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Agenda setting and visit openings in primary care visits involving patients taking opioids for chronic pain

Abstract

Background

Agenda setting is associated with more efficient care and better patient experience. This study develops a taxonomy of visit opening styles to assess use of agenda and non-agenda setting visit openings and their effects on participant experience.

Methods

This observational study analyzed 83 video recorded US primary care visits at a single academic medical center in California involving family medicine and internal medicine resident physicians (n = 49) and patients (n = 83) with chronic pain on opioids. Using conversation analysis, we developed a coding scheme that assessed the presence of agenda setting, distinct visit opening styles, and the number of total topics, major topics, surprise patient topics, and returns to prior topics discussed. Exploratory quantitative analyses were conducted to assess the relationship of agenda setting and visit opening styles with post-visit measures of both patient experience and physician perception of visit difficulty.

Results

We identified 2 visit opening styles representing agenda setting (agenda eliciting, agenda reframing) and 3 non-agenda setting opening styles (open-ended question, patient launch, physician launch). Agenda setting was only performed in 11% of visits and was associated with fewer surprise patient topics than visits without agenda setting (mean (SD) 2.67 (1.66) versus 4.28 (3.23), p = 0.03).

Conclusions

In this study of patients with chronic pain, resident physicians rarely performed agenda setting, whether defined in terms of “agenda eliciting” or “agenda re-framing.” Agenda setting was associated with fewer surprise topics. Understanding the communication context and outcomes of agenda setting may inform better use of this communication tool in primary care  practice.

Peer Review reports

Background

Agenda setting is a communication strategy physicians use at the beginning of clinical visits to elicit, propose, and organize a complete list of topics to be covered [1]. Topics are clinical issues raised by either patient or physician [2]. Agenda setting is thought to improve patient outcomes and experience [3], physicians’ understanding of patients’ concerns [4], and physician organization and time management by reducing the number of unaddressed concerns and, by extension, the number of “surprise” topics patients introduce later in the visit [5, 6]. Agenda setting is a standard skill taught to medical students and residents, does not significantly affect visit length [7,8,9], and is accepted as best practice [10,11,12]. Physicians, however, rarely perform agenda setting [13, 14], which can result in more frequent unaddressed concerns [4, 9, 15, 16]. Studies have shown that training physicians in agenda setting and visit organization strategies can result in improved communication, particularly by reducing the introduction of surprise topics [9, 17].

There are several existing gaps in research on agenda setting. Previous research found a large variation of its occurrence, ranging from 32 to 68% of visits [4, 9, 13, 14, 18]. A lack of a standard agenda setting definition across studies is likely an important but underappreciated cause of this variability. For instance, some studies include all visits that start with an open-ended question in their agenda setting definition [14] while others have set time limits (e.g., the first five minutes [18]) for when agenda setting must occur.

Previous studies of agenda setting have predominantly focused on visits addressing new patient concerns. Relatively little is known about physician behavior and visit organization in follow-up visits for chronic conditions, which comprise the majority of primary care visits [19, 20]. Visits for chronic pain are an example of challenging chronic care conditions that are worthy of attention due to their prevalence, impact on quality of life, and their influence on physician perception of visit difficulty [21,22,23]. Additionally, chronic pain can take a substantial amount of visit time during which multiple other chronic problems must also be addressed [24, 25]. Patients themselves can bring multiple concerns to a single visit [8, 26,27,28,29], and physicians must also address many guideline-based clinical directives.

Limited data exists for the specific impact of agenda setting on patient experience and physician perception of visit difficulty [22, 23]. Taking the physician perspective into consideration is important given the current prevalence of physician dissatisfaction and burnout, which in turn can decrease patient centeredness and increase physician turnover [30,31,32,33,34,35]. Physician-reported visit difficulty has also been associated with worse patient experience and higher healthcare utilization [36, 37]. Communication strategies are needed to assist physicians in navigating “difficult” visits [23], and this study specifically examines visits focused on chronic pain and opioids, which have been associated in other studies with high levels of physician-reported difficulty [23, 38].

