Skip to main content

Effectiveness of Intensive Physician Training in Upfront Agenda Setting

Journal of General Internal Medicine volume 26, Article number: 1317 (2011) Cite this article

Abstract

Background

Patients want all their concerns heard, but physicians fear losing control of time and interrupt patients before all concerns are raised.

Objective

We hypothesized that when physicians were trained to use collaborative upfront agenda setting, visits would be no longer, more concerns would be identified, fewer concerns would surface late in the visit, and patients would report greater satisfaction and improved functional status.

Design and Participants

Post-only randomized controlled trial using qualitative and quantitative methods. Six months after training (March 2004—March 2005) physician-patient encounters in two large primary care organizations were audio taped and patients (1460) and physicians (48) were surveyed.

Intervention

Experimental physicians received training in upfront agenda setting through the Establishing Focus Protocol, including two hours of training and two hours of coaching per week for four consecutive weeks.

Main Measures

Outcomes included agenda setting behaviors demonstrated during the early, middle, and late encounter phases, visit length, number of raised concerns, patient and physician satisfaction, trust and functional status.

Key Results

Experimental physicians were more likely to make additional elicitations (p < 0.01) and their patients were more likely to indicate agenda completion in the early phase of the encounter (p < 0.01). Experimental group patients and physicians raised fewer concerns in the late encounter phase (p < 0.01). There were no significant differences in visit length, total concerns addressed, patient or provider satisfaction, or patient trust and functional status

Conclusion

Collaborative upfront agenda setting did not increase visit length or the number of problems addressed per visit but may reduce the likelihood of “oh by the way” concerns surfacing late in the encounter. However, upfront agenda setting is not sufficient to enhance patient satisfaction, trust or functional status. Training focused on physicians instead of teams and without regular reinforcement may have limited impact in changing visit content and time use.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price includes VAT (USA)
Tax calculation will be finalised during checkout.

Figure 1

References

  1. Flocke SA, Frank SH, Wenger DA. Addressing multiple problems in the family practice office visit. J Fam Pract. 2001;50(3):211–6.

    PubMed  CAS  Google Scholar 

  2. Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209–14. May-Jun.

    PubMed  Article  Google Scholar 

  3. Yarnall KS, Ostbye T, Krause KM, Pollak KI, Gradison M, Michener JL. Family physicians as team leaders: "time" to share the care. Prev Chronic Dis. 2009;6(2):A59.

    PubMed  Google Scholar 

  4. Linzer M, Konrad TR, Douglas J, et al. Managed care, time pressure, and physician job satisfaction: results from the physician worklife study. J Gen Intern Med. 2000;15(7):441–50.

    PubMed  Article  CAS  Google Scholar 

  5. Mechanic D. How should hamsters run? Some observations about sufficient patient time in primary care. BMJ. 2001;323(7307):266–8.

    PubMed  Article  CAS  Google Scholar 

  6. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101(5):692–6.

    PubMed  CAS  Google Scholar 

  7. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda: have we improved? JAMA. 1999;281(3):283–7.

    PubMed  Article  CAS  Google Scholar 

  8. Mauksch L, Hillenburg L, Robins L. The Establishing Focus Protocol: Training for collaborative agenda setting and time management in the medical interview. Families, Systems & Health. 2001;19(2):147–57.

    Article  Google Scholar 

  9. Stein T, Frankel RM, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Educ Couns. 2005;58(1):4–12.

    PubMed  Article  Google Scholar 

  10. Baker LH, O'Connell D, Platt FW. "What else?" Setting the agenda for the clinical interview. Ann Intern Med. 2005;143(10):766–70.

    PubMed  Google Scholar 

  11. Williams GC, Frankel R, Campbell TL, Deci EL. Research on relationship-centered care and healthcare outcomes form the Rochester Biopsychosocial Program: A self-determination theory integration. Families, Systems & Health. 2000;18(1):79–90.

    Article  Google Scholar 

  12. Williams GC, Freedman ZR, Deci EL. Supporting autonomy to motivate patients with diabetes for glucose control. Diabetes Care. 1998;21(10):1644–51.

    PubMed  Article  CAS  Google Scholar 

  13. 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.

    PubMed  Article  CAS  Google Scholar 

  14. 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(2):155–65.

    PubMed  Article  CAS  Google Scholar 

  15. Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282(9):867–74.

