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

Introduction

The 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.

Methods

We 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, 0.73–0.95), 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 26–32 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.

Results

The mean time until the trainee made the first redirection to modify patient discourse was 23±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. Patients mentioned new problems at closure (“Oh, by the way…”) more frequently when physicians redirected the focus of the interview before they completed an initial statement of concerns in the early moments of the visit. More than half of the trainees directed the focus of the interview before the patient had completed an initial statement of concerns (Table I).

Table I.  Patients’ new remarks at closure, physician redirection, and consultation and closure length.

	Redirection
	No (%)	Yes (%)	p value
n = 307	143 (46.6)	164 (53.4)
Raising new problem (54, 17.5%)	18 (12.6)	36 (22)	0.03
New information about his/her problem (39, 12.7%)	20 (14)	19 (11.6)	n.s.
New doubt about his/her problem (46, 15%)	24 (16.8)	22 (13.8)	n.s.
Consultation length (min:s)	7:37 (SD 3:45)	7:40 (SD 3:32)	n.s.
Closure length (s)	15 (SD 16)	60 (SD 94)	0.001

n.s.: non-significant.

χ² and Student's t-test.

Discussion

Time pressure has been argued as an important reason for this widespread behaviour among doctors. However, allowing patients to complete their monologues requires little time [4], [5], and our results show that early redirection does not save global consultation time (as others have also reported [3]) but makes closures longer and more dysfunctional by the patient's raising of new problems at this phase of the interview. In addition, the average time for redirection in our study was closer to others carried out in consultations 8 min longer than ours [3], so this behaviour may not reflect doctors’ concerns about time pressure so much as concern about consultation control.

Funding was granted by Consejería de Salud, Junta de Andalucía (278/03). The study protocol was approved by the “Reina Sofía” Hospital Ethic Committee (Córdoba, Spain). There were no conflicts of interest.