One Issue Per Visit Strategy Could Pose a Safety Risk
When an Ontario mother took her teenaged son to his doctor appointment recently, she noticed a new sign in the waiting room that asked patients to limit their visit to the discussion of one medical issue. When she posted a photo of the sign on Twitter, the conversation went viral.
Some of those who engaged in the debate argued that limiting a patient to the discussion of one issue was just smart time management — a way of allowing doctors to stay reasonably on schedule for the benefit of all patients. Others argued that it was not acceptable from a clinical practice perspective to expect patients to be able to identify the one problem most deserving of the doctor’s immediate attention.
The College agrees that the one-issue per visit strategy poses risk to the patient. Setting rigid limits on the number of issues that patients can voice in a single visit requires patients to triage their own health issues – something many patients are not capable of doing. The issue most important to the patient may not be the most clinically significant issue.
Physicians have the requisite training and clinical skills to know which issues need to be addressed urgently and which can wait until a later time. They also have the judgment to avoid inappropriate prioritization that might jeopardize a patient’s health.
While physicians are encouraged to give patients an opportunity to express all of their health concerns, they are not required to deal with all of them immediately. Once the most important issue is identified, along with any other urgent issues, patients can be reassured that their other concerns can be addressed more fully in subsequent appointments.
Strategies for “Door Knob” syndrome
Dr. Sheila Laredo, the College’s Chief Medical Advisor, understands the frustration of “door knob syndrome,” those late-breaking questions that patients ask about a clinical concern just as they head out the office door.
“It is usually the question the patient had been wanting to ask, but had to build up the nerve to ask. I was taught in school to never ignore that ‘hand on the door knob’ question or concern,” she said. But she acknowledged that their timing could be a source of frustration for the doctor, who had thought the interview with the patient was finished.
She encourages physicians to use other strategies that could prompt patients to speak up earlier. Physicians, for example, can use support staff to make the triaging and prioritization of concerns more efficient. Support staff in many physicians’ offices ask that patients state the principal reason for their visit upon scheduling appointments. They can also provide patients with a form in the waiting room asking them to list their concerns prior to their visit with the physician. This not only gives patients an opportunity to list all of their issues, but also gives them a moment to reflect upon their health concerns so that they can express them more clearly and coherently during the encounter with their physician.
Another strategy, said Dr. Laredo, is for the doctor to simply get into the habit of asking the question at the beginning of each visit – what are you most concerned about today? This encourages open communication at the outset, and importantly, enables the physician to prioritize the investigation and treatment based on a better picture of the patient’s symptoms.