By examining chronic care visits, our study sought to address these knowledge gaps by pursuing the following goals: 1) characterize primary care physicians opening styles within the framework of agenda setting as a first step towards developing a standardized definition of agenda setting 2) assess associations between agenda setting and a) topics discussed (e.g., surprise topics), b) patient experience ratings, and c) physicians’ perception of visit difficulty. Chronic pain is an example of a symptom-driven chronic condition that is broadly representative of other chronic conditions seen in primary care [39]. This study expands on current knowledge on agenda setting and is important because observations from patient-physician interactions can help inform next steps in educational and health system priorities around organizing chronic care visits and communicating about chronic conditions such as chronic pain.

Methods

This is a qualitative, observational study. We first used conversation analysis [40, 41] to create a taxonomy of visit opening styles. We then applied this inductively derived taxonomy to our data and examined quantitative associations between these categories and topics discussed and post-visit measures of patient experience and physician perception of visit difficulty.

Data sources and participants

Data sources were 86 video recorded clinical visits and associated patient and resident physician questionnaires. Three of the 86 recorded encounters were excluded from our study because they did not include the initial opening sequence, leaving 83 encounters in our study. Physicians were second- or third-year internal medicine or family medicine residents at the University of California Davis Medical Center. Patients were established adult patients planning to discuss pain management with an enrolled physician during a routine appointment. Patients were ineligible if they spoke a language other than English during visits, were getting active cancer treatment or palliative care, or were receiving an opioid prescription from someone other than their primary care physician. Patient and physician demographic information were collected at enrollment. The University of California Davis Institutional Review Board approved the study. Written consent was obtained from all participants, and detailed study procedures have been previously described [42, 43].

Participant experience measures

After each visit, physicians completed the 10-item Difficult Physician-Patient Relationship Questionnaire [44]. Physician difficulty scores could range from 10 to 60 and higher scores represent more difficult visits. Patients completed 4 measures of patient experience: the short form of the Wake Forest trust scale [45], a 3-item measure of agreement with treatment plan [46], an assessment of physician communication skills from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Adult Visit Survey [47], and a patient-facing version of the Difficult Physician-Patient Relationship Questionnaire described in prior studies by Henry et al. [43] Exploratory factor analysis indicated that all 4 measures assessed a single latent construct; therefore, these 4 measures were combined into a single standardized (population mean = 0, SD = 1) measure of patient experience, with higher values indicating a better experience [43].

Coding procedures

Two authors, a primary care physician and a medical sociologist trained in conversation analysis [40, 41] (AECW) watched study video recordings and coded visits together. We worked in tandem to determine two coding schemes for Visit Openings and for Topic-Level review. Our complementary expertise allowed us to simultaneously analyze data both for medical content and for interactional process, allowing for richer analysis. For instance, a conversation analyst may not recognize when one medical topic shifts into another topic. A physician may not recognize the communicative practices speakers use to accomplish shifting between topics.

Qualitative analysis: visit openings

First, we determined the visit opening style by watching visits from their onset through the first topic discussed. Initially, we anticipated developing a binary coding scheme indicating whether agenda setting occurred or not. After reviewing 20 videos, however, we realized we needed a more nuanced coding of agenda setting, which led to an inductively-driven analysis of visit openings (still based on the basic purpose of generating an upfront list of topics) informed by conversation analysis principles which focus on how participants begin an interaction [16, 48], introduce topics for discussion [29, 49], transition from one topic to the next [50], and analyzes the overall sequential order in which topics are discussed [51].

We defined agenda setting as strategies to explicitly elicit or confirm an upfront list of agenda topics before discussing the first topic, and our definition did not include an arbitrary time limit. Previous research has shown that broad open-ended questions during visit openings (e.g., “What can I do for you today?”) typically generate a single topic and are ineffective in soliciting an upfront list of topics [13, 16], so open-ended questioning by itself did not fulfill our definition. We expanded our analysis to include the opening sequence of 45 visits, at which point we reached saturation. In tandem we then applied the final visit opening coding scheme to all 83 visits. Disagreements were negotiated and a conclusion achieved by consensus.

Qualitative analysis: topic-level

Subsequently, we performed in tandem a topic-level review of 15 visits, at which point we reached saturation for development of a coding schema for topic-related variables. This entailed watching visits from when physicians entered the room until they exited. This initial review established a coding scheme for the types of topics discussed and how to represent their occurrence. This inductively-driven analysis led to the final list of topic-related variables. We coded for the frequency of the following: total topics, major topics, surprise topics, return topics, and the length of the visit (see Table 3 for definitions). We coded topics initiated by patient companions as patient-initiated topics. Disagreements were negotiated and a conclusion achieved by consensus.

