Journal of General Internal Medicine

, Volume 22, Issue 10, pp 1429–1433 | Cite as

Reducing Patients’ Unmet Concerns in Primary Care: the Difference One Word Can Make

  • John HeritageEmail author
  • Jeffrey D. Robinson
  • Marc N. Elliott
  • Megan Beckett
  • Michael Wilkes
Original Article



In primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed.


To test an intervention to reduce patients’ unmet concerns.


Cross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys.


Twenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania.


A volunteer sample of 20 family physicians (participation rate = 80%) and 224 patients approached consecutively within physicians (participation rate = 73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition.


After seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: “Is there anything else you want to address in the visit today?” (ANY condition) and “Is there something else you want to address in the visit today?” (SOME condition).

Main Outcome Measures

Patients’ unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys.


Relative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR) = .154, p = .001). The ANY intervention could not be significantly distinguished from the control condition (p = .122). Neither intervention affected visit length, or patients’; expression of unanticipated concerns not listed in previsit surveys.


Patients’ unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form. Both the learning and implementation of the intervention require very little time.


unmet concerns unanticipated concerns intervention care physician-patient communication 



Funding for this project was provided by the Agency for Healthcare Research and Quality, Grant no. R01 HS13343.

The authors wish to thank Jerome Hoffman MD for his assistance with the training video, and Iris Halldorsdottir, Erika Lamoureaux and Seung-Hee Lee for their assistance in data analysis. Marc Elliott is supported in part by the Centers for Disease Control and Prevention (CDC U48/DP000056). The contents of the publication are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

John Heritage had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conflicts of Interest

No author has a potential or actual financial conflict of interest regarding the research reported in this article.


