Is the expression “Oh, by the way …” a problem that arises in the early moments of a consultation?

Abstract

IntroductionThe expression ''Oh, by the way. . .'' usually announces the patient's intention to talk about a new problem, air doubts or give new relevant information about his/her former consultation problems at the closure of a medical visit. Demands at this moment are quite frustrating for physicians for different reasons (1). We know that some doctors' behaviour throughout the visit is associated with the occurrence of new problems during closure (2), and also that patients' difficulties to talk fully about concerns at the beginning of a consultation are related to concerns arising later in the visit (3). However, we have no information about whether these early interruptions affect the closure of a visit. We therefore assessed whether early redirection during the first moments of consultation affected the duration of the consultation, its closure and the raising of new concerns at this stage. MethodsWe conducted the study in primary care consultations with family physician trainees and patients attending for a new clinical problem. All consultations were videotaped. Residents and patients were informed about the aims of the study.Inter-rater reliability was measured by 20 new interviews for the identification of closure time (intraclass correlation coefficient 0.89, 0.73 Á0.95), new information or doubt about the consultation problem (kappa 0.77, EE 0.15), or new concerns that arise at this phase of the interview (kappa 0.64, EE 0.3). All third-year residents in our region participated in the study (37 trainees, 26 males, mean age 28 y, range 26 Á32 y). We obtained permission for 370 primary care consultations from patients who agreed to participate. Of these, 307 were consultations for a new clinical problem and were of good audiovisual quality. We studied the period from immediately after the point when the trainee invited the patient to reveal his/her consultation reasons until the moment the resident made a verbal intervention before the patient had completed his/her initial statement of concerns (''redirection''), the patient had finished speaking spontaneously, or both came to another phase of the interview (such as physical examination, giving information, etc.). Closure was identified by citing sentences believed to be a transition from one phase of the interview, such as gathering or giving of information, prescription or education, to closure. We examined the total encounter time, the length of the closure, and any patient remarks about new problems, or new information or doubt about the former consultation problem arising at this point. ResultsThe mean time until the trainee made the first redirection to modify patient discourse was 239/21 (median 16) s. The most common barriers to the completion of patient discourse were closed-ended questions (138 interviews /80%) and physician statements or comments (15 interviews, 9%). The physician initiated closure in 85% of the visits.