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Eliciting the Patient’s Agenda: Analysis of Recorded Clinical Encounters [pdf] (springer.com)
13 points by bookofjoe 9 months ago | hide | past | web | favorite | 9 comments

Times change: when I was an intern in the ER at Los Angeles County-University of Southern California Hospital in 1974-75, "5 minutes or 5 problems — whichever comes first," was our guideline.

That’s really interesting - I’ve never heard that.

I only work ED these days and only a few shifts a month, but I love the interview. And I also hate the interview.

When I have worked 60 hrs a week it’s easy to develop compassion fatigue: it’s just so hard listening to story after story and allowing someone to just tell their story.

I want you to tell me in your own words, and I want to know what the root cause was that lead you to the department, and how long that bit went on for, but if I don’t cut you off and prompt you for some really weird specific details that aren’t necessarily going to roll out of your mouth. You’re the 70th patient this month and I’m currently juggling 4 stories around in me head at once - I can’t get too involved with you.

So - there my experience anyway

Perfect. 5 seems a bit much (5 problems that is), but 3-4 minutes or problems seems like a moderate guideline in today's world. Great measure.

A while ago I joined my girlfriend for a few doctors' visits because of chronic pain. I definitely noticed that with most of them it's really hard to get a word in. You go in, they ask what the problem is, barely listen for a few moments, order tests and then proceed with what they want to do. It feels like the patient is just a thing that needs to be processed as quickly as possible.

I don't recall a single visit where there was a real exchange between patient and doctor.

> clinicians elicited patient concerns, the clinician interrupted the patient after a median of 11 seconds (interquartile range 7–22; range 3 to 234 s). Uninterrupted patients took a median of 6 s (interquartile range 3–19; range 2 to 108 s) to state their concern.

I’m not sure what conclusions to draw from this. On one hand, I find that people who interrupt me make whatever I need to say take much longer. On the other hand, I feel that patients would be shy when answering, if they were asked broad questions, and therefore take less time to answer, possibly hoping for more guiding questions to follow.

Most medical advice is designed to minimize liability, not actually help patients. Doctors don't need to listen, and can't.

The fundamental problem I see is that doctors treat patients as threats to be managed: They will take too much time, they might sue, they will misinform you, they tire you out (per another comment). That's not a healthy attitude and it doesn't lead to productive relationships.

My experience with doctors is that they are unprofessional: Their communication skills are poor, causing potentially dangerous misconceptions (someone mentioned a secret 5 minute rule; what if critical info is in the 6th minute?), and a lack of understanding on my part (they barely listen so they don't know the question and therefore don't answer it); they are disrespectful, often treating patients like mentally challenged children (5 minutes and that's it, and we won't tell you there's a time limit), have no regard for patients' time[0], and won't return phone calls or emails; they are often sloppy and often unprepared, which I know from personal experience[1] and from the fact that hospital errors are a leading cause of death (at least in the U.S.).

Doctors behave as if they are the only ones challenged by constrained time, by communicating with clients, and by weariness at the end of the day. But every other profession, from lawyers to accountants to IT consultants, has the same problems and deals with it. My lawyers and accountants master communication skills, respect clients, and are productive. I want to say: Grow up, be a professional, I don't give f- that you're tired and busy, so am I. Every other profession manages.

[0] I'm busy too; I have people waiting for me too; how about if I make you sit around for an hour in the middle of your day? Doctors commonly schedule patients to come before the doctor will be ready, to make sure the doctor doesn't have to wait - as if their time is more important than mine. They fall behind schedule every day, making patients wait - after the third day, you learn and adjust your schedule; after three years, it's just complete disrespect for patients' time. One doctor I had to see regularly for awhile would schedule me at 8:15 and wander in at 8:45 with a bagel, coffee, and reading the news. Another schedules his entire day at the same time in the morning, and patients just sat around the waiting room all day; after 2 hours, I asked others and the nurse, found out what was going on (and that it was his standard procedure), and left; the woman waiting for hours in a wheelchair with an oxygen tank and nurse apparently didn't have that option.

[1] Just off the top of my head: Seeing a doctor for a second opinion on a serious back problem. When the doctor walked in, opened the file, and started reading, I told myself she was just refreshing herself. Her advice was for the wrong problem in the wrong part of my back; when I tried to tell her, she didn't listen and when she finally realized it, she just tried to cover for herself.

I'm sorry you have had bad experiences with physicians.

But not every other profession has the same problems. I have been on call for 12 days in a row where anyone who tells my answering service they are a patient of our office can call anytime to ask any question, no matter how ridiculous, for free. Today I have returned calls to a patient who is pregnant but concerned that she does not feel enough pregnancy symptoms and someone whose temperature is 99.8 and is concerned.

I am almost always in the office before my patients arrive, often as much as two hours, doing charting. I am signing forms to get people FMLA. We don't charge for filling out these forms. Do you think your lawyer would?

Frequently patients are late, but then still want to be seen. So either I make the late patient angry, or everyone else behind them is angry.

How many lawyers get called all night long? How many accountants are at their place of business in the middle of the night?

I have a nurse to return phone calls, but it seems that hardly anyone can have a voice mail that it set up, and due to HIPAA regulations we are advised not to leave any personal messages anyway. So we pay a whole office full of people to play phone tag all day.

Sometimes I am late, but sometimes people are unexpectedly trying to die. Sorry I never met this lady who has 2 liters of blood in her belly, so I didn't know she was going to come to the ER with her ectopic pregnancy today, and inconvenience you. We do try to call and reschedule, but again can't always get through.

I know your frustrations, because I see the same things in IT and other professions. The difference I see is that doctors seem to think they are a special case (in this and other things) and helpless to manage these issues; the truth is that they are a common case and that there are solutions that other professionals commonly use and are expected to use.

All that you describe is common for IT professionals (support and system administrators), and sometimes with just as much on the line or more (large amounts of money, careers, and sometimes even lives). I know some who have been on call for years in a row, and when they travel outside of cellular coverage they rent a satellite phone. They have no nurse to return calls; when someone calls (or a system sends an automated alert), they logon and get to work.

They work all hours; all-nighters and 7 day workweeks are common. One sysadmin I know estimates one all-nighter per month. When a deadline is approaching, you can count on 100+ hour weeks. Just read HN to hear people talk about it.

Their customers (users) have the same absurd requests, same demands, same communication problems, etc., though of course about different topics. For example, some send ambiguous problem reports and don't respond to attempt to clarify - but if the problem isn't fixed, money will be lost and you know who will be blamed!

Their scheduling problems are the same: Unpredictable issues arise and always at the worst time. That means they have to schedule with a large margin for error.

> How many lawyers get called all night long?

I know many who do. First, some have clients in many time zones around the world and most have clients around the country (in the U.S., the latter means a 5am-6pm minimum workday on the west coast). More often, they are working on urgent projects and must respond ASAP to the other attorneys and clients working on the issue lest they delay everyone else or, worse, fail to contribute value and influence the outcome.

As for accountants, in the U.S. ask them what tax season is like.

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