Vol. 9, No. 2 Printed in Great Britain
FamHy Practice © Oxford University Press 1992
The Interrupted Consultation PESACH SHVARTZMAN AND AARON ANTONOVSKY*
INTRODUCTION The traditional image of the interaction in the outpatient doctor-patient consultation is one of undivided attention. It may well be true that in many Western societies the uninterrupted consultation is still the norm. Or it may be that, as practice becomes more and more institutionalized into group settings, this norm has changed. The fact is that we have not found a single empirical study of the interrupted consultation, even in Israel, where many physicians will confirm its widespread existence. Nor is there consideration of the issue in other contexts. Thus, in Engel and Morgan's1 fine text on interviewing patients, 15 index entries are recorded under 'interruption'. But without exception these refer to interruptions occasioned by the unskilled interviewer, the patient, or sensitivity to the patient's condition, and not to interruptions from the environment. Thus it may be that the phenomenon is rare. On the other hand, it may well be that it is widespread but simply unrecognized, much as the 'impaired physician' was unrecognized publicly two decades ago. It is the primary purpose of this paper to raise the question in a modest empirical way. Its findings, we suggest, take on particular significance as medical practice becomes more and more bureaucratized in the Western world. Does an interrupted consultation have undesirable consequences? It is superfluous, in the pages of this journal, to stress the centrality of communication in physician-patient interaction. Successful communica* Department of Family Medicine, and Department of the Sociology of Health, Division of Health in the Community, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel.
219
tion depends upon characteristics of the doctor, the patient and the nature of their relationship.2 Such factors go far in explaining the extent to which a reliable, detailed anamnesis can be taken and the patient's anxieties, beliefs and perceptions attended to. They also help explain the extent to which the physician is open to hearing what goes on. Most patients reasonably expect that the 6 or 10 minutes allotted to the average consultation will be devoted to their concerns.3 All consultations, however, take place in the context of a physical and social environment. The extent to which this environment minimizes or imposes interruptions, we propose, affects the quality of the communication, and has implications for the accuracy of the diagnosis, quality of treatment, patient satisfaction and, no less, for physician satisfaction. The senior author, an experienced family physician in Israel who has worked with interruptions for many years, thus initiated a preliminary study of the subject. The vast majority of Israeli primary care practitioners are employed by Kupat Holim, the health insurance fund of the General Federation of Labour. This is the health service provider for 82% of the Israeli population. A typical urban neighbourhood health centre serves some 10000 patients and is staffed by four or five physician-nurse teams, a pharmacy, some laboratory facilities, and clerical and maintenance personnel. To place the data in context, several characteristics of the centre under study should be noted which are not necessarily found in all Israeli health centres. Patients are seen by the physician by appointment. Patient files are kept in the doctor's surgery rather than in the centre's archives. Many patients with
Downloaded from http://fampra.oxfordjournals.org/ at OCLC on July 24, 2015
Shvartzman P, Antonovsky A. The interrupted consultation. Family Practice 1992; Sfc 219-221. This paper focuses attention, in a modest empirical way, on a hitherto unexplored phenomenon. Widespread in Israel, the interrupted patient-physician consultation may or may not be found extensively elsewhere. It is assumed that interruptions coming from the social environment affect communication and hence diagnosis and therapy, as well as satisfaction of both doctor and patient. Observations were conducted in a random sample of 100 consultations, averaging 9.4 minutes, of four physicians in a neighbourhood health centre in Israel. Interruptions were recorded in 94 cases, with an average of 1.36 interruptions per consultation. Contrary to Israeli myth, most interruptions were not by other patients but by clinic staff. The phenomenon is considered in terms of cultural practices and the consequences of group practice, nurse autonomy and medical student teaching. Further research is proposed to study the extent, sources and consequences of interruptions in family practice and, if warranted, methods of coping.
220
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
chronic disease making routine checkup and prescription renewal visits are seen only by the nurse. The centre is a teaching clinic for undergraduate medical students and residents in family medicine.
