Objectives: To examine patient, physician, and health care system character
istics associated with unvoiced desires for action, as well as the conseque
nces of these unspoken requests.
Patients and Methods: Patient surveys were administered before, immediately
after, and 2 weeks after outpatient visits in the practices of 45 family p
ractice, internal medicine, and cardiology physicians working in a multispe
cialty group practice or group model health maintenance organization. Data
were collected at the index visit from 909 patients, of whom 97.6% were sur
veyed 2 weeks after the outpatient visit. Before the visit, patients rated
their trust in the physician, health concerns, and health status. After the
visit, patients reported on various types of unexpressed desires and rated
their visit satisfaction. At follow-up, patients rated their satisfaction,
health concerns, and health status, and also described their postvisit hea
lth care use. Evaluations of the visit were also obtained from physicians.
Results: Approximately 9% of the patients had I or more unvoiced desire(s).
Desires for referrals (16.5% of desiring patients) and physical therapy (8
.2%) were least likely to be communicated. Patients with unexpressed desire
s tended to be young, undereducated, and unmarried and were less likely to
trust their physician. Patients with unvoiced desires evaluated the physici
an and visit less positively;, these encounters were evaluated by physician
s as requiring more effort. Holding an unvoiced desire was associated with
less symptom improvement, but did not affect postvisit health care use.
Conclusions: Patients' unvoiced needs affect patients' and physicians' visi
t evaluations and patients' subjective perceptions of improvement. Implicat
ions of these findings for clinical practice are examined.