Safety of care
Limiting discussion to one medical issue per visit: Know the risks
An article for physicians by physicians
Originally published June 2011
Doctor-patient communication is a critical component of effective care. In an environment where the demands on physicians' time are greater than the practice time available, scheduling patients and communicating effectively become all the more challenging and important.
Some doctors are coping with increasing workloads and the need to better manage their time by limiting patients to one medical issue per visit. As a means of communicating this time-management technique, some physicians have posted signs in their offices indicating "one problem per visit please."
This approach may appear attractive to some doctors, but it has the potential to expose them to medico-legal risk. Even though physicians are trained to be on the alert for urgent or emerging health issues while attending to patients, the risk of not detecting serious health problems may increase if patients are limited to one issue per visit. The risk may also increase if a patient misunderstands the reasons for placing limits on the number of medical issues discussed and perceives such a policy to be rigid or insensitive.
The bottom line
Physicians are encouraged to give patients the opportunity to express their health concerns, and it is up to the physician's clinical judgment to decide which health concerns could be deferred to a subsequent visit. The growing use of "one issue per visit" policies highlights the importance of physicians being respectful and diplomatic in their approach to communications with patients. The December 2010 issue of CMPA Perspective provides additional information on communication between physician and patient (see "Physician-patient communication: making it better").
Addressing patient concerns
The CMPA advises members to be attentive and listen carefully to a patient's health concerns, as patient dissatisfaction can stem from an impression that a physician is too busy or does not care.
A blanket policy of "one problem per visit" is likely to lead to such negative impressions, particularly for patients who may have good reasons to not visit their doctor for every health concern, but rather "save" all their health worries for one visit. For example, such a situation might arise if a patient has to wait a long time to secure an appointment or has personal circumstances that make it difficult to schedule time with their physician.
Potential medico-legal problems
In addition to hindering a physician's ability to meet his or her patients' needs, "one issue per visit" policies may also increase medico-legal risk if patients feel compelled to triage their own issues or symptoms without the knowledge, skills, and judgment to do so.
Such self-assessment may lead patients to focus the discussion on peripheral or secondary issues, in part through the information they provide. However, if they have an incomplete picture, physicians can arrive at an improper diagnosis or miss important health issues.
Physicians who choose to display signage in their offices may consider alternatives to a restrictive message that may be seen as limiting patients' access to medical care.
These physicians may choose a message that is more informative and uses a "softer" tone. A sign that encourages patients to respect the time of others who are waiting and also need care is more likely to be respected by patients. Many patients may be unaware of how appointments are scheduled in a medical practice and the implications of appointments that are longer than anticipated. Appropriate signage may be an opportunity for physicians to improve patients' understanding of scheduling and resource issues, while conveying that each patient's best interest is being served to the extent possible.
Another approach that may be effective is to ask patients to describe their concerns when an appointment is scheduled or at the beginning of the visit. This encourages open communication at the outset, and importantly, enables the physician to prioritize the investigation and treatment based on a more comprehensive picture of the patient's symptoms.
A study aimed at assessing techniques to reduce patients' concerns found that the way in which a physician concludes a visit can also have an impact1. When a doctor asks her patient "Is there something else you want to address in the visit today?" instead of "Is there anything else you want to address today," a patient's unmet concerns have been shown to be reduced without increasing the duration of the appointment.
1. Fullerton, M. "Understanding and improving on 1 problem per visit". Canadian Medical Association Journal (Sept. 23, 2008) Vol. 179, no. 7 p. 623. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2535752/