About TOW: I’m excited to kick off another year of continuity clinic teaching and our TOW series. A big welcome to our fabulous new crew of interns! TOW is intended to provide standard teaching topics that allow us to review key aspects of outpatient care for children. Each month I try to include a range of topics so that if you’re on a clinic month you’ll have variety, from well visits to acute care issues that affect all ages, including social determinants of health. The format is structured around case-based resources and review materials that can stimulate discussion. For each topic, I write a brief bulleted highlight of the topic that everyone can review by email, whether they are in clinic that week or not. I’ve created a blog format with hyperlinked resources and key-word linked, so hopefully it’s easy to access anytime. There are 50 topics per year over a 2 year cycle, and you can also review archived topics (including age-based well visit review from last year’s set). The scheduled topics for the year will be posted on the blog sidebar. Here’s the blog link you can bookmark: http://depts.washington.edu/uwpeds/tow/
This week’s topic is agenda setting, which we are doing early in the year to review the importance of setting an agenda in outpatient visits, which by nature have fixed times and require prioritizing. Agenda setting allows us to make sure we have addressed the most important concerns for the family, and balance these with our own agenda for the visit. This is really important in building relationships with families and helping them feel that we are responsive to their needs.
Materials for this week:
- Case and discussion
- What else? Setting the agenda for the clinical interview – Ann Int Med 2005
- 5-step patient centered interview
Take-home points for setting the agenda:
- What is agenda setting? A brief dialogue at the beginning of the visit between patient/family and clinician to ensure we can agree on the most important priorities for the visit. It can be as simple as opening with “What concerns do you want to be sure we discuss today?” or “What are your priorities for today’s visit?” Asking “what else?” until no more concerns come up can help us elicit all concerns and set priorities. We can then follow with adding ours: “Thank you. That’s really helpful – I agree those are important. I also want to be sure we talk about X today. Is that okay?”
- Why agenda setting is important? Multiple reasons: Agenda setting helps us 1) address the most important family concerns (we can easily fill the time with our own agenda/priorities in well child checks), 2) avoid trying to do too much with one visit and running behind, and 3) not hearing about a major issue until the end of a visit – “the doorknob complaint.” Some studies have found that up to half of patient complaints and symptoms were not elicited in an interview. The likelihood of psychosocial complaints being brought up without asking about them is especially low.
- What are barriers to agenda setting? Our biggest concern is that it will take too much time. Actually, doing agenda setting well has been found to add just seconds to the visit and helps avoid the doorknob complaints that can take a lot of time. Another concern is that too many issues will be elicited. Adult studies have found that patients typically have 2-3 concerns (up to 5), and this seems to be similar for pediatric visits. When a long list does occur, this may have some diagnostic meaning – like parental anxiety/depression.
- What if there are too many issues to address in one visit? This is important for us to acknowledge if we can’t get to everything and work with parents to prioritize. Parents will accept addressing some items later if their importance is validated, an attempt is made to deal with the most pressing ones, and it is discussed at the outset. We can also use respectful redirection/ interruption to get back on track when parents digress.
- How do we use this in a way that still keeps us on time? The 5-step patient-centered beginning of interview is one suggested approach: 1) Set stage with welcome, introductions, privacy/ confidentiality, ensuring comfort, 2) elicit chief concerns and set agenda (may be helpful to inform them how much time you have available), 3) use open-ended questions and attentive listening (this is where it’s really important to not interrupt right away), 4) elicit more specifics, 5) check accuracy, ask more questions, summarize, then move into clinician-centered phase (exam, etc.).