BMJ  2006;332:1225-1226 (27 May), doi:10.1136/bmj.332.7552.1225

Editorial

Patient agendas in primary care

Perhaps the main benefit is to encourage patients to voice embarrassing problems

People often have difficulty in fully expressing their concerns in consultations with doctors¹ and this may adversely affect outcomes. Some issues go unvoiced or are introduced in a "by the way" presentation at the end of the consultation. The temporal order by which patients present their agendas may not reflect their perceived importance or match the doctor's prioritisation. The first item raised may be the most socially acceptable, and the last (or unvoiced) item—such as breast lumps or rectal bleeding—may be the vaguest or most embarrassing.

If they have time doctors may try to counter this by an open question, asking if there are any other problems.² But doctors have to work within time constraints, and a few actively discourage the presentation of more than one problem per consultation. Examining the issue of patients' agendas—their ideas, concerns and expectations—brings out the tension between a patient-centred model of the consultation and the structural constraints of medicine. Against this background, Middleton and colleagues report in this week's BMJ (p 1238) a trial of a self completed agenda form in primary care, embedded in a trial of general practitioner education.³

General practitioners were randomised either to attend an educational workshop and learn how to use the patient agenda form or to a control group invited to attend the workshop after the trial. In both arms of the trial, patients who were about to see their general practitioners were randomised to use the agenda form during their consultation or not. Both interventions had a similar aim—to improve gathering of the patient's agenda by the doctors. The agenda form was a single sheet inviting patients to list their points, related thoughts and questions, and asking whether they wanted a prescription, explanation, investigation, or certificate.

There have now been three large randomised controlled trials of agenda gathering in primary care, although the third—ours—has not yet reported. The other published study was of a leaflet encouraging patients in the waiting room to list issues they wished to discuss (though without writing them down).⁴ Such interventions can serve two broad functions. Patients may use the form to expand on the main problem by outlining their concerns and expectations, or they may list additional problems. If an agenda form allows the patient to elaborate on the problem, doctor and patient may be more likely to reach a common view about what the outcome of the consultation should be.⁵ Such concordant consultations may alter prescribing, investigation, or referral decisions, in either direction.

Some patients may use an agenda form to express their wish for a prescription, which the doctor may not have considered. Conversely, some patients may regard their problem as not warranting a prescription that might otherwise have been issued. Middleton and colleagues' study did not report such outcomes, although Little and colleagues found an increase in investigation and prescribing, but not referral, when such items were specifically requested on the pre-consultation questionnaire.⁶ Middleton and colleagues' study shows that additional problems are identified when patients use an agenda form and when doctors are trained to use such a form. These additional problems come with a price tag, owing to increased consultation time. Little and colleagues also found this.⁴ The overall time per problem was unchanged: this was not a case of three problems being managed for the price of two, but three for the price of three. An increase in overall patient satisfaction was seen only in the smaller one of these trials,⁴ and it is not known whether the slight delay affected the satisfaction of subsequent patients.

The key issue will be the importance, to the patient or the doctor, of the additional problems or concerns uncovered by the intervention. If these problems were always going to be raised—presumably at a later consultation—then there has been an efficiency gain. This should manifest itself in a reduction in reattendances, though this outcome was not measured. There is a large pool of symptoms in the community which never reach medical attention.⁷ Patients judge the seriousness of their problems when choosing whether or not to consult, and they are usually right.^{8 9} Agenda forms may simply medicalise problems that would otherwise not rise above the threshold for consultation. This is not necessarily a bad thing, because the doctor may be able to explain the circumstances in which a similar problem would warrant medical attention.

Perhaps the main benefit from agenda forms is allowing embarrassing problems to be voiced. Until the content of such forms is analysed, however, this must remain supposition and the potential value of agenda forms in routine clinical practice will not have been fully assessed.

(w.t.hamilton{at}btopenworld.com), Department of Community Based Medicine, University of Bristol, Bristol BS8 1AU

Institute of Health and Social Care Research, Peninsula Medical School, Exeter EX1 2LU

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Research p 1238

Competing interests: WH and NB have performed a trial of self completed agenda forms in primary care with colleagues, which is yet to report.

References

1. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients' unvoiced agendas in general practice consultations: qualitative study. BMJ 2000;320: 1246-50.[Abstract/Free Full Text]
2. Robinson JD. Closing medical encounters: two physician practices and their implications for the expression of patients' unstated concerns. Soc Sci Med 2001;53: 639.[Medline]
3. Middleton JF, McKinley RK, Gillies CL. Effect of patient completed agenda forms and doctors' education about the agenda on the outcome of consultations: randomised controlled trial. BMJ 2006;332: 1238-41.[Abstract/Free Full Text]
4. Little P, Dorward M, Warner G, Moore M, Stephens K, Senior J, et al. Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care. BMJ 2004;328: 441-4.[Abstract/Free Full Text]
5. Gabbay M, Shiels C, Bower P, Sibbald B, King M, Ward E. Patient-practitioner agreement: does it matter? Psychol Med 2003;33: 241-51.[Medline]
6. Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. BMJ 2004;328: 444-6.[Abstract/Free Full Text]
7. Green LA, Fryer GE Jr, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344: 2021-5.[Free Full Text]
8. Crosland A, Jones R. Rectal bleeding: prevalence and consultation behaviour. BMJ 1995;311: 486-8.[Abstract/Free Full Text]
9. Hamilton W, Sharp D. Diagnosis of colorectal cancer in primary care: the evidence base for guidelines. Fam Pract 2004;21: 99-106.[Abstract/Free Full Text]

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