The medical consultation is the major arena of the patient-doctor interaction. The key objectives of the consultation are to make diagnoses, to institute treatments, and to set out plans that will achieve these goals. The success of the medical consultation depends almost entirely on the effectiveness of the communication between the patient and the doctor, with patients being freely able to express their concerns, and doctors enabling them to do so. The crucial importance of effective communication in the medical consultation was highlighted by Linda Gask and Tim Usherwood in their paper titled ABC of psychological medicine. The consultation. Pointing out that ‘there is now firm evidence linking the quality of this communication to clinical outcomes‘, Gask and Usherwood affirmed that ‘the success of any consultation depends on how well the patient and doctor communicate with each other’.
Because the medical consultation is a human interaction, it is subject to human factors and therefore vulnerable to patient safety threats. This is indeed the case from the outset when the presenting complaint is being explored. And one of the major perils of the medical consultation, highlighted by Robert Burack and Robert Carpenter in their paper titled The predictive value of the presenting complaint, is to accept the presenting complaint at its face value. Pointing out that there is a lack of concordance between the presenting complaint and the ‘specific underlying motivation for the visit’, Burack and Carpenter stressed that the value of the presenting complaint ‘is limited in specifically identifying the principal problem‘ behind the patient’s visit.
The importance of understanding that the presenting complaint may not be the patient’s primary concern was also addressed by Richard Riegelman in his book titled Minimizing Medical Mistakes: Art of Medical Decision Making. Riegelman pointed out that the patient’s actual reason for the medical consultation may not even emerge until very late in the consultation – sometimes as late as when they are leaving the room. Referring to this phenomenon as ‘the doorknob syndrome‘, he urged doctors to be patient before choosing which of a patient’s various symptoms to use as a pivot because this is a decision that will determine the ultimate outcome of the consultation. To prevent the presenting complaint from inadvertently distorting the diagnosis, Riegelman advised doctors to avoid focusing excessively on it, and to let their patients bring up all their symptoms.
Equally threatening to the success of the medical consultation is the tendency of doctors to interrupt their patients – a trait which, according to Candace West in her book Routine Complications: Troubles with Talk Between Doctors and Patients, manifests in male doctors twice as often as in female doctors. The frequency and seriousness of physicians interrupting their patients were documented by Howard Beckman and Richard Frankel in their paper titled The effect of physician behavior on the collection of data. They reported that doctors interrupt their patients 70% of the time, and they do so on average 18 seconds after the consultation starts – sometimes even before the patients complete their opening statements. Beckman and Frankel also reported that doctors, after interrupting their patients, go on to take control of the conversation with close-ended questions; this further threatens the medical consultation and may lead to inaccurate or misleading medical histories.
Amongst the serious consequence of physicians interrupting their patients, highlighted by Beckman and Frankle, is the risk that it hinders patients from bringing up their ‘chief complaint‘, thereby derailng the whole consultation. Physician interruptions may also evoke a ‘strongly negative emotional response‘ from the patient, as pointed out by Andrew Dearden and colleagues in their paper titled Interruptions during general practice consultations- the patients’ view. A diagnosis which is based on a history that was disrupted by interruptions, and that was obtained from a dissatisfied patient, is obviously a recipe for failure. The ironic futility of interrupting the patient, as pointed out by Gask and Underwood, is that most patients, when left uninterrupted, will stop talking within just 60 seconds.
Unlike the adverse effects that physician interruptions have on the consultation, patient-initiated interruptions are most often beneficial. Tony Realini and colleagues demonstrated this in their paper titled Interruption in the medical interaction where they reported that ‘75% of patient-initiated interruptions resulted in new information (solicited and unsolicited) being contributed to the interaction’. They therefore concluded that ‘interruption by patients can be an informative event‘. For this and other reasons discussed above, Gask and Underwood urged doctors to leave patients to speak, uninterrupted, until they stop, and then ‘ask if the patient has any further concerns‘. They also urged physicians to pay attention to verbal and non-verbal cues such as ‘changes in posture, eye contact, and tone of voice‘ that may point to critical but unexpressed complaints.
Beyond the perils of the doctor-patient conversation, the physical setting in which the medical consultation takes place – the consulting room – may itself undermine the consultation. Highlighting this underrated issue in an article titled What is the main cause of avoidable harm to patients?, Gordon Caldwell argued that enough attention has not been paid to ‘the physical and psychological environments where the diagnosis and treatment plan are thought through’. Observing that the consultation is frequently held in ‘small hot rooms subject to constant interruption‘, Caldwell asserted that this, along with disorganised patient records and poor access to laboratory results, predisposes to ‘serious errors in working diagnoses‘. He therefore advocated for better designed working spaces and information systems ‘to maximise doctors’ ability to see, understand, and deliberate on the information needed for more precise diagnosis‘. He also argued for more time for doctors to enable them make careful diagnoses and implement effective treatments.
This introductory post on the theme of the clinical foundations of patient safety leads us to the next post which will delve deeper into the diagnostic decision-making process.