Ask ‘What else?’
As doctors, there are few things more frustrating than attending a department or other meeting without a clear agenda, so it makes sense that we and our patients have the same expectation of why we are meeting and why we’re gathering and what we’re hoping to achieve.
A colleague recently told me that she had spent 45 minutes addressing concerns of intimate partner violence with a patient, putting herself way behind schedule only to be reprimanded by the patient when she told her she’d have to come back to discuss her shoulder pain.
I begin the clinical encounter with an open-ended question to initiate the discussion, like, “What brings you in today?” Then give the patient a full 90 seconds to respond.
The goal here is to create an agenda. When necessary, we reorient the patient to elicit all their concerns: “I’d like a list of all the things you’d like to address today.”
Then ask “what else” until all of their concerns have been identified.
Summarize the list to ensure the agenda is thorough, then ask the patient to prioritize. This is especially important if they have a long list of issues; oftentimes these exhaustive lists end up providing related information, particularly when other issues inform your differential. You may need to help them prioritize the list if there are issues the patient thinks are low acuity but you think are higher.
Avoiding the doorknob phenomenon
The risk we accept by not setting an agenda is the doorknob issue — when we don’t ask for all the issues up front, we end up with a case of chest pain just as we’re ending the appointment, and then our schedule is shot.
In their paper Effect of Patient Completed Agenda Forms and Doctors’ Education (2006), Middleton, McKinley, and Gillies report: “Doctors require similar times (about five minutes) to deal with each problem whether or not patients have made their agenda explicit or if the doctor is trained in how to elicit the agenda.”
The point is to get all of the issues up front, to organize our time with the patient. If there is a door knob issue at the end, and if it’s benign, we can add it to the agenda for an upcoming appointment.
Middleton JF, McKinley RK, Gillies CL. Effect of patient completed agenda forms and doctors’ education about the agenda on the outcome of consultations: randomised controlled trial [published correction appears in BMJ. 2006 Jun 17;332(7555):1418]. BMJ. 2006;332(7552):1238-1242. doi:10.1136/bmj.38841.444861.7C