RESULTS A total of 100 consultations were observed. The number of observed consultations for the four physicians were 32, 23, 22 and 17. All in all, 136 interruptions were recorded, for an average of 1.36 interruptions per session. No interruptions were observed in only six sessions. The average duration of the 94 interrupted consultations was 9.4 minutes, with only 14% extending for over 15 minutes. As can be seen in Table 1, the great majority (79%) of interruptions were 'equitably' distributed: one per consultation. Thus there is little or no relationship between most interruptions and the length of consultation or the physician observed. Interruptions, then, are not rare events in this setting. Who are the interrupting agents and what are the rationales? These questions are answered by the data in Tables 2 and 3. What is clear from Table 2 is the untenability of a stereotype widespread in Israel. It can be seen that other patients ("Doctor, may I see you for just a minute?") account for only 6% of the interruptions. (Since there was no way to reliably record who the caller was, the 19 telephone interruptions are omitted from the distribution.) All others are accounted for by actions of personnel of the health centre. Over 3/4 of the interrupters were nurses (44%) and medical students (35%). Medical colleagues and non-professional personnel account for relatively few interruptions. The data in Table 3 confirm the 'professional' character of most interruptions. One quarter are occasioned by nurses, having seen chronic patients on a routine visit, or sixth year medical students who
of consultations interruptions
Number of interruptions
Number of consultations
Percent of consultations
1 2 3 4 5
74 8 4 6 2
78.7 8.5 4.3 6.4 2.1
Total
94
100.0
TABLE 2.
by number of
The agents of interruption*
Agent
Number of interruptions
Percent of interruptions
51 41 10 7 5 3
44.0 35.4 8.6 6.0 4.3 1.7
117
100.0
Nurse Student Physician Patient Maintenance worker Clerical worker Total • 19 telephone calls are excluded. TABLE 3.
The rationale for interruption*
Rationale Sign prescription Obtain patient file Consultation Telephone Appointment diary entry Other* Total
Number of interruptions
Percent of interruptions
33 29 21 19 3 31
24.3 21.3 15.4 14.0 2.2 22.8
136
100.0
• Mail, coffee, informal conversation, borrowing a book, etc.
examine patients on their own, who then request physicians to sign prescriptions. Almost the same proportion involves obtaining a patient file, while a somewhat smaller number (15%) involve consultation, of colleagues or students, with the doctor. DISCUSSION The verbal and non-verbal interaction between patient and physician can be a powerful therapeutic tool per se, in addition to the core of the diagnostic process.
Downloaded from http://fampra.oxfordjournals.org/ at OCLC on July 24, 2015
METHOD The four family practice units in one centre in a southern city in Israel were selected for study. Physicians receive patients in either morning (08:00-15:00) or afternoon (12:00-19:00) shifts. As part of their teaching responsibilities, physicians have medical students sitting in with them. Arrangements were made with these students to record, for randomly selected patient consultations, the time devoted to each consultation, the number of interruptions and the nature of each. (With the exception of the clinic chief, the physicians did not know of the study. In a post-study debriefing, they were informed of the study and the data were shared with them.) Observation sessions were conducted randomly in 1 week on the 4 days when the centre has two shifts. AJI interruption was defined as the ringing of the phone, any opening of the door to the surgery, or any action of the physician not directly related to the patient.
TABLE 1. Distribution
THE INTERRUPTED CONSULTATION
nurses providing direct care for many patients, raised their status and professional satisfaction and allowed greater efficiency in allocation of the physician's time. But it also led to the need to consult with the doctor, to obtain the doctor's signature on prescriptions, or to consult the patient file, located in the surgery. Second, the transformation of the ambulatory care clinic into a teaching institution is designed to enhance the prestige of primary care, raise the level of practitioners, stimulate research and so on. The presence of advanced medical students and residents, however, who work autonomously or nearly so, inevitably pressures for interruptions. These changes have taken place in a system in which health care is delivered in a health centre which physically and organizationally brings health professionals together. Jefferys and Sachs5 have studied the development of this trend in Great Britain. The development of a variety of types of group practice is also well known in many other societies. We have not, however, discovered any reference to the unintended consequence reported here. Our major concern in this paper was, by providing initial data from one Israeli health centre, to call formal public attention to the phenomenon of the interrupted consultation. The study, we believe, raises a number of significant questions. First, are our data idiosyncratic, limited to our clinic or to Israel alone? If not, do the cultural and organizational factors to which we have pointed provide an adequate explanation? Third, and most important, is our assumption warranted that interruptions are of serious negative consequence for communication, satisfaction and therapeutic efficacy? Finally, if it turns out that interruptions are indeed widespread and dysfunctional, we must then face the question how the problem is to be dealt with. REFERENCES 1 Engel GL, Morgan WL. Interviewing the Patient. London: Saunders, 1973. 2 McWhinney IR. An Introduction to Family Medicine. New York: Oxford, 1981: 52-79. 3 Cartwright A, Anderson R. General Practice Revisited. London: Tavistock, 1981. 4 Cooper CL, Rout U, Faragher B. Mental health, job satisfaction and job stress. Br Med J 1989; 298: 366-370. 5 Jefferys M, Sachs H. Rethinking General Practice. London: Tavistock, 1983.
