‘The Hand on the Doorknob’: Visit Agenda Setting by Complex Patients and Their Primary Care Physicians

Patient and Physician Preparation for Upcoming Visits

The majority of patients reported some form of previsit preparation, including written lists of concerns (eg, handwritten, smart phone), emails to physicians, information seeking about conditions or medications, or discussion of priorities with family members/spouses. In addition to lists, well-prepared patients brought data logs (eg, blood pressure readings, glucose levels) in printouts or as data in an electronic device such as a tablet or cell phone.

Patients commonly noted 2 main reasons for previsit preparation. The first was to ensure they did not forget or were not too intimidated to mention something (Quote 1, Table 1). A second reason was to make sure that their agenda was incorporated into the discussion with PCPs so that mutually developed strategies were employed to work toward patient health goals. Other patients did not prepare for their visits with PCPs, most commonly because they felt that the physician's agenda should drive the visit or due to the perception that there was not much wrong with their health.

Most PCPs reported a uniform method of previsit preparation for all patient encounters; they reviewed their patient's previous clinical notes in advance and recent specialist notes and labs to remind them about what was discussed and what items the patient may be due for (eg, vaccines, lab screenings, mammograms) or that require followup. Physicians spent time preparing so that they would have more time to listen to patients and build rapport (Quote 2).

Physicians generally appreciated when the patient was organized and prepared with a list, but with caveats around list length and expectation setting (quote 3). Physicians also expressed concern about patients with very lengthy lists (quote 4). Physicians preferred that the patient bring up items during a visit, as opposed to contacting them afterward about a forgotten item. Conversely, some PCPs worried about unmet expectations, stating that just because an item is on a patient's list does not mean it will get covered.

Insights into Agenda Setting

Patient agenda-setting strategies typically fell into 3 types: 1) letting the provider set the priorities (Quote 5); 2) prioritizing based on symptoms, sometimes expressed as what was interfering the most with their quality of life (Quote 6); and 3) prioritizing based on creating a mutual agenda (Quote 7).

Three key themes emerged regarding how PCPs set their visit agendas: 1) prioritizing the most important of the patient's listed concerns, 2) prioritizing items they considered urgent and/or dangerous, and 3) acknowledging that “realistic prioritizing” meant some items would “fall off” the agenda. One PCP described joint prioritization of visit topics and agenda setting as an interaction that gets easier in time, but can be very difficult in the beginning (Quote 8). Another PCP described how his view of patient lists has changed over the years (Quote 9).

Factors that Facilitate or Impede Alignment of Visit Agendas

Both patients and physicians acknowledged that effective patient and physician previsit preparation was an important facilitator contributing to alignment. Both also agreed that both the need to prioritize topics for discussion and early joint-agenda setting were important facilitators (see Quotes 3, 7, 8, and 9). To help prevent patient delays in raising stigmatizing concerns, some physicians thought it would be useful to reassure patients about that safety of raising such concerns (Quote 10).

Patients noted 2 major barriers to alignment of priorities: 1) short visit lengths, and 2) difficulty in raising sensitive concerns. While some patients described having enough time with their PCPs to address their needs, others felt that short visit lengths made it difficult for them to communicate their priorities. For example, 1 patient described a list of 5 things that she wanted to address in the visit but could not (Quote 11). Similarly, another patient described not asking about an immediate health concern due to lack of time with the PCP (Quote 12).

Potentially embarrassing or stigmatizing concerns were another source of misalignment that affected visit flow because patients described waiting until the very end of the visit to raise these. Examples of these types of concerns provided by our patients included sexual dysfunction, blood in stool, anxiety, panic attacks, depression, suicidal ideation, and housing issues. Sometimes such concerns did not get addressed at all (quote 13).

Physicians described short visit lengths, added burden of computer documentation, differences in relative ranking of condition importance (and mismatched views about the number of concerns that can be addressed in a single visit), nonactionable items, patient hesitancy to bring up embarrassing or stigmatizing concerns, and differences related to medications versus lifestyle management as important barriers to aligning priorities with their complex patients.

Physicians agreed with patients on the challenges of limited visit times and the need to establish priorities from longer lists of potential concerns. Many physicians described experiencing stress surrounding the process for setting priorities and time limitations in an increasingly complex primary care patient population (Quote 14).

Despite the reported time constraints, several physicians reported that they went over the allotted appointment time to address all the patients' concerns. Patients valued knowing that their physician would take extra time with them when necessary, realizing this may mean that the physician would be running behind in clinic at times (Quote 15). Patients also expressed awareness that if they were going over their allocated time, another patient would be affected (Quote 16).

Physicians expressed concerns over the added burden of necessary computer documentation, for example, electronic medical record (EMR), within time constraints (Quote 17). Some physicians discussed how they attempt to overcome the EMR focus during their patient visits (Quote 18). A patient in the corresponding dyad to that PCP independently noted that he really appreciates how his PCP reviews his chart before he arrives for the visit and does not enter things into the EMR while speaking to him (Quote 19).

Another frequent source of misalignment between patient and physician involved differences in relative ranking of condition importance, which generally reflected a greater patient focus on current symptoms compared with the physician tendency to prioritize medical risk reduction. For example, 1 patient receiving end-of-life treatment for renal failure wanted to focus on what the physician considered the comparatively less important issue of toenail fungus. Another patient prioritized his eczema and felt his heart was fine, whereas his physician prioritized cardiovascular risk reduction due to his past history of a heart attack. Some patients felt that all the items on their list were important and they could not rank 1 over another, while other patients preferred to let their physician prioritize.

Items perceived by physicians as “nonactionable” tended to create a barrier to effective agenda coordination. PCPs reported that a key goal while listening to patient information was to determine actionable steps for patient care. For example, 1 physician described frustration with receiving excessive, nonactionable information (Quote 20). “Nonactionable” items could also include existing patient concerns that had been previously addressed. For example, 1 patient had listed her dizziness as a top priority, while her physician reported that this symptom had been extensively evaluated in the past and that no further management actions were planned.

Patient delays in raising concerns (or physician inability to elicit them early in the visit) led to the problem of new issues coming to light at the end of the visit (Quote 21). One final example of potential misalignment was differences related to medications versus lifestyle management. One patient described how she felt her PCP was “pushing” medication to manage her elevated blood pressure and early diabetes; however, she preferred to focus on a strict diet and exercise plan to avoid having to take additional medications.