Our study sought to replicate the work of Beckman-Frankel5
and Marvel et al.6
and to gain greater understanding of the cause and effect of physician interruption. We found distributions of solicitation types and times to interruption similar to those found by the Beckman-Frankel and Marvel et al. studies. As expected, physicians who solicited an agenda from their patients and allowed them to complete a statement of concerns were able to report their patients' problems more accurately than doctors who did not make such inquiry. However, our expectation that interrupting patients would negatively affect the accuracy of information collected by physicians proved not to be true: physicians' ability to identify patient concerns, as measured by the IOU, was not affected by interruption.
Our findings suggest that solicitation carries more weight than interruption in the collaborative exchange necessary for effective bilateral communication. Several possibilities might account for this. Interruption by itself might not be a robust variable, or it may be defined too broadly to discriminate the subtleties of doctor-patient communication. Alternatively, as suggested by Beckman and Frankel, interruption might actually serve a positive function if it is well timed. And perhaps the act of physician solicitation itself accords a voice to the patient that reduces the disruptive impact of subsequent interjections by the physician.
This study as well as that of Marvel et al. found that a large percentage of the visits contained no physician inquiry about current patient concerns. While this might be attributed to an effect of physician-initiated follow-up visits, Marvel et al.'s study found that physician-initiated and patient-initiated encounters did not differ significantly in solicitation rates.
Previous studies have shown that when physicians understand patient concerns, there is an improvement in patient satisfaction7,8
and patient adherence.19–23
This study demonstrates that failure to solicit the patient's agenda is also associated with a significantly diminished physician database.
Our speculation that external factors such as level of physician experience, degree of medical difficulty, or time pressure might affect our variables was not borne out. The findings question the assumption that time pressure or physician anxiety about case difficulty account for lowered rates of solicitation.15,21
This study is limited by the fact that our principal outcome measure, the Index of Understanding, employs a relatively new instrument without a known sensitivity. It may have been unable to discriminate differences in the understanding levels of physicians who interrupted their patients and those who did not. In addition, the sample was of modest size, involved a preponderance of residents, a single clinic, excluded Spanish-speaking subjects, and was drawn from a population of relatively low socioeconomic status, each of which might affect the generalizability of the findings.
The study leaves unanswered the question of how interruption might affect patient satisfaction. If a positive association were to be demonstrated between patient statement completion rates and patient satisfaction, Beckman and Frankel's conclusions might be supported on the basis of patient-physician relationship enhancement. Future studies might use a refined definition of interruption to distinguish physician interjections that assume control of the discourse from those that are used to organize, clarify, or facilitate the patient's presentation. One alternative would be an interactive coding system that would define interruption based on whether or not patients were able to resume their narrative thread after the physician interjection (K. Marvel, PhD, personal communication, December 2001). The landmark study of Beckman and Frankel, with its appealing simplicity, highlights critical issues for communication research and physician training. However, our efforts to grasp the vicissitudes of human interaction may require an expansion beyond linear methodologies.