    PubMed  Article  CAS  Google Scholar 

  16. Langewitz WA, Eich P, Kiss A, Wossmer B. Improving communication skills--a randomized controlled behaviorally oriented intervention study for residents in internal medicine. Psychosom Med. 1998;60(3):268–76. May-Jun.

    PubMed  CAS  Google Scholar 

  17. 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.

    PubMed  Article  CAS  Google Scholar 

  18. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282(18):1737–44.

    PubMed  Article  CAS  Google Scholar 

  19. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64(2):258–66. Mar-Apr.

    PubMed  Google Scholar 

  20. Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE Jr. Characteristics of physicians with participatory decision-making styles. Ann Intern Med. 1996;124(5):497–504.

    PubMed  CAS  Google Scholar 

  21. Kasser VM, Ryan RM. The relation of psychosocial needs for autonomy and relatedness to health, well-being, and mortality in a nursing home. Journal of Applied Social Psychology. 1999;29:935–54.

    Article  Google Scholar 

  22. Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care. 1998;36(5):728–39.

    PubMed  Article  CAS  Google Scholar 

  23. Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. 2001;134(9 Pt 2):897–904.

    PubMed  CAS  Google Scholar 

  24. Dyche L, Swiderski D. The effect of physician solicitation approaches on ability to identify patient concerns. J Gen Intern Med. 2005;20(3):267–70.

    PubMed  Article  Google Scholar 

  25. Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001;76(4):390–3.

    PubMed  Article  CAS  Google Scholar 

  26. Lang F, Floyd MR, Beine KL. Clues to patients' explanations and concerns about their illnesses. A call for active listening. Arch Fam Med. 2000;9(3):222–7.

    PubMed  Article  CAS  Google Scholar 

  27. Simmons L, Baker NJ, Schaefer J, Miller D, Anders S. Activation of patients for successful self-management. J Ambul Care Manage. 2009;32(1):16–23. Jan-Mar.

    PubMed  Google Scholar 

  28. Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res. 2007;42(5):1871–94.

    PubMed  Article  Google Scholar 

  29. Tai-Seale M, Bramson R, Bao X. Decision or no decision: how do patient-physician interactions end and what matters? J Gen Intern Med. 2007;22(3):297–302.

    PubMed  Article  Google Scholar 

  30. Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med. 2007;22(10):1429–33.

    PubMed  Article  Google Scholar 

  31. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood). 2009;28(1):75–85. Jan-Feb.

    Article  Google Scholar 

  32. Epstein R, Mauksch L, Carroll J, Jaen C. Have you really addressed your patient's concerns? Fam Pract Manag. 2008;15(3):35–40.

    PubMed  Google Scholar 

  33. Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med. 2007;5(5):457–61. Sep-Oct.

    PubMed  Article  Google Scholar 

  34. Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med. 2008;168(13):1387–95.

    PubMed  Article  Google Scholar 

Download references

Acknowledgements

The authors wish to express their appreciation to Helene Starks, PhD for her excellent project management and to Ron Epstein, MD, Wendy Levinson, MD, and Kim Marvel, PhD for their design and analysis advice.

This work was supported by the funds from the Agency Healthcare Research and Quality, RO1 HS 13172–01

Conflicts of Interest

Mr. Mauksch declares that he receives consultation and training fees from health care organizations to train health care providers in upfront agenda setting and other communication skills.

Author information

Authors and Affiliations

  1. Department of Medical Education and Biomedical Informatics, University of Washington School of Medicine, Box 357240, 1959 Pacific Ave NE, Seattle, WA, 98195, USA

    Douglas M. Brock PhD, Pamela Nagasawa PhD & Lynne S. Robins PhD

  2. Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, 98195, USA

    Larry B. Mauksch MEd

  3. School of Journalism and Communication, Chinese University of Hong Kong, Shatin, Hong Kong, China

    Saskia Witteborn PhD

  4. Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98195, USA

    Jeffery Hummel MD

Authors
  1. Douglas M. Brock PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Larry B. Mauksch MEd
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Saskia Witteborn PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jeffery Hummel MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Pamela Nagasawa PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Lynne S. Robins PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Douglas M. Brock PhD.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Brock, D.M., Mauksch, L.B., Witteborn, S. et al. Effectiveness of Intensive Physician Training in Upfront Agenda Setting. J GEN INTERN MED 26, 1317 (2011). https://doi.org/10.1007/s11606-011-1773-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11606-011-1773-y

KEY WORDS

  • agenda setting
  • training
  • effectiveness
  • time management