A few weeks ago I called a neurosurgeon to discuss a patient’s recent headaches. My patient had been seen in the emergency room several days prior with the worst headache of his life. A complete work-up had not revealed a cause for the headache. Although he was found to have a small aneurysm on CT angiogram, there was no evidence of bleeding by lumbar puncture. The story, however, was slightly more complex than this. There had been several other findings that remained unexplained. One of the findings led me to discuss the patient’s case with a cardiologist. My patient had also undergone cervical spine decompression surgery several months prior to treat cervical myelopathy. I wanted to engage the neurosurgeon and get his professional opinion about my patient’s headache, which had now recurred several days after his ER visit.
The surgeon was cordial, but about 5 seconds into my story he seemed inpatient and interrupted me. “I heard about this guy,” he said, “What he needs is to be seen by one of our neurovascular specialists.” I had more I wanted to say, but the doctor did not seem to want to listen. I raised my voice slightly, interrupted him before he had a chance to end the conversation, and bulldozed through, telling the rest of the story in about two minutes. “Now we’re talking,” he said, as I explained further about a family history of clotting and my concern about a dural thrombus as a potential etiology. Together we formulated a plan that I was satisfied with–though the interaction left me with a feeling of unease.
Interruption is a pervasive communication style with doctors. In a well known study by Beckman and Frankel patients were allowed to complete their opening statement expressing their agenda in its entirety in only 23% of physician interviews. The average time to interruption was 18 seconds. This study’s findings have been replicated by several others. In a more recent study of primary care residents, patients were allowed to speak for only 12 seconds on average before they were interrupted. Female patients experience interruption more frequently than males. In contrast, studies have suggested higher rates of patient satisfaction with physician visits during which patients and doctors interrupt at similar frequency and also with visits in which there is more “reflective” silent time during the conversation. Perhaps the tendency to interrupt extends to all physician derived professional communications, as in my case with the neurosurgeon on the phone.
Why do physicians interrupt? In practical terms, throughout the course of a given day a physician may be tasked with listening to twenty to thirty patient derived histories and with solving difficult problems for each of these patients in a matter of ten to fifteen minutes. This is a tough, if not impossible job. Consequently, once a physician believes that the meat of the story is out there, he or she may respond and interrupt before hearing details that the patient (or colleague) feels are important. In more abstract terms interruption is a communication strategy that reinforces physician dominance in the hierarchy of the patient-physician relationship.
The most frequent complaint that I hear from patients about other physicians is that a physician did not “listen,” or did not “seem to care” about their problem. My advice to physicians and medical trainees: sit down, bite your tongue and wait. If you do interrupt, do so with brief questions allowing your patient to return to his or her agenda. You might be surprised and learn something, and no doubt you’ll certainly have happier patients (and colleagues).
Juliet Mavromatis is a general internist based in Atlanta, GA. She blogs at DrDialogue where this post first appeared.
Sometimes patients go on tangents. A LOT of very long tangents. Do you want to be the last patient a doctor sees after letting all of his patients go on tangents all day long?
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if you come to any guider or go to a person which is expert in his field ,you should give him free hand on your task …interruption may be or mostly affected reverse on you. so don’t try to make expert in every field be interruption..
I am not a doctor but I am a Science postgrad and recently started my career of Clinical Research Associate. I would say that I have always had a complain from doctors that they don’t listen to their patients. If they have time constraints then the question is why they take responsibility for handling too many patients within a limited time period? A patient goes thru some psychological changes along with physical and he/she needs to feel satisfied after having a conversation with their doctor but I see (talking about my personal experience) doctors are always in rush and they jump on their conclusions even without listening to the whole story of their patients. your opinion may vary.
Jumping to conclusions is an interesting one because I have heard doctors complaining about patients assuming they have rare or exotic diseases in the past.
Perhaps doctors sometimes go too far the other way, and extrapolate common diseases from just one or two symptoms.