We then applied this final topic-level coding scheme to a subset of 41 videos due to the time intensive nature of tandem coding (each visit took approximately 2 h to code) and coordinating research schedules. We purposefully selected all visits with agenda setting for topic-level coding (n = 9), and we selected 32 additional visits using maximum variation sampling to represent family medicine and internal medicine resident physicians, a proportionate distribution of the visit opening styles, and a wide range of patient experience and physician difficulty scores [53].

Quantitative analysis: visit openings

Using the whole sample (n = 83), we constructed separate linear regression models with patient experience and physician perception of visit difficulty as dependent variables and agenda setting (present/absent) as the independent variable. We then ran 2 additional regressions with the same 2 dependent variables analyzing visit opening style as 5-level categorical variable. Open-ended question visit opening style was the reference group for all analyses using the 5-level categorical variable.

Quantitative analysis: topic-level

Using the 41 visits that underwent topic-level coding, we constructed separate linear regression models to assess for differences in means of 5 dependent variables (total topics, major topics, surprise topics, return topics, length of visit) among groups defined by agenda setting (present/absent) as the independent variable. We then ran additional regressions with the same variables analyzing visit opening style as a 5-level categorical variable.

All analyses controlled for standard demographics (patient age, sex, and white versus nonwhite race) that may act as confounders, and used general estimating equations to account for clustering of patients within physicians. Analyses were conducted using SAS 9.4.

Results

The 83 visits coded for visit opening style had a mean patient experience standardized score of 0.02 (SD = 0.87) and a mean physician difficulty score of 27.4 (SD = 10.71). Table 1 provides demographic information for patients and physicians.

Table 1 Patient and Physician Demographics

Qualitative results: conversation analysis of visit openings

Visits demonstrated 5 distinct visit opening styles (see Table 2 for definitions and example transcripts). We found 3 opening styles that did not qualify as agenda setting: open-ended question, patient launch, and physician launch. The non-agenda setting openings launched into a first topic without establishing, at least on a pro tem basis, the full set of topics to be discussed.

Table 2 Descriptions and examples of visit openings

We found two distinct visit opening styles physicians used to perform agenda setting. The first style was agenda eliciting, which is a standard approach taught to medical students and residents. In this approach, physicians request from patients an upfront list of their medical concerns (e.g.,“What are the main things we want to talk about?”). The second style we identified was agenda reframing, as it allows physicians to reformulate the patient’s talk at the beginning of the visit (which could be about one or more potential topics to be discussed) into an explicit agenda.

Using conversation analysis, we demonstrate a case of agenda reframing to provide a detailed description of this novel conceptualization of agenda setting (see Table 2 for transcript). The visit begins with the physician asking an open-ended question, “What can I do for you today?”, a standard agenda eliciting opening. However, instead of conforming to the topic of the question, the patient responds to this general inquiry as if it were a “How are you” question [16] with, “I’m not doing no good.”, which the physician unpacks in line 3. The patient then begins to describe the array of concerns she is suffering from including fever, coughing, and a sore throat. Instead of launching into an investigation of these concerns, the physician tries to reframe these concerns as a list of topics (line 10).

In response to the physician’s first attempt to have her agree to an agenda, the patient provides only a token confirmation, “Yeah” (line 11), and she then rushes into her next-turn-at-talk (with a compressed “cuz”) about another topic—a question about a prescription and its potential relatedness to having restless legs. At this point, the physician shifts the conversation away from the patient’s attempted launch into the restless leg topic, and again tries to synthesize the patient’s concerns into an upfront agenda while also negotiating what the priorities of the visit are and in what order these topics should be discussed (lines 17–19, 21). While the physician is attempting to get the patient to recognize the act and content of agenda setting, the patient does neither. The patient transforms the physician’s confirmation question about restless legs (and the topic being on the agenda (line 21)) into a request for more information and as a launch into the topic of her legs. This is evident in the patient’s elaboration about her legs (lines 24, 26).

For the third and final time, the physician repeatedly refrains from following the patient’s attempted path into a discussion about a medical topic before establishing an agenda, and again pauses to set the agenda. The physician now does so with a declarative formulation of the agenda to “first” discuss the fever and the cough (line 27), which implicitly leaves the restless leg topic as the subsequent topic. Only then, after having established an agenda unilaterally after two failed collaborative attempts, does the physician move out of the opening phase of the visit and into the history taking phase (line 28).