Downloaded from http://fampra.oxfordjournals.org/ at OCLC on July 24, 2015
This is true, above all, in family practice. The possibility of such successful interaction, however, is contingent upon its being conducted in a relaxed, uninterrupted context. Such a context, it might well be noted, also mitigates the stress inherent in medical practice and may well increase the work satisfaction of the physician.4 As far as could be determined, the present modest investigation is the first empirical study of consultation interruptions. In this study of four family practitioners in an Israeli neighbourhood health centre, it was found that in only six of the 100 observed consultations were there no externally-imposed interruptions. This was the case in spite of the fact that most consultations lasted less than 10 minutes. It is striking that the great majority of the interruptions are of a professional character. Nurses, clerks, students and physician colleagues enter the surgery in order to obtain resources in the doctor's hands, head or room. The interruption is in the interest of other patients, and presumably justified in these terms. Yet these interruptions occur when the patient is speaking of her or his anxieties, pains and feelings, as well as in the midst of a physical examination. We would suggest that interruptions have both cultural and organizational reasons. The centrality of uninterrupted communication between physician and patient has not been internalized. Legitimate interruptions are countenanced by the agent and the physician, and possibly by the patient as well. Even nonprofessional interruptions may culturally be seen as part of 'the normal course of events'. In the absence of comparable studies elsewhere, there is no way of knowing whether this pattern is peculiar to Israeli culture. It must be asked: Would British or Danish or Polish nurses, students and colleagues as readily interrupt a consultation? Our data point to the importance of organizational factors. In the Israeli health care centre studied, we suggest that these considerations not only do not inhibit interruptions, but actively promote them. Moreover, paradoxically, they can be seen as unintended consequences of changes which in and of themselves are highly desirable. Two such changes must be noted. Traditionally, each patient had direct access to the physician. The creation of nurse-doctor teams, with
221
FamHy Practice © Oxford University Press 1992
The Interrupted Consultation PESACH SHVARTZMAN AND AARON ANTONOVSKY*
INTRODUCTION The traditional image of the interaction in the outpatient doctor-patient consultation is one of undivided attention. It may well be true that in many Western societies the uninterrupted consultation is still the norm. Or it may be that, as practice becomes more and more institutionalized into group settings, this norm has changed. The fact is that we have not found a single empirical study of the interrupted consultation, even in Israel, where many physicians will confirm its widespread existence. Nor is there consideration of the issue in other contexts. Thus, in Engel and Morgan's1 fine text on interviewing patients, 15 index entries are recorded under 'interruption'. But without exception these refer to interruptions occasioned by the unskilled interviewer, the patient, or sensitivity to the patient's condition, and not to interruptions from the environment. Thus it may be that the phenomenon is rare. On the other hand, it may well be that it is widespread but simply unrecognized, much as the 'impaired physician' was unrecognized publicly two decades ago. It is the primary purpose of this paper to raise the question in a modest empirical way. Its findings, we suggest, take on particular significance as medical practice becomes more and more bureaucratized in the Western world. Does an interrupted consultation have undesirable consequences? It is superfluous, in the pages of this journal, to stress the centrality of communication in physician-patient interaction. Successful communica* Department of Family Medicine, and Department of the Sociology of Health, Division of Health in the Community, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel.
