General practice

Asking patients to write lists: feasibility study

^a Department of General Practice, University of Leicester, Leicester General Hospital, Leicester LE5 4PW

During consultations the patient's agenda is of paramount importance.^{1 2} To ignore it is to risk dysfunctional consultations and reduced compliance, with management being directed to issues not regarded as wholly relevant by the patient.³ For the patient to write a list of concerns seems logical. Yet doctors negatively stereotype patients who bring lists,⁴ and this presents a barrier to communication. In this pilot study I investigated the feasibility of all patients writing lists of concerns. I also investigated the effect of having a list on the number of problems raised and the time spent on each one.

Patients, methods, and results

I conducted this study during consultations with my own patients in an urban group practice. On booking appointments my patients were advised to draw up a list of their concerns, to bring spectacles or an interpreter if needed, and to come five minutes early to complete a form. On arrival, they were given a form, which had space for a list of concerns and asked four questions on their reasons for attendance; their answers were scored on a seven point Lickert scale derived from McWhinney's classification.⁵ The patients were asked to hand the form to me on entering the consulting room.

I studied 150 consecutive patients who attended morning surgeries on Wednesdays and Thursdays. In one group of 50 patients (A) I began the consultation by studying the list. In a second group of 48 patients (B) I said that the list was to be used for a survey and placed it face down in a box. A third group of 52 patients had no lists and served as controls. Parents accompanying children completed the form on their behalf. For each consultation I recorded the number of problems elicited and the time taken to deal with them using a stopwatch, which I stopped during interruptions.

Data on consultations according to whether patients completed or showed lists of concerns to general
practitioner
-------------------------------------------------------------------------------------------------------------------
                        Group A (list shown; n=49*)      Group B (list not shown; n=48)   Group C (no list; n=52)
-------------------------------------------------------------------------------------------------------------------
No of problems identified:
 Mean (SD)                      1.65 (1.03)                        1.52 (0.65)                     1.40 (0.60)
 Median (range)                 1 (1-5)                            1 (1-3)                         1 (1-3)
 Statistics+:
   Three groups                         x2=0.91, P=0.64
   A v B                                x2=0.04, 95% confidence interval -0.22 to 0.48; P=0.84
   A v C                                x2=0.42, 95% confidence interval -0.09 to 0.59; P=0.52
   B v C                                x2=0.90, 95% confidence interval -0.13 to 0.37; P=0.34
Time of consultation (s):
 Mean (SD)                    445.9 (263.8)                        406.4 (141.5)                   456.0 (255.7)
 Median (range)               444.0 (86-1260)                      409.5 (145-685)                 392.5 (170-1342)
 Statistics:
   Three groups++                       F=0.65; P=0.52
   A v B^                               95% confidence interval -46.2 to 125.2; P=0.36
   A v C^                               95% confidence interval -93.4 to 113.6; P=0.85
   B v C^                               95% confidence interval -32.2 to 131.4; P=0.23
Time per problem (s):
 Mean (SD)                    299.2 (163.7)                        302.3 (135.5)                   357.3 (219.6)
 Median (range)               254.0 (86-809)                       289.0 (104-621)                 305.5 (104-1342)
 Statistics:
   Three groups++                       F=1.72, P=0.18
   A v B^                               95% confidence interval -57.9 to 64.1; P=0.92
   A v C^                               95% confidence interval -18.7 to 134.9; P=0.13
   B v C^                               95% confidence interval -17.4 to 127.4; P=0.13
-------------------------------------------------------------------------------------------------------------------
*One patient was unwilling to complete list and was excluded from analysis.     ++Analysis of variance.
+Kruskal-Wallis test.                                                           ^Two tailed t test.

One patient in group A was unwilling to complete the list and was excluded from the study; 94 of the 98 patients who completed the list also completed the McWhinney questionnaire. The mean number of problems per consultation was 1.52 (range 1-5). The table shows an increase in the number of problems elicited when the patient made a list, with a further increase when the list was shown. These differences were not, however, significant. The time taken on each problem was reduced when a list was made, but there was not further reduction when the list was shown. Again, neither these differences nor the differences in consultation times were significant (table).

Comment

It is feasible for most patients to complete lists when given advance warning. Doctors' fears about long lists seem to be unjustified. The act of making a list could improve communication by helping patients to organise their thoughts. Sharing the list with the doctor might further improve the consultation by making the patient's agenda explicit.

I found that consultations were more efficient in terms of more problems being found and less time being spent on each problem when lists of concerns were drawn up and shown to me. The trend was most obvious in relation to the number of problems identified, but the differences were not significant between the groups. Two limitations of my study are that I analysed my own consultations (introducing the possibility of bias in a non-blind study) and I did not randomly allocate my patients to the three groups.

Future studies will need to be randomised; more consultations need to be studied and the consultations of more than one doctor analysed. To show whether lists are beneficial, additional outcome measures are needed. These might include patients' and doctors' satisfaction and patients' compliance and subsequent consultation rates.

I thank Dr R K McKinley, senior lecturer, department of general practice, University of Leicester, for help in compiling the statistics, and Dr S Hills of the University of Nottingham for statistical advice.

Source of funding: the analysis and writing up of the study were done with the help of funding from a research training fellowship from the Royal College of General Practitioners.

Conflict of interest: none.

1. Middleton JF. Successful consultations: the patient's agenda. Modern Medicine 1991 April:183-6.
2. Middleton JF. The exceptional potential of the consultation revisited. Journal of the Royal College of General Practitioners 1989;39:383-6.
3. Tuckett D, Boulton M, Olson C, Williams A. Meetings between experts: an approach to sharing ideas in medical consultations. London: Tavistock, 1985.
4. Middleton J. Written lists in the consultation: attitudes of general practitioners to lists and the patients who bring them. Br J Gen Pract 1994;44:309-10. [Medline]
5. Stewart MA, McWhinney IR, Buck CW. How illness presents: a study in patient behaviour. J Fam Pract 1975;2:411-4. [Medline]

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