While this excerpt may show an exceptional amount of demonstrated restraint by the physician to curtail the patient’s many attempts to delve straightaway into a medical topic, this physician has successfully shown how agenda reframing potentially helps make the visit less disorganized than it would have been otherwise. Agenda reframing is a helpful practice when patients, as demonstrated here, do not readily provide an upfront list of topics to an agenda eliciting question (or to other open-ended question visit openings). Physicians can also use agenda reframing when patients begin a visit with a patient launch. Agenda reframing allows physicians to hit the brakes while still incorporating the concerns raised by the patient into the potential agenda.

Qualitative results: topic-level

Table 3 defines the topic-level variables we assessed for each visit (total topics, major topics, surprise topics, return topics) and provides an illustrative example visit.

Table 3 Topic-level review definitions with an illustrative example

This visit begins with the patient launching into a first topic about his recent fall off a moving truck, and the visit proceeds without the physician pausing to set an agenda. Because the physician does not solicit an upfront list of topics from the patient, every patient-initiated topic throughout the visit is therefore an unanticipated surprise topic for the physician. All but 2 topics (stomach issues and smoking cessation) are patient-initiated surprise topics. This topic-level review allowed us to ascertain not only the types of topics discussed but also how often the same topic gets returned to (e.g., chronic pain gets returned to 3 times). While this particular visit only has one major topic (chronic pain) that receives a comprehensive discussion, there are 8 total topics discussed.

Quantitative results: visit openings

We found the 3 opening styles that did not qualify as agenda setting comprised the vast majority of the visits: open-ended question (n = 41), patient launch (n = 15) and physician launch (n = 18), while the 2 opening styles that qualified as agenda setting occurred relatively infrequently: agenda eliciting (n = 6) and agenda reframing (n = 3). In total, 9 of the 83 visits (11%) included agenda setting.

We re-categorized these 5 visit opening styles into a 2-level variable of those visits that met the agenda setting definition (agenda eliciting, agenda reframing) and those that did not (open-ended question, patient launch, physician launch). There was no statistically significant difference in patient experience and physician perception of visit difficulty for visits in which agenda setting was present versus absent, (Table 4) nor among the 5 visit opening styles.

Table 4 Mean patient experience and physician difficulty with or without agenda setting

Quantitative results: topic-level

The 41 visits coded for topics discussed had a mean length of 25.6 min (SD 7.12), and a mean of 8.10 (SD = 3.47) total topics discussed. Visits averaged 1.63 (SD = 0.70) major topics and 7.85 (SD = 4.14) returns to prior topics. Visits averaged 3.93 (SD = 3.01) surprise topics. All visits had at least 1 surprise topic.

We found visits with agenda setting had a statistically significantly lower number of surprise topics (mean = 2.67, SD = 1.66) compared to visits without agenda setting (mean = 4.28, SD = 3.23) (p-value = 0.03) (Table 5). No significant differences were found in visit length, number of total topics covered, return topics, or number of major topics discussed between visits with or without agenda setting. No significant differences were found for any dependent variables among the 5 different visit opening styles.

Table 5 Visit topic variables with or without agenda setting

Discussion

In this study examining physicians’ agenda setting in primary care visits for patients taking opioids for chronic pain, we developed a taxonomy of visit opening styles. We identified two distinct methods physicians used to set an agenda: agenda eliciting and agenda reframing. This study is the first to identify and describe agenda reframing, which is a practice physicians use to reformulate the patient’s talk at the beginning of the visit (which could be about one or more potential topics to be discussed) into an explicit agenda. Our study also confirmed the importance of agenda setting, as our exploratory quantitative analysis found that any use of agenda setting was associated with fewer surprise topics, but no form of visit opening style was associated with a change in patient experience or physician perception of visit difficulty.

We found that resident physicians performed agenda setting in only 11% of chronic care visits. Almost 50% of visits started with a broad open-ended question that then transitioned into the first topic without physicians pausing to establish (or reframe) the agenda. Thus, open-ended questioning does not, by itself, reliably establish a complete visit agenda. This finding suggests open-ended questioning should not be included in the definition of agenda setting. Even though our agenda setting frequency is lower than other studies of recorded visits [4, 9, 13, 14, 18], a finding potentially attributable to our relatively constrained agenda setting definition, we believe our definition is a more accurate representation of the phenomena and will set a more clear rubric for future studies.