219
tion depends upon characteristics of the doctor, the patient and the nature of their relationship.2 Such factors go far in explaining the extent to which a reliable, detailed anamnesis can be taken and the patient's anxieties, beliefs and perceptions attended to. They also help explain the extent to which the physician is open to hearing what goes on. Most patients reasonably expect that the 6 or 10 minutes allotted to the average consultation will be devoted to their concerns.3 All consultations, however, take place in the context of a physical and social environment. The extent to which this environment minimizes or imposes interruptions, we propose, affects the quality of the communication, and has implications for the accuracy of the diagnosis, quality of treatment, patient satisfaction and, no less, for physician satisfaction. The senior author, an experienced family physician in Israel who has worked with interruptions for many years, thus initiated a preliminary study of the subject. The vast majority of Israeli primary care practitioners are employed by Kupat Holim, the health insurance fund of the General Federation of Labour. This is the health service provider for 82% of the Israeli population. A typical urban neighbourhood health centre serves some 10000 patients and is staffed by four or five physician-nurse teams, a pharmacy, some laboratory facilities, and clerical and maintenance personnel. To place the data in context, several characteristics of the centre under study should be noted which are not necessarily found in all Israeli health centres. Patients are seen by the physician by appointment. Patient files are kept in the doctor's surgery rather than in the centre's archives. Many patients with
Downloaded from http://fampra.oxfordjournals.org/ at OCLC on July 24, 2015
Shvartzman P, Antonovsky A. The interrupted consultation. Family Practice 1992; Sfc 219-221. This paper focuses attention, in a modest empirical way, on a hitherto unexplored phenomenon. Widespread in Israel, the interrupted patient-physician consultation may or may not be found extensively elsewhere. It is assumed that interruptions coming from the social environment affect communication and hence diagnosis and therapy, as well as satisfaction of both doctor and patient. Observations were conducted in a random sample of 100 consultations, averaging 9.4 minutes, of four physicians in a neighbourhood health centre in Israel. Interruptions were recorded in 94 cases, with an average of 1.36 interruptions per consultation. Contrary to Israeli myth, most interruptions were not by other patients but by clinic staff. The phenomenon is considered in terms of cultural practices and the consequences of group practice, nurse autonomy and medical student teaching. Further research is proposed to study the extent, sources and consequences of interruptions in family practice and, if warranted, methods of coping.
220
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
chronic disease making routine checkup and prescription renewal visits are seen only by the nurse. The centre is a teaching clinic for undergraduate medical students and residents in family medicine.
RESULTS A total of 100 consultations were observed. The number of observed consultations for the four physicians were 32, 23, 22 and 17. All in all, 136 interruptions were recorded, for an average of 1.36 interruptions per session. No interruptions were observed in only six sessions. The average duration of the 94 interrupted consultations was 9.4 minutes, with only 14% extending for over 15 minutes. As can be seen in Table 1, the great majority (79%) of interruptions were 'equitably' distributed: one per consultation. Thus there is little or no relationship between most interruptions and the length of consultation or the physician observed. Interruptions, then, are not rare events in this setting. Who are the interrupting agents and what are the rationales? These questions are answered by the data in Tables 2 and 3. What is clear from Table 2 is the untenability of a stereotype widespread in Israel. It can be seen that other patients ("Doctor, may I see you for just a minute?") account for only 6% of the interruptions. (Since there was no way to reliably record who the caller was, the 19 telephone interruptions are omitted from the distribution.) All others are accounted for by actions of personnel of the health centre. Over 3/4 of the interrupters were nurses (44%) and medical students (35%). Medical colleagues and non-professional personnel account for relatively few interruptions. The data in Table 3 confirm the 'professional' character of most interruptions. One quarter are occasioned by nurses, having seen chronic patients on a routine visit, or sixth year medical students who
of consultations interruptions
Number of interruptions
Number of consultations
Percent of consultations
1 2 3 4 5
74 8 4 6 2
78.7 8.5 4.3 6.4 2.1
Total
94
100.0
TABLE 2.
by number of
The agents of interruption*
Agent
Number of interruptions
Percent of interruptions
51 41 10 7 5 3
44.0 35.4 8.6 6.0 4.3 1.7
117
100.0
Nurse Student Physician Patient Maintenance worker Clerical worker Total • 19 telephone calls are excluded. TABLE 3.
The rationale for interruption*
Rationale Sign prescription Obtain patient file Consultation Telephone Appointment diary entry Other* Total
Number of interruptions
Percent of interruptions
33 29 21 19 3 31
24.3 21.3 15.4 14.0 2.2 22.8
136
100.0
• Mail, coffee, informal conversation, borrowing a book, etc.
examine patients on their own, who then request physicians to sign prescriptions. Almost the same proportion involves obtaining a patient file, while a somewhat smaller number (15%) involve consultation, of colleagues or students, with the doctor. DISCUSSION The verbal and non-verbal interaction between patient and physician can be a powerful therapeutic tool per se, in addition to the core of the diagnostic process.
