OH, BY THE WAY ... - THE CLOSING MOMENTS OF THE MEDICAL VISIT

Objective: To define and describe the communication between phy sician s and patients in the closing phase of the medical visit. To identify types of communication throughout the visit that are associated with t he introduction of a new problem during the closing moments of the vis it or with longer closures. Design: Audiotaping of office visits. Tape s were analyzed using a modified Roter Interactional Analysis System ( RIAS). The coders' definition of closure was compared with the opinion of communication experts. Setting: Outpatient offices of practicing p hysicians. Participants: Eighty-eight patients visiting 20 primary car e physicians participated. Physicians were selected by a letter from t he Oregon Board of Medical Examiners. The mean number of years from gr aduation was 16 (range 3-47). One physician per site participated. Mea surements: Frequencies of physician and patient communication behavior s and global affect scores were calculated and correlations were drawn using t-test and chi-square analyses. Results: The physicians initiat ed the closing in 86% of the visits. The physicians clarified the plan of care in 75% of the visits and asked whether the patients had more questions in 25% of the cases. The patients introduced new problems no t previously discussed in 21% of the closures. New problems in closure were associated with less information exchanged previously by physici ans and patients about therapy (t = -3.28, p = 0.002; t = -2.26, p = 0 .03), fewer orientation statements by physicians(t = 1.86, p = 0.001), and higher patient affect scores (t = 0.252, p = 0.016). long closure s (> 2 minutes) correlated with physicians' asking open-ended question s (0.2438; p = 0.019), laughing (0.3002; p = 0.005), showing responsiv eness to patients (0.3396; p <0.001), being self-disclosing (0.3948; p <0.001), and engaging in psychosocial discussion with patients (0.241 0; p = 0.020) Conclusion: This study is the first description of how p hysicians and patients communicate during the closing of office visits . Notably, the patients raised new problems at the end of the visit in 21% of the cases. The findings suggest ways physicians might improve communication in the closing phase of the medical interview. Orienting patients in the flow of the visit, assessing patient beliefs, checkin g for understanding, and addressing emotions and psychosocial issues e arly on may decrease the number of new problems in the final moments o f the visit.