The Effect of Physician Solicitation Approaches on Ability to Identify Patient Concerns
Lawrence Dyche, MSW,
Deborah Swiderski, MD
Family Medicine and Community Health and
Internal Medicine, Montefiore Medical Center/Albert Einstein College of
Medicine, Bronx, NY, USA.
CONTEXT: Studies showing that physicians often interrupt the pa-
tient’s opening statement assume that this compromises data collection.
OBJECTIVE: To explore the association between such interruptions
and physician accuracy in identifying patient concerns.
DESIGN: This study replicates the Beckman-Frankel methodology and
adds exit interviews to assess physician understanding. The authors
audiotaped a convenience sample of 70 encounters and surveyed both
parties following the visit.
SETTING: A community-based ambulatory clinic.
PARTICIPANTS: Internal medicine residents (77%) and attending phy-
sicians and their adult, English-speaking patients who were primarily
low income and ethnic minority.
OUTCOME MEASURE: The Index of Understanding measures patient-
physician problem list concordance. It is the percentage of patient
problems, obtained on exit, that the physician correctly identifies.
RESULTS: In 26% of the visits, patients were allowed to complete their
agenda without interruption; in 37% the physicians interrupted; and in
37% no inquiry about agenda was made in the first 5 minutes. Neither
physician experience nor their assessment of time pressure or medical
difficulty was associated with these rates. Exit interviews showed no
significant difference in Index of Understanding between those involv-
ing completion of agenda (84.6%) and those involving patient interrup-
tion (82.4%) (P
.83). But when the physician did not solicit an agenda,
the concordance was 59.2%, significantly lower than either the com-
.014) or the interruption group (P
CONCLUSION: Interruption as defined by Beckman-Frankel does not
curtail ability to identify patient concerns, but failure to ask for the
patient’s agenda associates with a 24% reduction in physician under-
KEY WORDS: solicitation; communication; problem list concordance.
J GEN INTERN MED 2005; 20:267–270.
he communication between patient and physician, as
with all human interaction, yields but stubbornly to sci-
entific analysis. Despite sophisticated methodologies for teas-
ing apart the critical elements of discourse in a medical
encounter, clear links to health outcomes prove elusive.
this study, we examined physician approaches to the begin-
ning of the medical interview and the effect these have on the
accuracy of data gathering.
The medical interview is often divided into phases for pur-
poses of study and teaching. The survey phase is that in which
the physician usually obtains the patient concerns or patient
agenda. In a well-known study of the survey phase, Beckman
found that physicians prevented patients from
completing an opening statement 77% of the time. Those who
interrupted their patients did so in a mean time of 18 seconds.
They concluded, ‘‘There is little doubt that the physician re-
sponse and, in particular, early termination or interruption of
patients during their initial expression of concerns at a time of
the visit specifically reserved for such discourse, inhibits fur-
ther patient identification of additional concerns.’’ Marvel
repeated the study with a larger sample and found that
physicians prevented a completed opening statement in 72%
of the visits. Those who interrupted did so in a mean time of 23
seconds. Twenty-five percent did not solicit the patient agenda
Numerous authors have emphasized the importance of
the physician taking a careful survey of patient concerns,
and many cite the Beckman-Frankel study of physician inter-
ruption as evidence of physician difficulty with listening.
Yet the templates developed for taking a survey of patient con-
cerns sometimes recommend physician activity that would
constitute interruption by the Beckman-Frankel defini-
Further, Beckman and Frankel themselves acknowl-
edge that physician interruption might sometimes help
patients formulate their concerns (p. 695).
Marvel et al. found
in their study that physicians with the most training in inter-
viewing tended to interrupt with focused questions and then
resume solicitation (p. 286).
To date, there have been no studies to determine whether
physician interruption compromises physician understanding
of patient concerns or patient satisfaction, or to explore why
some physicians interrupt so quickly. We hypothesized that
physicians who solicit an agenda from their patients and who
allow them to complete a statement of their concerns would
have a better understanding of their patient’s problems than
those who do not, and that patients would have a higher rate of
satisfaction if they are allowed to complete their opening state-
ment. We also hypothesized that physician experience would
associate positively with solicitation and completion rates and
that physician concern about time pressure and medical dif-
ficulty would associate negatively.
During the period from June 2001 to March 2002, the authors
audiotaped a convenience sample of 101 patient-physician en-
counters by placing a recorder in the physician’s office. The
sample included resident and attending internal medicine
physicians and their English-speaking patients. The study
was conducted in an inner-city neighborhood health center
affiliated with a large teaching hospital. The project was ap-
proved by the Institutional Review Board of Montefiore Medical
Center. The research was described to participants as a study
of patient-physician communication. Consent for participation
was obtained from both physicians and patients by one of the
authors or a research assistant. Physician subjects were re-
cruited to represent all levels of experience, and an effort to
obtain sample encounters from a large number of physicians
Accepted for publication July 1, 2004
There are no conflicts of interest to report for any of the authors.
Address correspondence and requests for reprints to Mr. Dyche: Depart-
ment of Family Medicine and Community Health, Montefiore Medical
Center/Albert Einstein College of Medicine, 3544 Jerome Avenue, Bronx,
NY 10461 (e-mail: firstname.lastname@example.org).