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Levinson W, Gorawara-Bhat R, Lamb J. A Study of Patient Clues and Physician Responses in Primary Care and Surgical Settings. JAMA. 2000;284(8):1021–1027. doi:10.1001/jama.284.8.1021
Author Affiliations: Section of General Internal Medicine (Drs Levinson and Gorawara-Bhat) and Pritzker School of Medicine (Ms Lamb), University of Chicago, Chicago, Ill.
The Patient-Physician Relationship Section Editor: Richard M. Glass, MD, Deputy Editor.
Context Patients often present clues (direct or indirect comments about personal
aspects of their lives or their emotions) during conversations with their
physicians. These clues represent opportunities for physicians to demonstrate
understanding and empathy and thus, to deepen the therapeutic alliance that
is at the heart of clinical care. A paucity of information exists regarding
how physicians address the psychological and social concerns of patients.
Objectives To assess how patients present clues and how physicians respond to these
clues in routine primary care and surgical settings.
Design, Setting, and Participants Descriptive, qualitative study of 116 randomly selected routine office
visits to 54 primary care physicians and 62 surgeons in community-based practices
in Oregon and Colorado, audiotaped and transcribed in 1994.
Main Outcome Measures Frequency of presentation of clues by patients during office visits,
nature (emotional vs social) and content of clues, and nature of physician
responses to clues, coded as positive or missed opportunity.
Results Fifty-two percent and 53% of the visits in primary care and surgery,
respectively, included 1 or more clues. During visits with clues, the mean
number of clues per visit was 2.6 in primary care and 1.9 in surgery. Patients
initiated approximately 70% of clues, and physicians initiated 30%. Seventy-six
percent of patient-initiated clues in primary care settings and 60% in surgical
settings were emotional in nature. In surgery, 70% of emotional clues related
to patients' feelings about their biomedical condition, while in primary care,
emotional clues more often related to psychological or social concerns (80%)
in patients' lives. Physicians responded positively to patient emotions in
38% of cases in surgery and 21% in primary care, but more frequently they
missed opportunities to adequately acknowledge patients' feelings. Visits
with missed opportunities tended to be longer than visits with a positive
Conclusion This study suggests that physicians in both primary care and surgery
can improve their ability to respond to patient clues even in the context
of their busy clinical practices.
Physician: More often than not, I will keep patients in after a pacemaker
is placed, at least overnight, in order to make certain that the pacemaker
is functioning properly.
Patient: Dr Smith told me it'd be 2 days.
Physician: Frequently it is 2 days, but as I say, at least overnight.
Patient: I'm alone.
Physician: And the routine goes like this. We get you to the OR and
then we. . . .
In the above dialogue the patient expresses her anxiety about being
alone during her recovery, while the physician remains focused on the logistics
of the operative procedure and does not take the opportunity to understand
the patient's concerns or to express empathy. In routine visits like this
one, patient clues offer opportunities for understanding patients' lives and
define a clue as a direct or indirect comment that
provides information about any aspect of a patient's life circumstances or
feelings. These clues offer a glimpse into the inner world of patients and
create an opportunity for empathy and personal connection. By exploring the
meaning of these clues for patients, physicians can deepen the therapeutic
and potentially enhance clinical outcomes.8-14
Patients view medical experiences as intertwined with the issues of
their everyday lives. Not surprisingly then, patients expect physicians to
go beyond merely attending to their biomedical needs. In fact, many patients
view their physicians as individuals whom they can trust with their most intimate
information—including the stresses of their daily lives and their personal
worries. However, patients often do not verbalize their anxieties directly,
rather, they raise these issues indirectly by offering clues or hints about
these psychological and social concerns.15
A growing body of literature suggests that outcomes of care are optimal
when physicians address patients' emotional and personal concerns in addition
to their biomedical problems.16-19
Patient satisfaction, patient adherence, and biological outcomes can be improved
with a patient-centered model of care that demonstrates respect and caring
In addition, the demonstration of caring and compassion for patients may potentially
prevent malpractice litigation.26,27
Yet, despite evidence demonstrating the benefits of understanding patients,
there is a paucity of information about how physicians address the psychological
and social concerns of patients in the routine practice of medicine and in
the surgical disciplines.
How do physicians respond to patients' clues during routine visits?
