How patients understand physicians’ solicitations of additional concerns: implications for up-front agenda setting in primary care

Abstract

In the more than 1 billion primary-care visits each year in the United States, the majority of patients bring more than one distinct concern, yet many leave with “unmet” concerns (i.e., ones not addressed during visits). Unmet concerns have potentially negative consequences for patients’ health, and may pose utilization-based financial burdens to health care systems if patients return to deal with such concerns. One solution to the problem of unmet concerns is the communication skill known as up-front agenda setting, where physicians (after soliciting patients’ chief concerns) continue to solicit patients’ concerns to “exhaustion” with questions such as “Are there some other issues you’d like to address?” Although this skill is trainable and efficacious, it is not yet a panacea. This article uses conversation analysis to demonstrate that patients understand up-front agenda-setting questions in ways that hamper their effectiveness. Specifically, we demonstrate that up-front agenda-setting questions are understood as making relevant “new problems” (i.e., concerns that are either totally new or “new since last visit,” and in need of diagnosis), and consequently bias answers away from “non-new problems” (i.e., issues related to previously diagnosed concerns, including much of chronic care). Suggestions are made for why this might be so, and for improving up-front agenda setting. Data are 144 videotapes of community-based, acute, primary-care, outpatient visits collected in the United States between adult patients and 20 family-practice physicians.