A few weeks ago I called a neurosurgeon to discuss a patient’s
recent headaches. My patient had been
seen in the emergency room several days prior with the worst headache of his
life. A complete work-up had not revealed a cause for the headache. Although he was found to have a small aneurysm
on CT angiogram, there was no evidence of bleeding by lumbar puncture. The story, however, was slightly more complex
than this. There had been several other findings that remained unexplained. One of the findings led me to discuss the
patient’s case with a cardiologist. My
patient had also undergone cervical spine decompression surgery several months
prior to treat cervical myelopathy. I
wanted to engage the neurosurgeon and get his professional opinion about my
patient’s headache, which had now recurred several days after his ER visit.
The surgeon was cordial, but about 5 seconds into my story
he seemed inpatient and interrupted me. “I
heard about this guy,” he said, “What he needs is to be seen by one of our
neurovascular specialists.” I had more I
wanted to say, but the doctor did not seem to want to listen. I raised my voice slightly, interrupted him before
he had a chance to end the conversation, and bulldozed through, telling the rest of the
story in about two minutes. “Now we’re
talking,” he said, as I explained further about a family history of clotting
and my concern about a dural thrombus as a potential etiology. Together we formulated a plan that I was satisfied with--though the interaction
left me with a feeling of unease.
Interruption is a pervasive communication style with
doctors. In a well known study by
Beckman and Frankel patients were allowed to complete their opening statement
expressing their agenda in its entirety in only 23% of physician interviews. The average time to interruption was 18
seconds. This study’s findings have been
replicated by several others. In a more recent study of primary care residents, patients were allowed to speak for only 12 seconds on
average before they were interrupted.
Female patients experience interruption more frequently than males. In
contrast, studies have suggested higher rates of patient satisfaction with physician
visits during which patients and doctors interrupt at similar frequency and
also with visits in which there is more “reflective” silent time during the
conversation. Perhaps the tendency to interrupt extends to all physician derived professional
communications, as in my case with the neurosurgeon on the phone.
Why do physicians interrupt? In practical terms, throughout
the course of a given day a physician may be tasked with listening to twenty to
thirty patient derived histories and with solving difficult problems for each
of these patients in a matter of ten to fifteen minutes. This is a tough, if not impossible job. Consequently, once a physician believes that the
meat of the story is out there, he or she may respond and interrupt before
hearing details that the patient (or colleague) feels are important. In more abstract terms interruption is a
communication strategy that reinforces physician dominance in the hierarchy of
the patient-physician relationship.
The most frequent complaint that I hear from patients about
other physicians is that a physician did not “listen,” or did not “seem to care”
about their problem. My advice to
physicians and medical trainees: sit down, bite your tongue and wait. If you do
interrupt, do so with brief questions allowing your patient to return to his or
her agenda. You might be surprised and learn
something, and no doubt you’ll certainly have happier patients (and
colleagues).