Our low rate of observed agenda setting may also be related to physician preference, perceived lack of time, lack of comfort with agenda setting, lack of education about agenda reframing as a method, or physicians taking a tailored approach to particular patients. Furthermore, patient behavior may also curtail physicians’ best efforts to agenda set and may reflect unique challenges in a chronic care environment, where patients and physicians negotiate multiple topics. These results resonate with the work of Stuart et al. [54] in the UK, who found that physicians often delay soliciting additional concerns until the end of the visit. Future studies should assess which patient- or physician-related factors influence agenda setting. Understanding these influences could inform pre-visit interventions, potentially leading to better visit experiences.

We next address studying agenda setting in the context of chronic pain. Despite indications that chronic pain can dominate visits and distract attention from other clinical issues [55,56,57,58], our data show participants addressed a multitude of topics (an average of 8 per visit). Our finding exceeds the number of total topics discussed in Brock et al.’s study which compared visits with and without agenda setting (an average of 4.75 and 5.15 per visit, respectively) [7]. One potential explanation is that patients in resident clinics tend to have more complicated chronic health concerns and transportation issues that may encourage physicians to address more topics [59, 60]. Furthermore, recent studies found patients who take opioids for chronic pain receive improved care because more frequent visits provide opportunities for more preventive care topics to be addressed [61, 62].

In our analysis of surprise topics, we found that agenda setting was associated with fewer surprise topics, which could be attributed to the inherent benefit of agenda setting—having physicians elicit an “unsurprising” upfront list of topics at the beginning of the visit. This finding aligns with other studies [7, 13], suggesting our definition of agenda setting, which excludes open-ended questions if performed without agenda reframing, has some construct validity. Averting surprise topics could improve quality of care by shifting critical discussions earlier in the visit, where they are likely to be afforded more time [2]. An important caveat is that all 9 of the agenda setting visits ultimately contained at least one surprise topic. Since surprise topics can occur despite agenda setting, physicians may view agenda setting as ineffective.

We did not find differences in physician perception of visit difficulty between visits with or without agenda setting. We theorized that if physicians generally perceive visits for chronic pain as difficult [22], there may not be sufficient variation in visits to detect a change. We did not have a comparison group of non-pain visits. Future studies could investigate more diverse chronic care visits. Physician wellbeing is part of the quadruple aim which expands on the triple aim of improving healthcare (through better outcomes, lower costs, improved patient experiences) by including staff wellbeing [63, 64]. Developing improved communication skills for use in this patient population could improve the patient-physician experiences [36, 65].

The strengths of this study include direct observation of clinical visits using videotape and use of mixed analytic methods, but like all studies ours has limitations. This study took place at two clinics in a single academic health center, limiting generalizability to other settings. However, findings from this setting are highly relevant to medical education. Additionally, our sample size limited our statistical power to identify small differences between visits with and without agenda setting. Our study measured the number of topics discussed per visit but did not examine how effectively topics were discussed.

Along with prior studies, our work demonstrates that agenda setting may be a useful strategy for reducing surprise topics. A unique finding from our study is identifying the practice of agenda reframing, which has not to our knowledge been formally taught but seems to be a viable agenda setting strategy. Agenda reframing can be potentially taught as a simple 3 step process: 1) Ask ‘What brings you in today?’ 2) Encourage patients to expound 3) Redirect to additional items on the agenda. Teaching physicians multiple strategies for agenda setting (i.e. agenda eliciting or agenda reframing) may help physicians feel more comfortable setting agendas. Of course, further research is needed to explore these hypotheses. Because agenda setting is a free communicative intervention, does not make visits longer, and can provide benefits such as reducing surprise topics, we believe our findings match current consensus that agenda setting is a valuable strategy.

Conclusion

In this study examining physicians’ agenda setting in primary care visits for patients taking opioids for chronic pain, we developed a taxonomy of visit opening styles which comprised 2 styles of agenda setting (agenda eliciting and agenda reframing) and 3 styles of non-agenda setting (open-ended question, patient launch, or physician launch). Resident physicians rarely perform agenda setting with patients who have chronic pain. When performed, it was associated with fewer surprise patient topics, but no form of visit opening style was associated with a change in patient experience or physician perception of visit difficulty. Understanding the use of agenda setting in visits for chronic problems may help primary care physicians to decide the best use of this communication tool in their practice.