All the comments above are valid. Physicians get crunched for time as volume pressures grow. HIT overloads and sometimes diminishes the physician’s ability to get relevant or important information quickly. Patients also often don’t know what information is most useful to present or don’t know how to present it effectively.
That being said, we physicians don’t always do so well either. We get impatient or rush to conclusions. Jerome Groopman talks about this in ‘How Doctors Think’. It isn’t a lack of caring but rather a combination of time constraints, technology distractions and yes, our own belief that we’ve seen a set of symptoms before and know what the condition is just after hearing a portion of someone’s comments.
Medicine is facing a series of challenges requiring physicians to be masters of many new skills simultaneously. Empathy and communication skills are teachable and both will be required for physicians to do their best work, which is ultimately to help patients.
I think all doctors nowadays should be required to undergo training on communication skills and displaying empathy. I have unfortunately had to access health care numerous times in the past few years and it seems to now be the exception, not the rule, when a doctor actually listens to my concerns. I am not a chatty Cathy by any means either. I know doctors are hurried and I try to be respectful of this by coming to each appointment prepared with my list of most pressing concerns and symptoms. So if people like me aren’t feeling listened to, I can’t imagine what it’s like for those who struggle to summarize their health concerns for whatever reason.
Certainly as Colin states there are times when doctors need to interject when a patient is going off on a tangent and time constraints are limited, but even then there are tactful ways of doing so that don’t invalidate a patient’s concerns. Also, I think it’s important that doctors understand shyness as well and that sometimes they need to be the ones asking questions to get out information and not expect the patient to know everything that is important to say.
Successful communication is key and something they don’t seem to train doctors in any more, which is unfortunate.
Redirection techniques in conversations are a social skill that can be difficult and I suppose that interruption is a kinda a crass one. That doesn’t mean it is never appropriate.
I would make an argument that physicians are under such unique pressures that often times moving the conversation forward is a necessity, even if such requires interruption. I don’t think the post addresses the very reality that for every story that is missed because of interrupting, many many more are appropriately cut short, without the loss of clinically relevant information.
I remember one of the first patients I ever saw as an intern in clinic. Seeking out a history of his cervical radicularesque pain he almost verbatim began, “Well, it started in 1976 during a sand volleyball game. We used to play a lot of volleyball on base…” The wall on the clock was behind him and watching it it took six and a half minutes of monologue, without a word from me, to describe the details of a low back pain he had developed three decades from an injury during a volleyball game which turned out to be clinically irrelevant.
It’s true, if I interrupted him there’s a possibility I might have missed something important, but in my experience that seems the less common scenario. Verbose and irrelevant histories from patients and other physicians are a reality and any physician who remembers their humility as a resident and sitting through such while biting their tongue, knows that the vast majority of those histories have no hidden gems in them.
I don’t need the consulting physician to list the entire past medical history of a new consult, just the pertinent things. I don’t need to know about the specifics of how a three decade old volleyball game was organized.
And it isn’t merely a matter of convenience for the physician, it is a matter of cost and effectiveness and the health of an entire patient load arguably.
Sometimes interrupting, redirecting patients, even other physicians, is the right thing to do and patient satisfaction needs to take a back seat to the health of everyone.
Thanks for your comments. I agree that redirecting conversation is important–particularly when one has just a short time with a patient, as is virtually always the case in medicine these days. At the same time–at least in outpatient medicine and with treatment of chronic conditions, I find it is invaluable to attempt to figure out what the patient’s agenda and hypothesis is. Often this involves listening to stories and multiple details that we deem irrelevant in our traditional biomedical model. However, unless you address these stories and concerns patients feel unheard and are less likely to trust your explanatory model and treatment advice.
Doctors are rushed, more now than ever before. They are suffering from HIT induced productivity deficiencies.
They are required use devices that bring to waste 5-10 minutes clicking on every patient, searching through silos of irrelevant information, searching for pertinent physical therapy notes, working around the intrinsic defects and flaws in the CPOE device, and when one wants to know something as basic as the BP (with HIT, nurses never have the information), a 30-45 second sign on is required. I want to throw up on this transformation of health care.