Stephen Wilkins MPH is a former hospital executive, consumer health behavior research and recent care giver. He has witnessed incredible oversights and gaps in physician-patient communications that have had “near catastrophic” consequences for patients like his wife who was diagnosed with Stage 4 Lung Cancer in 2004. He is the co-founder of a Health Messaging Inc., which focuses on developing ideas and solutions for improving the quality of communications between physicians and patients. He blogs on Mind The Gap.

The most popular post on my blog is entitled Five Reasons Why People Do Not Ask Their Doctor Questions. Well it seems there is a sixth reason.

The Reason?

I am forever reminded of this when I see my retinal surgeon for follow-up for my surgery to fix a recently detached retina.   Every time I try and ask a question, I am told to wait until he’s finished with the exam…at which point I have forgotten the question.
 
Turns out today’s “medical exam” (aka medical interview) is actually a highly structured process which has changed little in many ways since its inception in the early 1900s.  Both the patient and physician have defined roles which have evolved over time.
 
The physician’s role is that of scientist and problem solver.  He or she listens, albeit often briefly, to the patient’s presenting complaints.  Next they examine the patient asking questions as they go along. Then comes a working diagnosis followed by tests (if needed), then a treatment plan is presented to the patient and viola…the physician is out the door.
 
The patient’s role in the medical exam is two-fold: 1) present their problems in a clear and concise fashion and 2) answer the physician’s questions when asked.  That’s it.  Remember it’s all about arriving at a diagnosis and treatment.  In fact the patient’s opening statement – describing their reason for the visit – is the only place in the medical exam where patients are supposed to talk freely.
 
Otherwise, if not explicitly asked by the physician, most patients, including “empowered patients,” are unlikely to bring up unvoiced concerns, expectations or questions.  After all who wants to interrupt their doctor.  There is just no place in the medical exam process formally designated for patient questions.  It isn’t that they are unimportant; they are just not needed by the physician to make a diagnosis.
 
All the talk about patient-centered care aside, the medical exam is a physician-directed affair.  Research shows that primary care physicians on average dominating 60% of available visit talk time.  The predominant communication style employed by the majority of primary care physicians is what is called biomedical.  This style relies on closed ended questions, evidence and hard science to arrive at a diagnosis and treatment plan.  In studies using conversational analysis (audio-recording and coding of physician-patient exchanges during the medical exam) patient questions are the least frequent form of patient verbal utterance during the typical office visit.
 
To be sure, the medical exam as taught in medical school over the last 5 years has taken on a more patient-centered orientation.   But physicians are busy people.  Like the rest of us, busy physicians gravitate to what will get us where we need to be in the least amount of time.  Unfortunately that means little time for unscripted patient questions.
 
That’s what I think.  What do you think?
 
Sources:

Kaplan CB, Siegel B, Madill JM, Epstein RM. Communication and the Medical Interview Strategies for Learning and Teaching.; 49-55.

Putnam SM, Stiles WB, Jacob MC, James S a. Patient exposition and physician explanation in initial medical interviews and outcomes of clinic visits. Medical Care. 1985;23(1):74-83.

Cegala DJ, Street RL, Clinch CR. The impact of patient participation on physiciansʼ information provision during a primary care medical interview. Health Communication. 2007;21(2):177-85.