practice. JAMA, 282, 2313-2320.
5. Marvel, M. K., Epstein, R. M., FLowers, K., & Beckman, H. B. (1999). Soliciting the patient’s agenda. Have we improved? JAMA, 281, 283-287.
6. Heritage, J., Robinson, J. D., Elliott, M. N., Beckett, M., & Wilkes, M. (2007). Reducing patients’ unmet concerns in primary care: The difference one word can make. Journal of General Internal Medicine, 22, 1429-1433. doi: 10.1007/s11606-007-0279-0
7. Robinson, J. D, & Heritage, J. (2006). Physicians’ opening questions and patients’ satisfaction. Patient Education and Counseling, 60, 279-285. doi: 10.1016/j.pec.2005.11.009
8. Beckman, H. B., & Frankel, R. M. (1984). The effect of physician behavior on the collection of data. Annals of Internal Medicine, 101, 692-696.
9. National Ambulatory Medical Care Survey. (2010). 2010 Summary tables. Retrieved from http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf
10. Street, R. L., Gordon, H. S., Ward, M. M., Krupat, E., & Kravitz, R. L. (2005). Patient participation in medical consultations: Why some patients are more involved than others. Medical Care, 43, 960-969.

Bibliography

Griffith, C. H., Wilson, J. F., Langer, S.,  & Haist, T. A. (2003). House staff nonverbal communication skills and standardized patient satisfaction. Journal of General Internal Medicine, 18, 170-174. doi: 10.1046/J.1525-1497.2003.10506.X

Richmond, V. P., McCroskey, J. C., & Hickson, M. L., III.  (2012). Nonverbal behavior in interpersonal relations 7/e. New York, NY: Pearson.

Rodriguez, H. P., Anastario, M. P., Frankel, R. M., Odigie, E. G., Rogers, W. H., von Glahn, T., & Safran, D. G. (2008). Can teaching agenda-setting skills to physicians improve clinical interaction quality? A controlled intervention. BMC Medical Education, 8, 1-7. doi: 10.1186/1472-6920-8-3

Robinson, J. D. & Heritage, J. (2005). The structure of patients’ presenting concerns: The completion relevance of current symptoms. Social Science & Medicine, 61, 481-493.