Branch and Malik28 videotaped 5 expert physicians
during office visits and described the surfacing of these clues as "windows
of opportunity" for physicians to demonstrate empathy and understanding. More
recently, Suchman and colleagues15 studied
interactions between faculty or residents and patients and proposed a model
describing how patients present "empathic opportunities" and how physicians
respond to them. Suchman et al suggested that physicians often "terminate"
the empathic opportunity by changing the topic from the patient's emotional
concerns to a salient biomedical issue that seems to be a more comfortable
topic for physicians. These small studies, done exclusively in primary care
settings within academic medical centers, raise important questions about
how physicians address patients' emotional and social concerns during routine
care: What is the nature of patients' clues and physicians' responses in community-based
practice? How do clues arise in specialties other than primary care? Does
it take too much time to respond to patients' clues?
This study was designed to explore clues in a large, audiotaped data
set of routine visits between community-based primary care physicians and
surgeons and their patients. Our specific objective was to examine the nature
of clues as presented by patients in the medical encounter, the frequency
with which they occur, and how physicians respond to them.
Data for this study were collected in 1994 for a larger research project
examining the relationship between physician-patient communication and medical
malpractice.26 The study included 59 primary
care physicians (general internists and family practice physicians) and 65
surgeons (orthopedic and general surgeons), practicing in community nonacademic
settings in Colorado and Oregon. Physicians were selected based on their malpractice
claims history (2 or more lifetime claims vs none). Physicians were primarily
male (94%), white (91%), had been in practice at least 7 years, and were in
solo (33%) or group (67%) practice. Ten patients per physician were selected
sequentially from the office waiting rooms, and visits were audiotaped. Primary
care patients were eligible only if they had at least 2 prior visits with
the physician. For surgery patients, all patient visits other than those scheduled
for a procedure only (eg, suture removal) were included. A research assistant
obtained written consent from the patients. The study was approved by the
institutional review board of Legacy Good Samaritan Hospital, Portland, Ore.
The majority of the patients were white (88%), had a middle-class income
level (60%), were married (71%), and had completed high school or some college
education (60%). Their average age was 54 years. The overall percentage of
female patients was 54% (primary care patients, 53%; surgery patients, 56%).
The subset of data used for the present study included transcripts of
124 visits, with 1 randomly selected visit per physician. Of the 124 transcripts,
8 were eliminated because of technical difficulties with the tapes (eg, a
tape was not clearly audible). The remaining 116 transcripts were reviewed
by a team of coders to identify and describe segments of the interview in
which there were clues about patients' emotional or social concerns in the
visit. Clues initiated by patients were coded for type and timing of the clue
and nature of physicians' response. Also coded were physician questions that
encouraged the patient to discuss a personal topic; these were called physician-initiated clues. The length of interviews was
The research team comprised 4 members. One member coded all of the tapes
in their entirety, 2 coded a 10% sample to assess intercoder reliability,
and the senior investigator resolved differences in coding. In addition to
reading the transcripts, coders listened to the audiotapes for content and
voice tone to determine the types of clues and categories of responses. The
research team met regularly to compare independent assessments of the transcripts
and to develop a consensus of the coding categories of clues and responses.
Broadly, clues were coded as either emotional or social. Clues were social if they provided an opportunity for the physician
to learn more about the patient's life but were not associated with an emotion.
In particular, such clues pertained to topics of common interest such as sports,
weather, and vacations. For example, in the following case, the patient mentioned
a possible trip and a discussion related to the patient's family followed:
Patient: For once I'm going to leave the state of Oregon in the rain
for a couple of weeks.
Physician: Is that right? Where are you going?
Patient: I'm going to California.
Patient: My daughter wants me to come down there, so I'm going to try
to . . .
Physician: How long will you be gone?
Patient: A couple of weeks.
Physician: OK . . . enjoy California.
In contrast, clues that were associated with emotion, or where patients
implicitly sought support from physicians, were coded as emotional. The following is an example of an emotional clue in which
the patient initiates the topic of the death of his wife. The physician confirms
that the disease she had was dreadful to cope with and encourages the patient
to express his feelings.
Patient: I've enjoyed myself this year, more than I have since the wife
died 5 years ago, and of course even before that she was an invalid for many
years with Parkinson's.
Physician: Mmmm hmmm, Parkinson's is not a fun disease.
Patient: She had an extremely progressive supranuclear palsy, a real
severe . . .