  1. 1.
    Stewart M, Brown J, Levenstein J, McCracken E, McWhinney IR. The patient-centered clinical method, 3: changes in residents’ performance over two months of training. Fam Prac. 1986;3:164–7.CrossRefGoogle Scholar
  2. 2.
    Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision making style: results from the Medical Outcomes Study. Medical Care. 1995;33:1176–87.PubMedCrossRefGoogle Scholar
  3. 3.
    Beckman H, Frankel R. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101:692–6.PubMedGoogle Scholar
  4. 4.
    Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: Have we improved? JAMA. 1999;281(3):283–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Callahan E, Stange K, Zyzanski S, Goodwin M, Flocke S, Bertakis K. Physician-elder interaction in community family practice. J Am Board Fam Pract. 2004;17(1):19–25.PubMedCrossRefGoogle Scholar
  6. 6.
    White J, Levinson W, Roter D. “Oh, by the way ...”: the closing moments of the medical visit. J Gen Intern Med. 1994;9(1):24–8.PubMedCrossRefGoogle Scholar
  7. 7.
    White JC, Rosson C, Christensen J, Hart R, Levinson W. Wrapping things up: a qualitative analysis of the closing moments of the medical visit. Patient Educ Couns. 1997;30:155–65.PubMedCrossRefGoogle Scholar
  8. 8.
    Lipkin M, Putnam S, Lazare A, eds. The Medical Interview: Clinical Care, Education And Research. New York: Springer; 1995.Google Scholar
  9. 9.
    Cohen-Cole SA. The medical interview: The three function approach. St. Louis: Mosby Year Book; 1991.Google Scholar
  10. 10.
    Lang F, McCord RS. Agenda setting in the patient-physician relationship. JAMA. 1999;282:942.PubMedCrossRefGoogle Scholar
  11. 11.
    Lipkin M, Frankel R, Beckman H, Charon R, Fein O. Performing the interview. In: Lipkin M, Putnam S, Lazare A, eds. The Medical Interview: Clinical Care, Education and Research. New York: Springer; 1995:65–82.Google Scholar
  12. 12.
    Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s guide to physical examination. 3rd edn. St. Louis: Mosby Year Book; 1995.Google Scholar
  13. 13.
    Swartz MH. Textbook of Physical Diagnosis: History and Examination. 4th edn. Philadelphia: W. B. Saunders; 1998.Google Scholar
  14. 14.
    Schuman H, Presser S. Questions and Answers in Attitude Surveys: Experiments on Questions Form, Wording and Context. Orlando FL: Academic; 1981.Google Scholar
  15. 15.
    Wellman FL. The Art of Cross-Examination. New York: Touchstone; 1997.Google Scholar
  16. 16.
    Loftus E. Eyewitness Testimony. Cambridge, MA: Harvard University Press; 1979.Google Scholar
  17. 17.
    Clayman S, Heritage J. The News Interview: Journalists and Public Figures on the Air. Cambridge: Cambridge University Press; 2002.Google Scholar
  18. 18.
    Boyd E, Heritage J. Taking the patient’s medical history: questioning during comprehensive history taking. In: Heritage J, Maynard D, eds. Communication in Medical Care: Interactions between Primary Care Physicians and Patients. Cambridge, England: Cambridge University Press; 2006.Google Scholar
  19. 19.
    Bolinger D. Interrogative Structures of American English. University, Alabama: University of Alabama Press; 1957.Google Scholar
  20. 20.
    Borkin A. Polarity items in questions. Chicago Linguistic Society. 1971;7:53–62.Google Scholar
  21. 21.
    Horn LR. Some Aspects of Negation. In: Greenberg JH, Ferguson CA, Moravscik EA, eds. Universals of Human Language, Vol.4: Syntax. Stanford, CA: Stanford University Press; 1978:127–210.Google Scholar
  22. 22.
    Graubard BI, Korn EL. Predictive margins with survey data. Biometrics. 1999;55(2):652–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: Wiley; 1989.Google Scholar
  24. 24.
    StataCorp. Stata Statistical Software: Release 9.0. College Station, TX: Stata Corporation; 2005.Google Scholar
  25. 25.
    Williams RL. A note on robust variance estimation for cluster-correlated data. Biometrics. 2000;56:645–6.PubMedCrossRefGoogle Scholar
  26. 26.
    White H. A heteroskedasticity-consistent covariance matrix estimator and a direct test for heteroskedasticity. Econometrica. 1980;48:817–30.CrossRefGoogle Scholar
  27. 27.
    Williams RL. A note on robust variance estimation for cluster-correlated data. Biometrics. 2000;56:645–6.PubMedCrossRefGoogle Scholar
  28. 28.
    Cegala D, Broz L. Physician communication skills training: a review of theoretical backgrounds, objectives and skills. Med Educ. 2002;36:1004–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Ihler E. Patient-physician communication. JAMA. 2003;289:92.PubMedCrossRefGoogle Scholar
  30. 30.
    Baile W, Lenzi R, Kudelka A, et al. Improving physician-patient communication in cancer care: outcome of a workshop for oncologists. J Cancer Educ. 1997;12:166–73.PubMedGoogle Scholar
  31. 31.
    Stein T, Kwan J. Thriving in a busy practice: physician-patient communication training. J Eff Clin Prac. 1999;2:63–70.Google Scholar
  32. 32.
    Joos SK, Hickam DH, Gordon GH, Baker LH. Effects of a physician communication intervention on patient care outcomes. J Gen Intern Med. 1996;11(3):147–55.PubMedCrossRefGoogle Scholar
  33. 33.
    Street RL, Gordon HS, Ward MM, Krupat E, Kravitz RL. Patient participation in medical consultations: why some patients are more involved than others. Medical Care. 2005;43(10):960–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Cassell E. Talking with Patients, Volume 2: Clinical Technique. Cambridge MA: MIT; 1985.Google Scholar
  35. 35.
    Heritage J, Maynard DW, eds. Communication in Medical Care: Interactions between Primary Care Physicians and Patients. Cambridge: Cambridge University Press; 2006.Google Scholar
  36. 36.
    Stivers T. Prescribing Under Pressure: Parent-Physician Conversations and Antibiotics. New York: Oxford University Press; 2007.Google Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • John Heritage
    • 1
    Email author
  • Jeffrey D. Robinson
    • 2
  • Marc N. Elliott
    • 3
  • Megan Beckett
    • 3
  • Michael Wilkes
    • 4
  1. 1.Department of SociologyUniversity of CaliforniaLos AngelesUSA
  2. 2.Department of CommunicationRutgers UniversityBrunswickUSA
  3. 3.RAND CorporationSanta MonicaUSA
  4. 4.School of MedicineUniversity of CaliforniaDavisUSA

Personalised recommendations