The 11-Second Problem and How to Fix It

Recently, our smart colleagues at the Journal of General Internal Medicine updated the classic study — how long does it take for a doctor to interrupt the patient at the beginning of the interview, when patients begin their opening statement about “why I am here today” — and published the results.

In years past, we had found that the time it takes for a doctor to interrupt the patient was 18 seconds. Then 23 seconds (hey! we’re getting better!). Now it’s 11 seconds. Eleven seconds?! That is, IF the doctor asked an open-ended question AT ALL. Yikes.

Seriously disappointing. But, are we surprised? The time pressures on doctors have increased over time. More regulation. More required elements in the documentation. Meaningful Use requirements of EHRs. Decreasing reimbursement. Not sufficient time or effort dedicated to redesigning the exam room, or to redesigning teamwork so that doctors can be doctors and not clerical workers.

This is what our EHR 2.0 Sprint and our Practice Redesign have been about.

Beyond that, we’ve implemented Excellence in Communication, an internal clinician retraining program at UCHealth to improve communication in healthcare encounters between patients and physicians. Led by our inimitable Patrick Kneeland, executive for Patient and Provider Experience, and a team of a dozen physician coaches (myself included), the program teaches our docs highly effective communication strategies. In a 4-hour workshop, we can improve clinician experience, patient experience, and reduce physician burnout. Who doesn’t want that?

Of the many techniques and tips, here’s a trio that work particularly well:

1. Start with an open-ended inquiry — “How can I help you today?”—and then wait until the patient is done with their opening statement. According to published data, the vast majority of patients complete their opening statement in far less than a minute, and the exception will go up to maybe 3 minutes, if uninterrupted. The trouble is that docs feel like they’re under so much pressure that every second of listening is excruciating, and the other parts of their brain are already categorizing, creating a list of possible diagnoses, worrying about completing checklists, wondering about quality metrics, and are too “full” to be present in the moment. We train docs to practice listening for up to 2 full minutes to a colleague’s statement and committing to trying this in an exam room with a patient. Simple, but the behavior change is immensely challenging, and yet immensely rewarding when done well.
2. The second technique is “What else?” That’s it. Just keep asking “what else” until the patient runs out of stuff. This, of course, is the fear that docs have: “But that opens Pandora’s Box, and I’ll never get it shut ever again!” and “But then they’ll bring up stuff that I can’t help them with!” and “OMIGOD this will be 75 things and we’ll be here all day and night!” Yes, but we also know that the first thing patients mention only turns out to be the most important thing about 10 to 50 percent of the time. So if we run with the first thing patients say, we’re going to be wrong 50 to 90 percent of the time. So there.
3. Finally, and this is the piece-de-resistance, say: “Well, we have discussed quite a few things so far. Which of these topics would you like to cover today in the time that we have? I would like to discuss A, and sounds like B is also important to you. How does that sound?” Negotiating the agenda is a critical skill; it makes items 1 and 2 really useful, creates a win-win agreement between patient and physician, and even saves time. Imagine: a tool that increases patient and physician satisfaction, and saves time.

Notice that this has nothing to do with the EHR being for good or for evil. This works regardless of what you have in the exam room, as long as you have the presence of mind to remember to practice and use the tools. In this, the winter of our discontent, when everything seems to be going in the wrong direction, when all of our institutions are under attack, and public courtesy and discourse seems to have gone awry, and everyone has a complaint, it seems that so few have ideas to help us climb out of this morass.

These tools could be a glimmer of hope.

CMIO’s take? Use these three tools in the exam room (or the meeting room, the board room, any professional or personal setting where important conversations occur), see what transpires. They are easy to understand, but require discipline and hard work to make them work for you. Persist, and they will pay off in large ways for you and for your patients.

This piece was originally published on The Undiscovered Country, a blog written by CT Lin, MD, CMIO at University of Colorado Health and professor at University of Colorado School of Medicine. To follow him on Twitter, click here.