Availability of data and materials

Some data in this study are confidential. The video recordings contain identifiable data and so are not publicly available. But the datasets generated and analyzed during the study are available subject to required ethical and regulatory approvals. Those interested in using these data should contact the senior author (SGH).

References

  1. 1.

    Gobat N, Kinnersley P, Gregory JW, Robling M. What is agenda setting in the clinical encounter? Consensus from literature review and expert consultation. Patient Educ Couns. 2015;98(7):822–9.

    PubMed  Article  Google Scholar 

  2. 2.

    Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res. 2007;42(5):1871–94.

    PubMed  PubMed Central  Article  Google Scholar 

  3. 3.

    Rodriguez HP, Anastario MP, Frankel RM, et al. Can teaching agenda-setting skills to physicians improve clinical interaction quality? A controlled intervention. BMC Med Educ. 2008;8:3.

    PubMed  PubMed Central  Article  Google Scholar 

  4. 4.

    Dyche L, Swiderski D. The effect of physician solicitation approaches on ability to identify patient concerns. J Gen Intern Med. 2005;20(3):267–70.

    PubMed  PubMed Central  Article  Google Scholar 

  5. 5.

    Dugdale DC, Epstein R, Pantilat SZ. Time and the patient-physician relationship. J Gen Intern Med. 1999;14(Suppl 1):S34–40.

    PubMed  PubMed Central  Article  Google Scholar 

  6. 6.

    Bergh KD. Time use and physicians' exploration of the reason for the office visit. Fam Med. 1996;28(4):264–70.

    CAS  PubMed  Google Scholar 

  7. 7.

    Brock DM, Mauksch LB, Witteborn S, Hummel J, Nagasawa P, Robins LS. Effectiveness of intensive physician training in upfront agenda setting. J Gen Intern Med. 2011;26(11):1317.

    PubMed  PubMed Central  Article  Google Scholar 

  8. 8.

    Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med. 2007;22(10):1429–33.

    PubMed  PubMed Central  Article  Google Scholar 

  9. 9.

    Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda: have we improved? JAMA. 1999;281(3):283–7.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  10. 10.

    Fortin AH, Dwamena FC, Frankel RM, Smith RC. Smith's patient centered interviewing: an evidence-based method. New York: McGraw Hill Professional; 2012.

  11. 11.

    Henry SG, Holmboe ES, Frankel RM. Evidence-based competencies for improving communication skills in graduate medical education: a review with suggestions for implementation. Med Teach. 2013;35(5):395–403.

    PubMed  Article  PubMed Central  Google Scholar 

  12. 12.

    Hashim MJ. Patient-centered communication: basic skills. Am Fam Physician. 2017;95(1):29–34.

    PubMed  PubMed Central  Google Scholar 

  13. 13.

    Robinson JD, Tate A, Heritage J. Agenda-setting revisited: when and how do primary-care physicians solicit patients' additional concerns? Patient Educ Couns. 2016;99(5):718–23.

    PubMed  Article  PubMed Central  Google Scholar 

  14. 14.

    Singh Ospina N, Phillips KA, Rodriguez-Gutierrez R, et al. Eliciting the Patient’s agenda- secondary analysis of recorded clinical encounters. J Gen Intern Med. 2019;34(1):36–40.

    PubMed  Article  PubMed Central  Google Scholar 

  15. 15.

    Peltenburg M, Fischer JE, Bahrs O, van Dulmen S, van den Brink-Muinen A. The unexpected in primary care: a multicenter study on the emergence of unvoiced patient agenda. Ann Fam Med. 2004;2(6):534–40.

    PubMed  PubMed Central  Article  Google Scholar 

  16. 16.

    Heritage J, Robinson JD. The structure of patients' presenting concerns: physicians' opening questions. Health Commun. 2006;19(2):89–102.

    PubMed  Article  PubMed Central  Google Scholar 

  17. 17.

    Berger Z, Saha S, Korthuis PT, et al. Agenda-setting in routine primary HIV care encounters. Paper presented at: Journal of General Internal Medicine 2011.

    Google Scholar 

  18. 18.

    Rey-Bellet S, Dubois J, Vannotti M, et al. Agenda setting during follow-up encounters in a university primary care outpatient clinic. Health Commun. 2017;32(6):714–20.