Physician: Yup, that's a toughy.
Patient: It was awful. She was not able to walk for years, and it got
to where they had to put a tube in her stomach—she couldn't swallow—yeah,
it really was terrible. . . .
Initially, we coded physician responses to emotional clues based on
the categories used by Suchman et al.15 These
included empathic response, empathic opportunity continuer, empathic opportunity
terminator, and missed empathic opportunity. As the coding progressed, however,
we recognized that the categories did not fully capture the physicians' responses;
therefore, the team modified the classification system and developed a new
taxonomy of physician responses. When the team identified a type of clue or
physician response not adequately fitting into an existing category, a new
category was added or an older category was refined to reflect the differentiation.
This iterative process was used until the team found that the coding scheme
fully captured the clues and responses in the data set.
Physician responses were separated into 2 broad categories: positive
responses and missed opportunities, with subcategories for each. A positive response was one that generally supported or encouraged patients
to express their personal, psychological, or family-related concerns. Types
of positive responses coded were sorted into 3 categories including direct
acknowledgment of patients' feelings; encouragement, praise or reassurance;
and supportive statements. Clues were coded as missed opportunities if physicians did not support or encourage the discussion about emotional
concerns, or if they avoided the subject. Categories of missed opportunities
included inadequate acknowledgment, inappropriate humor, denial of concerns,
and termination of the discussion (Table
After a training period, coders had perfect agreement on the presence
or absence of clues in the transcripts, timing in the interview, and content
of clues. Differences in categories in physician responses were reconciled
at regular investigator meetings.
Clues occurred in 28 (52%) of 54 primary care visits, and 33 (53%) of
62 surgical visits (Table 2).
Of those visits with clues, the mean number of clues was 2.6 clues per visit
in primary care and 1.9 clues per visit in surgery. Patients initiated 51
(71%) of the 72 clues in primary care and 43 (69%) of the 62 clues in surgery,
and physicians initiated the remaining 21 (29%) in primary care and 19 (31%)
in surgery. Of the patient-initiated clues, 76% in primary care and 60% in
surgery were emotional, and the remainder were social clues.
The nature of the clues differed between surgery and primary care (Table 3). In surgery, 70% of emotional
clues related to patients' feelings about their medical condition. In contrast,
in primary care, 20% of emotional clues pertained to a biomedical condition,
and 80% related to psychological concerns, family, and life stresses such
as aging, loss of a family member, and major life changes.
Most often, emotional clues were embedded in a biomedical discussion
or surfaced during the physical examination (eg, during pauses in measurement
of blood pressure). Typically, such clues were raised indirectly when the
conversation touched on an emotional issue. In the following encounter, the
patient's clue—worry about her sister's injury and the possibility of
it affecting her blood pressure—emerges during part of her examination.
Physician: Your blood pressure is looking good; 140 over 75, pretty
Patient: My sister was in a car accident 4 weeks ago, and she's been.
. . .
Physician: How's she doing?
Patient: She's been staying with me, she's doing better, she gets dizzy
Physician: Dear me, any neck injuries?
Patient: I know they checked her, and they said it was OK.
Less often, the patient raised a concern directly with statements such
as, "I need to talk to you about some other stuff, too." In some visits (n
= 6), patients gave signals of distress or "cries for help" that seemed to
require immediate physician attention. In the following example, the patient
repeatedly expresses his desperation when the physician inquires about his
Physician: Yeah, what's keeping you awake?
Patient: I don't know, I'm not worrying about anything—things
are going pretty well, Kathy's taking wonderful care of me, I just, I just,
frankly want to die . . .
Physician: Well, I don't think we can arrange that.
Patient: No. . . .
Physician: Heh heh, heh heh . . .
Patient: I realize that.
Physician: Yeah, that's good, yeah.
Patient: But I am so discouraged and so desperate. . . .
The above interchange is also a poignant illustration of the extreme
contrast between the patient's profound feelings and the physician's dismissive
While patients most frequently initiated clues, 30% of clues were physician
initiated. They often did this by asking open-ended questions, and patients
responded with information about salient life events that were usually emotional
in nature. Some examples of open-ended questions used by physicians are "In
general, over the past year, would you say it's been a good year, bad year
. . . ?" Or, "How's everything else going on?" Another way physicians encouraged
these discussions was by initiating social questions about family, travel,
or leisure activities that provided an opportunity for the patient to talk
about a personal topic. While most of these conversations remained social
in nature, some resulted in the patient bringing up a latent emotional concern.
