Spontaneous talking time at start of consultation in outpatient clinic: cohort study
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7366.682 (Published 28 September 2002) Cite this as: BMJ 2002;325:682All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
In response to our article from Sept 28th Profs Bland and Goetzsche
correctly point to some errors in the presentation of our data. Indeed,
the numbers in brackets after the patients' age do not denote the 95% CI,
it describes the range in patients' age. The text should read as: 42.9
years (SD 18.2 (range 17 to 84) years).
Dr. Goetzsche is correct in criticizing that the standard deviation should
not have been applied with raw data so heavily skewed.
Competing interests:
None declared
Competing interests: No competing interests
The authors report that the spontaneous talking time in 335 patients
at start of consultation was 92 seconds (SD 105 seconds). Since the
standard deviation is bigger than the mean, the statistical interpretation
of this information is that a large proportion of the patients had
negative talking times. The clinical interpretation would be, perhaps,
that these patients swallowed unspoken words. The problem is, of course,
that the standard deviation has no meaning when the distribution of the
data is not approximately Gaussian, and it should therefore not have been
listed as a measure of dispersion.
Competing interests: No competing interests
Congratulations on an important piece of research.
I would be interested to learn more about the perceptions of the
participating doctors.
The data suggest that doctors must change their history-taking
strategy to allow the patient to finish their story uninterrupted. Whereas
they previously might have interrupted at 20 seconds, they must now wait
for 90 seconds before direct questioning.
The doctors felt that useful information was gained during the extra
time spent listening, but did they feel that the strategy was of overall
benefit. And more importantly, will they continue to use the strategy now
that the trial is over?
Are there plans to follow up the participating doctors to ascertain
this?
Competing interests: No competing interests
I apologize for TWO responses to this article.
I have felt that giving patients a chance to tell us what is wrong is the
most important thing we can do for most of them. Someone, it may have been
Osler, said - "If you listen to the patient long enough, he/she will tell
you what the problem is" And a cynic replied - "But who is listening?"
Yesterday, I lamented that the classic article was not referenced -
in a private email, a more astute individual wrote to me that there was a
limit on references and the authors had to leave it out. So, I want to
apologize.
Also - there was a short piece in the NY Times today (1/10/02) about
this article. Other than saying that the study came from Sweden - it was
pretty accurate.
VITAL SIGNS
Perceptions: When Patients Have Their Say
By JOHN O'NEIL
Are patients blabbermouths? Many doctors apparently think so.
Research has shown that doctors interrupt, on average, about 20
seconds after a patient begins to talk.
But a new Swedish study suggests that doctors actually have little to
fear from letting patients have their full say.
In the study, which was published on Friday in BMJ, the journal of
the British Medical Association, 14 doctors in the outpatient clinic of
University Hospital in Basel agreed to time their patients surreptitiously
while allowing them to talk without interruption at the beginning of a
visit.
They shut their timers off whenever the patients indicated that their
stories were complete with concluding lines like "That's all, doctor" or
"What do you think?"
The doctors had expected that the average statement would go on for
three and a half minutes.
In fact, the article said, the average patient finished in 92
seconds, and 78 percent were done within 2 minutes. Only 7 of the 335
patients hit the 5-minute mark, at which point the doctors were allowed to
cut in. "In all cases," the article said, "doctors felt that the patients
were giving important information and should not be interrupted."
The study's lead author, Dr. Wolf Langewitz, sent this advice in an e
-mail message:
"To patients, I'd suggest: Be prepared! Don't start with your
complaints right away. Start with the agenda. E.g.: `Dear Dr. Murphy, On
my list for today are the following items.' Wait until the doctor pays
attention! `First, what about the new pills you mentioned last time.
Second: My daughter's in trouble, perhaps you could help us?'
"Physicians should get the message," Dr. Langewitz continued. "Listen
— it won't take long."
Competing interests: No competing interests
How quickly one is forgotten!
The classic study looking at the time a patient needs to impart a chief
concern was done by Howard Beckman and Richard Frankel. Anyone interested
in this area should read this seminal paper. Here is the MEDLINE
citation:
Ann Intern Med 1984 Nov;101(5):692-6 Related Articles, Links
The effect of physician behavior on the collection of data.
Beckman HB, Frankel RM.
Determining the patient's major reasons for seeking care is of
critical importance in a successful medical encounter. To study the
physician's role in soliciting and developing the patient's concerns at
the outset of a clinical encounter, 74 office visits were recorded. In
only 17 (23%) of the visits was the patient provided the opportunity to
complete his or her opening statement of concerns. In 51 (69%) of the
visits the physician interrupted the patient's statement and directed
questions toward a specific concern; in only 1 of these 51 visits was the
patient afforded the opportunity to complete the opening statement. In six
(8%) return visits, no solicitation whatever was made. Physicians play an
active role in regulating the quantity of information elicited at the
beginning of the clinical encounter, and use closed-ended questioning to
control the discourse. The consequence of this controlled style is the
premature interruption of patients, resulting in the potential loss of
relevant information.
