There are a number of issues that lead to problems. First, here are at some general ones and some that lead to difficulties at the beginning of consultations.

  1. How many problems do people bring?

    In a variety of settings including primary care, paediatrics and internal medicine, the mean number of concerns ranged from 1.2 to 3.9 in both new and return visits

  2. How many are discovered?

    Approx 50% (Stewart, 1979 — 54% of patients’ complaints and 45 % of their concerns elicited)

  3. Which is the most important?

    Order of presentation is unrelated to importance yet doctors very often assume erroneously that the first complaint mentioned is the only one that the patient has brought

  4. What about doctors’ interruptions?

    Work by Beckman and Frankel (1984) shed important light:

    • Doctors frequently interrupt - mean time l8 seconds.
    • The earlier the interruption the less likely to hear more than one complaint and the more likely to have late arising complaints and to miss important complaints. Only 23% of patients completed their opening statement. In only 1 out of 51 interrupted statements was the patient allowed to complete their opening statement later. 94% of all interruptions concluded with the doctor obtaining the floor. The longer the doctor waited before interruption, the more complaints were elicited. Allowing the patient to complete the opening statement led to a significant reduction in late arising problems.
    • In 34 out of 51 visits, the doctor interrupted the patient after the initial concern, apparently assuming that the first complaint was the chief one.
    • The serial order in which the patients presented their problems was not related to their clinical importance. Patients who were allowed to complete their opening statement without interruption mostly took less than 60 seconds and none took longer than 150 seconds even when encouraged to continue.
  5. What happens if doctors use closed questioning to hypothesis generation?

    Poor hypothesis generation, poor problem solving issues

  6. In what percentage of consultations do we underestimate our patients desire for information?

    Waitzkin (1984) showed that in 65% of encounters, internists underestimated their particular patient’s desire for information, in only 6% did they overestimate. Many studies have shown that patients can be divided into information seekers (80%) and avoiders (20%), with seekers coping better with more information, and avoiders better with less (Miller and Maugan 1983, Deber 1994)

  7. How many minutes spent in information giving?

    On average only one minute in 20 minute interview, not 9 minutes as doctors thought (Waitzkiu and Stoekel, 1972).

  8. What proportion adhere to treatment?

    Figures depend on the context, eg new problem as opposed to a chronic one. On average 50% adhere.

  9. Medicolegal complaints are related to communication difficulties

    Physicians’ attitudes and communication were identified by lawyers as the primary reasons for malpractice litigation in 70% of complaints.

There are problems in other areas too:

Discovering the reasons for the patient’s attendance:

Gathering information

Explanation and Planning

Patient adherence

Medico-legal issues

Lack of empathy and understanding