Physician: What'd you do for Thanksgiving?
Patient: Went to my daughter's . . . well I told you I hadn't spoken
to my daughter for 10 years. . . .
In the above example, a social question initiated by the physician led
the patient to express her feelings about reestablishing a relationship with
her estranged daughter.
Another strategy used infrequently by physicians was soliciting emotions
directly, as in the following example:
Physician: And it's really annoying to you, isn't it?
Patient: Well, yes. I tell you what's the most annoying about it is
that. . . .
Physicians responded positively to 10 of 26 emotional clues (38%) in
surgery and 8 of 39 (21%) in primary care (Table 4). In both specialties, the most frequent positive response
was acknowledgment. In the following example, the surgeon acknowledges the
patient's frustrations by sharing his own frustration with the patient's slow
Patient: Yeah, it just gets real frustrating.
Physician: Oh, uh.
Patient: I used to walk 7 to 8 miles a day, and now I'm down to. . .
Physician: I'm very frustrated, so I'm sure that your frustration is
much more than mine, but I sure would like to see you come out of this without
In an example from a primary care visit, the physician acknowledges
the patient's feelings about trying to manage a work and home life.
Patient: I moved to the day shift, so we will have a normal life together,
hhh, umm, so you sacrifice one for the other.
Physician: Right, right, oh yeah, you have to do something, you're trying
to have some kind of quality time together.
However, more frequently physicians missed the opportunities to respond
to patients' clues (missed opportunities: 79% primary care, and 62% surgery).
There were 47 missed opportunities identified including failure to adequately
acknowledge patients' feelings (36), inappropriate humor (3), terminating
the topic (5), and denial of patient emotion (3) (Table 4). In cases of inadequate acknowledgment, approximately 75%
of the time the physicians said something about the topic raised by the patient
but did not respond to the patient's feelings. In the following example, the
patient articulates her worry about her weakness and the surgeon confirms
her limitation, but he does not directly address the emotional concerns.
Patient: I know you told me to (be more active), I just am so tired,
and. . . .
Physician: I would like you to do as much as you feel like doing, I
can't really tell ya anymore, you know. I used to encourage you to get out
and walk. . . .
Patient: I can't do those things (anymore).
In a smaller number of situations, physicians used inappropriate humor,
denied the patient's feelings, or terminated the discussion. In 1 case, for
example, a patient articulates his apprehension about a future surgery, but
the physician focuses on the details of where the surgery is to be performed.
Patient: I always think of all the stuff I wanna be doing, see, and
I can't . . . I didn't wanna take a month out again (for the surgical removal
of pins and plates).
Physician: Yeah. . . .
Patient: Like all summer long I've been having fun with my . . . uh,
ridin' my horses, and, 'course I still like to do that so, but uh, that will
be . . . I, I'll be out of that for a month.
Physician: Do you have to go to (X hospital)? You went (there) last
In 25 interviews in which physicians missed opportunities, half of the
patients brought up the same issue a second or third time. In all of the examples
in which repetition occurred, the physician missed subsequent opportunities
to respond. In 1 primary care visit, the patient repeatedly mentions retirement,
and the doctor repeatedly returns to discussing the biomedical topic:
Physician: I mean you can't stay off permanently for the. . . .
Patient: Oh, I know that, I don't want to, but at least, uh, hhh, I
have to take some of it off. I'm gonna retire in 3 months anyway.
Physician: I know that, 'kay, let me listen to your heart first (time
lapsed, 1.75 minutes).
Patient: I have about 4 more months to go, and then I'm gonna retire.
Physician: I know. And what was the other thing? Your blood pressure?
Clues were found throughout the interview, from the opening to the closing
minute. In primary care visits that included at least 1 clue, visits were
longer when there was a missed opportunity compared with visits in which physicians
demonstrated a positive response (mean time, 20.1 minutes vs 17.6 minutes).
A similar trend was present in surgery (14.0 minutes vs 12.5 minutes) (Table 5). In addition, primary care visits
in which patients repeatedly brought up emotional issues after the physician
missed an opportunity were longer than visits in which physicians made at
least 1 positive response (18.4 vs 17.6 minutes). We observed the same trend
in surgical visits (15.5 vs 12.5 minutes). It is noteworthy that the visit
length both in primary care and surgery was shortest when physicians made
at least 1 positive response compared with when they missed the opportunity
or when the patient repeatedly brought up the clue.