    PubMed  Article  PubMed Central  Google Scholar 

  19. 19.

    Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults - United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001–6.

    PubMed  PubMed Central  Article  Google Scholar 

  20. 20.

    Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being: a World Health Organization study in primary care. JAMA. 1998;280(2):147–51.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  21. 21.

    Fenton JJ, Franks P, Feldman MD, et al. Impact of patient requests on provider-perceived visit difficulty in primary care. J Gen Intern Med. 2015;30(2):214–20.

    PubMed  Article  PubMed Central  Google Scholar 

  22. 22.

    Henry SG, Holt ZB. Frustrated patients and fearful physicians. J Gen Intern Med. 2017;32(2):148–9.

    PubMed  Article  PubMed Central  Google Scholar 

  23. 23.

    Henry SG, Matthias MS. Patient-clinician communication about pain: a conceptual model and narrative review. Pain Med. 2018;19(11):2154–65.

    PubMed  PubMed Central  Article  Google Scholar 

  24. 24.

    Henry SG, Eggly S. How much time do low-income patients and primary care physicians actually spend discussing pain? A direct observation study. J Gen Intern Med. 2012;27(7):787–93.

    PubMed  PubMed Central  Article  Google Scholar 

  25. 25.

    Krein SL, Hofer TP, Holleman R, Piette JD, Klamerus ML, Kerr EA. More than a pain in the neck: how discussing chronic pain affects hypertension medication intensification. J Gen Intern Med. 2009;24(8):911–6.

    PubMed  PubMed Central  Article  Google Scholar 

  26. 26.

    Braddock CH 3rd, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282(24):2313–20.

    PubMed  Article  PubMed Central  Google Scholar 

  27. 27.

    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(7552):1238–42.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  28. 28.

    Rost K, Frankel R. The introduction of the older patient's problems in the medical visit. J Aging Health. 1993;5(3):387–401.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  29. 29.

    White AEC. Patient-initiated additional concerns in general surgery visits. Patient Educ Couns. 2018;101(12):2219–25.

    PubMed  Article  PubMed Central  Google Scholar 

  30. 30.

    Anagnostopoulos F, Liolios E, Persefonis G, Slater J, Kafetsios K, Niakas D. Physician burnout and patient satisfaction with consultation in primary health care settings: evidence of relationships from a one-with-many design. J Clin Psychol Med Settings. 2012;19(4):401–10.

    PubMed  Article  Google Scholar 

  31. 31.

    Braun SE, Auerbach SM, Rybarczyk B, Lee B, Call S. Mindfulness, burnout, and effects on performance evaluations in internal medicine residents. Adv Med Educ Pract. 2017;8:591–7.

    PubMed  PubMed Central  Article  Google Scholar 

  32. 32.

    Baer TE, Feraco AM, Tuysuzoglu Sagalowsky S, Williams D, Litman HJ, Vinci RJ. Pediatric Resident Burnout and Attitudes Toward Patients. Pediatrics. 2017;139(3):e20162163.

  33. 33.

    Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. BMC Health Serv Res. 2014;14:325.

    PubMed  PubMed Central  Article  Google Scholar 

  34. 34.

    Dewa CS, Loong D, Bonato S, Trojanowski L. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review. BMJ Open. 2017;7(6):e015141.

    PubMed  PubMed Central  Article  Google Scholar 

  35. 35.

    Pantenburg B, Luppa M, Konig HH, Riedel-Heller SG. Burnout among young physicians and its association with physicians' wishes to leave: results of a survey in Saxony, Germany. J Occup Med Toxicol. 2016;11:2.

    PubMed  PubMed Central  Article  Google Scholar 

  36. 36.

    Hinchey SA, Jackson JL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med. 2011;26(6):588–94.

    PubMed  PubMed Central  Article  Google Scholar 

  37. 37.

    Jackson JL, Kay C. Heartsink hotel, or "oh no, look who's on my schedule this afternoon!". J Gen Intern Med. 2013;28(11):1385–6.

    PubMed  PubMed Central  Article  Google Scholar 

  38. 38.

    Matthias MS, Parpart AL, Nyland KA, et al. The patient-provider relationship in chronic pain care: providers' perspectives. Pain Med. 2010;11(11):1688–97.