Langewitz et al's paper is an important continuation of the work of
Beckman and Frankel. The latter should receive acknowledgement since they
were early pioneers in this area. As I remember it, their patients were
interrupted in an average time of 17 seconds.
Competing interests: No competing interests
This is an interesting paper with a very pretty histogram, but it
suggests that talking time was negative for some patients. Surely the
first bar should start at zero, not minus 25!
Also the authors report that "mean age was 42.9 years (SD 18.2 (95%
confidence interval 17 to 84) years)". If this is a confidence interval,
either for the estimated mean or for the SD, it is far too wide. I
suspect that it is in fact the 95% range for the individual ages.
Competing interests: No competing interests
Listening to the patients. How much time will they spend talking about their initial complaints?
To the Editor,
Langewitz et at (1), reported in the September issue of the BMJ a
study analysing the time spent by patients in spontaneous talking at the
beginning of the first consultation. With a sample of 335 patients
referred to a tertiary care centre of internal medicine, they concluded
that the mean length of spontaneous talking was 59 seconds. As a
conclusion, they suggested that doctors do not risk being swamped by
patients’ complaints if they listen until the patient stated that they has
finished, since nearly 80% do so in less than 2 minutes. It was suggested
that in “less selected groups” (perhaps in primary or secondary care)
patients might need even less time for this initial disclosure. In fact,
the main interest of these findings could be in general practice, where
the pressure of time is greater, with a mean time of consultation for each
patient of 7 minutes.
From a similar methodological approach, but with a different aim, we
recently reported (2) a study analysing the contents of the speech of
patients in their first consultation. We assessed all the patients
referred to a community mental health centre in Santander (a city in the
North of Spain) for the first time throughout a year. They were invited to
explain the reasons of their visit without intervening at all, except for
active listening (“facilitators” such as echoing, etc.) and were allowed
to speak for five minutes, while the contents of their talk were recorded.
For the final sample of 162 consecutive new patients (mean age 40.9, with
a 57% of females), most of the patients (146 patients, 90.1%) spent all
the first five minutes disclosing the areas considered by them as more
relevant for the consultation. We found that in this spontaneous initial
talk, patients gave details of a mean of 2.3 psychiatric symptoms, but
also cited life events in 51% of the cases, previous psychiatric illness
in 22.3%, medical illnesses in 22%, and the date of the beginning of
symptoms in 32% of the cases.
The aim of this report was to analyse the amount of information
delivered by patients in the first minutes of the interview, and the
concordance between the first clinical impression and final diagnosis.
Finally, diagnoses were concordant in only 58% of cases, and unexpectedly,
those patients reporting more symptoms received less accurate initial
diagnoses. This study could highlight the fact that patients usually tend
to speak for a relatively long period prior the doctor inquiries, and the
fact that this time mainly relies on the expectations of the patients. In
tertiary care consultations the main complaint leading to referral is
usually more clearly defined (this referral is usually made for a well-
defined problem and it has been previously disclosed with the GP). This
could explain why in a previous report from a neurological practice
patients also spent a rather limited amount of time (100 seconds)(3).
However, when a patient makes the initial consultation with a secondary
care psychiatrist, he/she is expected to be allowed to speak for a longer
period, and to report not only symptoms, but also additional information
that is believed to be related to the clinical picture (life events, so
on). Then, one could expect that in consultations with the GP, where
sometimes the main reason for consultation in not self-evident, and a
biopsychosocial (instead a merely medical) approach is assumed by both the
patient and the doctor, the time spent in the initial spontaneous talking
may be actually longer. Of course, we should allow patients for an initial
disclosure of their symptoms and other thoughts, in order to perform an
adequate clinical interview. However, amount of time spent by patients in
this initial talk relies heavily on patients’ expectations, and
generalisation of results from one level of care or level or
specialisation to other is not possible.
Andrés Herrán, Associate Professor, herran@humv.es
Deirdre Sierra-Biddle, José Luis Vázquez Barquero, Head Professor
Clinical and Social Psychiatry Research Unit. Department of
Psychiatry. University of Cantabria. University Hospital Marqués de
Valdecilla.
Santander 39008, Spain.
References
1. Langewitz W, Denz M, Keller A, Kiss A, Rüttimann S, Wössmer B.
Spontaneous talking time at start of consultation in outpatient clinic:
cohort study. BMJ 2002; 325: 682-683.
2. Herrán A, Sierra-Biddle D, de Santiago A, Artal J, Díez-Manrique JF,
Vázquez-Barquero JL. Diagnostic accuracy in the first 5 min of a
psychiatric interview. Psychotherapy and Psychosomatics 2001; 70: 141-144.
3. Blau JN. Time to let the patient speak. BMJ 1989; 298: 39.
Competing interests:
None declared
Competing interests: No competing interests