Clues about patients' worries appear in more than half of routine office
visits in both surgery and primary care practice. We found that patients usually
initiate clues in subtle ways. Clues were typically embedded in the context
of a discussion about a health problem. For example, a primary care patient
might allude to a stressful life event when a physician comments on an elevated
blood pressure reading. This subtle, nonovert nature of clues has important
implications for physicians. Since these clues are hidden in the fabric of
discussion about medical problems, physicians who are busy attending to the
biomedical details of diagnosis and management may easily miss them.
When should physicians respond, or not respond, to patient clues? Medical
encounters are complex, and, at each branch point in a medical interview,
physicians may lead the discussion in different directions. We do not believe
it is essential, nor is it practical, for physicians to respond to emotional
issues each time they are presented. In some cases, physicians may choose
not to pursue a line of questioning, and it may have no consequences for the
interview. In other cases, similar to the findings of Suchman et al,15 a patient brings up the same emotional topic a second
time during the encounter when the physician failed to address it on the first
occasion. This allows a physician a second chance to discuss an emotional
topic of importance to the patient.
We found that the majority of the time physicians pass up opportunities
presented by patients. Furthermore, when physicians notice the clues, they
often fail to explore the deeper feelings behind the clue. Physicians may
avoid pursuing clues about emotional issues for several reasons. Some physicians
may feel uncomfortable responding because they may perceive that
they do not have the ability to fix or cure patients' emotions. While nursing,
psychology, and psychiatry training often emphasize skills of acknowledging
medical education provides relatively little training for physicians in this
area. In addition, in the present managed care environment with heightened
pressure on clinical productivity, physicians may be particularly worried
that addressing patients' emotional issues may increase the length of the
It is likely that, in the current practice environment, physicians may be
even less likely to pursue clues than they were in visits during 1994. While
our sample is small and no causal association can be determined, we do not
find evidence that responding to clues lengthens visits. In contrast, we noted
that visits in which a physician responded positively to a patient clue tended
to be shorter than those in which the physician missed the opportunity.
Occasionally, clues appeared to be a "cry for help." In 6 cases, patients
seemed markedly distressed, and their comments begged for acknowledgment by
physicians. For example, 1 patient in the study expressed feelings of desperation
such as "Frankly, I want to die." These cries for help are consistent with
the medical literature that demonstrates that patients often view primary
care physicians as their access to care for psychiatric problems like depression.38 Physician recognition of these "cries for help" is
critical since these clues may provide the sole opportunity to help patients
seek appropriate care.
Some stereotypes of surgeons suggest that they are "business-like" physicians
who prefer to "cut it out," rather than spend time talking to patients. Often
surgeons are portrayed as lacking empathic skills compared with their primary
care colleagues. In contrast, we found that surgeons resembled primary care
physicians in their responses to patient clues. While both physicians and
surgeons missed opportunities to respond to clues more than half of the time,
surgeons were as likely to respond positively as their primary care colleagues.
Further research is needed to study patterns of communication in surgical
disciplines to form a basis for education tailored for surgical specialties.
This study has several limitations. First, the sample included mainly
male physicians who were selected based on their malpractice claims history,26 and this may not be generalizable to the entire physician
population. However, 43% of physicians in our sample had no claims. Second,
our analysis was limited to verbal communication, and nonverbal clues that
might have been detected on videotape were unavailable. It is possible that
physicians expressed empathy in nonverbal ways by touching a patient or handing
a patient a tissue.39,40 Third,
the study did not directly address the relationship between how physicians
address or miss clues and patient outcomes. We cannot assess the consequences
of either positive responses or missed opportunities.
In summary, we found that patients offer clues that present opportunities
for physicians to express empathy and understand patients' lives. In both
primary care and surgery, physicians tend to bypass these clues, missing potential
opportunities to strengthen the patient-physician relationship. Research on
teaching communication skills demonstrates that physicians can learn to modify
their communication style.41-43
We propose that these 2 aspects of the medical encounter—patient clues
and physician responses—be recognized as being interdependent and a
key to building a trusting patient-physician relationship, thus ultimately
improving the outcome of care.
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