Downloaded from http://fampra.oxfordjournals.org/ at OCLC on July 24, 2015
METHOD The four family practice units in one centre in a southern city in Israel were selected for study. Physicians receive patients in either morning (08:00-15:00) or afternoon (12:00-19:00) shifts. As part of their teaching responsibilities, physicians have medical students sitting in with them. Arrangements were made with these students to record, for randomly selected patient consultations, the time devoted to each consultation, the number of interruptions and the nature of each. (With the exception of the clinic chief, the physicians did not know of the study. In a post-study debriefing, they were informed of the study and the data were shared with them.) Observation sessions were conducted randomly in 1 week on the 4 days when the centre has two shifts. AJI interruption was defined as the ringing of the phone, any opening of the door to the surgery, or any action of the physician not directly related to the patient.
TABLE 1. Distribution
THE INTERRUPTED CONSULTATION
nurses providing direct care for many patients, raised their status and professional satisfaction and allowed greater efficiency in allocation of the physician's time. But it also led to the need to consult with the doctor, to obtain the doctor's signature on prescriptions, or to consult the patient file, located in the surgery. Second, the transformation of the ambulatory care clinic into a teaching institution is designed to enhance the prestige of primary care, raise the level of practitioners, stimulate research and so on. The presence of advanced medical students and residents, however, who work autonomously or nearly so, inevitably pressures for interruptions. These changes have taken place in a system in which health care is delivered in a health centre which physically and organizationally brings health professionals together. Jefferys and Sachs5 have studied the development of this trend in Great Britain. The development of a variety of types of group practice is also well known in many other societies. We have not, however, discovered any reference to the unintended consequence reported here. Our major concern in this paper was, by providing initial data from one Israeli health centre, to call formal public attention to the phenomenon of the interrupted consultation. The study, we believe, raises a number of significant questions. First, are our data idiosyncratic, limited to our clinic or to Israel alone? If not, do the cultural and organizational factors to which we have pointed provide an adequate explanation? Third, and most important, is our assumption warranted that interruptions are of serious negative consequence for communication, satisfaction and therapeutic efficacy? Finally, if it turns out that interruptions are indeed widespread and dysfunctional, we must then face the question how the problem is to be dealt with. REFERENCES 1 Engel GL, Morgan WL. Interviewing the Patient. London: Saunders, 1973. 2 McWhinney IR. An Introduction to Family Medicine. New York: Oxford, 1981: 52-79. 3 Cartwright A, Anderson R. General Practice Revisited. London: Tavistock, 1981. 4 Cooper CL, Rout U, Faragher B. Mental health, job satisfaction and job stress. Br Med J 1989; 298: 366-370. 5 Jefferys M, Sachs H. Rethinking General Practice. London: Tavistock, 1983.
Downloaded from http://fampra.oxfordjournals.org/ at OCLC on July 24, 2015
This is true, above all, in family practice. The possibility of such successful interaction, however, is contingent upon its being conducted in a relaxed, uninterrupted context. Such a context, it might well be noted, also mitigates the stress inherent in medical practice and may well increase the work satisfaction of the physician.4 As far as could be determined, the present modest investigation is the first empirical study of consultation interruptions. In this study of four family practitioners in an Israeli neighbourhood health centre, it was found that in only six of the 100 observed consultations were there no externally-imposed interruptions. This was the case in spite of the fact that most consultations lasted less than 10 minutes. It is striking that the great majority of the interruptions are of a professional character. Nurses, clerks, students and physician colleagues enter the surgery in order to obtain resources in the doctor's hands, head or room. The interruption is in the interest of other patients, and presumably justified in these terms. Yet these interruptions occur when the patient is speaking of her or his anxieties, pains and feelings, as well as in the midst of a physical examination. We would suggest that interruptions have both cultural and organizational reasons. The centrality of uninterrupted communication between physician and patient has not been internalized. Legitimate interruptions are countenanced by the agent and the physician, and possibly by the patient as well. Even nonprofessional interruptions may culturally be seen as part of 'the normal course of events'. In the absence of comparable studies elsewhere, there is no way of knowing whether this pattern is peculiar to Israeli culture. It must be asked: Would British or Danish or Polish nurses, students and colleagues as readily interrupt a consultation? Our data point to the importance of organizational factors. In the Israeli health care centre studied, we suggest that these considerations not only do not inhibit interruptions, but actively promote them. Moreover, paradoxically, they can be seen as unintended consequences of changes which in and of themselves are highly desirable. Two such changes must be noted. Traditionally, each patient had direct access to the physician. The creation of nurse-doctor teams, with
221