    PubMed  Article  Google Scholar 

  39. 39.

    Bowman MA, Neale AV. Common illnesses, patient physician interactions, continuity, and practice organization. J Am Board Fam Med. 2013;26(4):347–9.

    PubMed  Article  PubMed Central  Google Scholar 

  40. 40.

    Heritage J, Maynard DW. Communication in medical care: Interaction between primary care physicians and patients, vol. 20. New York: Cambridge University Press; 2006.

  41. 41.

    Sidnell J, Stivers T. The handbook of conversation analysis, vol. 121. Hoboken: Wiley; 2012.

  42. 42.

    Henry SG, Chen M, Matthias MS, Bell RA, Kravitz RL. Development of the chronic pain coding system (CPCS) for characterizing patient-clinician discussions about chronic pain and opioids. Pain Med. 2016;17(10):1892–905.

    PubMed  PubMed Central  Article  Google Scholar 

  43. 43.

    Henry SG, Bell RA, Fenton JJ, Kravitz RL. Communication about chronic pain and opioids in primary care: impact on patient and physician visit experience. Pain. 2018;159(2):371–9.

    PubMed  PubMed Central  Article  Google Scholar 

  44. 44.

    Hahn S, Kroenke K, Spitzer R, Williams J, Brody D, Linzer M. deGruy FV. The difficult patient in primary care: prevalence, psychopathology and impairment. J Gen Intern Med. 1996;11:1–8.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  45. 45.

    Dugan E, Trachtenberg F, Hall MA. Development of abbreviated measures to assess patient trust in a physician, a health insurer, and the medical profession. BMC Health Serv Res. 2005;5(1):64.

    PubMed  PubMed Central  Article  Google Scholar 

  46. 46.

    Staiger TO, Jarvik JG, Deyo RA, Martin B, Braddock CH III. Brief report: patient-physician agreement as a predictor of outcomes in patients with back pain. J Gen Intern Med. 2005;20(10):935–7.

    PubMed  PubMed Central  Article  Google Scholar 

  47. 47.

    Lee Hargraves J, Hays RD, Cleary PD. Psychometric properties of the consumer assessment of health plans study (CAHPS®) 2.0 adult core survey. Health Serv Res. 2003;38(6p1):1509–28.

    PubMed  PubMed Central  Article  Google Scholar 

  48. 48.

    Robinson JD, Heritage J. Physicians’ opening questions and patients’ satisfaction. Patient Educ Couns. 2006;60(3):279–85.

    PubMed  Article  PubMed Central  Google Scholar 

  49. 49.

    White AEC. When and how do surgeons initiate noticings of additional concerns? Soc Sci Med. 2020;244:112320.

    PubMed  Article  PubMed Central  Google Scholar 

  50. 50.

    Jefferson G. On stepwise transition from talk about a trouble to inappropriately next-positioned matters. Struct Soc Act. 1984;191:222.

    Google Scholar 

  51. 51.

    Schegloff EA. Sequence organization in interaction: A primer in conversation analysis I, vol. 1. New York: Cambridge University Press; 2007.

  52. 52.

    Heritage J, Clayman S. Talk in action: Interactions, identities, and institutions, vol. 44: Wiley; 2011.

  53. 53.

    Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Admin Pol Ment Health. 2015;42(5):533–44.

    Article  Google Scholar 

  54. 54.

    Stuart B, Leydon G, Woods C, et al. The elicitation and management of multiple health concerns in GP consultations. Patient Educ Couns. 2019;102(4):687–93.

    PubMed  Article  PubMed Central  Google Scholar 

  55. 55.

    Bertakis KD, Azari R, Callahan EJ. Patient pain: its influence on primary care physician-patient interaction. Fam Med. 2003;35(2):119–23.

    PubMed  PubMed Central  Google Scholar 

  56. 56.

    Blyth FM, March LM, Brnabic AJ, Cousins MJ. Chronic pain and frequent use of health care. Pain. 2004;111(1–2):51–8.

    PubMed  Article  PubMed Central  Google Scholar 

  57. 57.

    Darnall BD, Stacey BR, Chou R. Medical and psychological risks and consequences of long-term opioid therapy in women. Pain Med. 2012;13(9):1181–211.

    PubMed  PubMed Central  Article  Google Scholar 

  58. 58.

    Reid MC, Engles-Horton LL, Weber MB, Kerns RD, Rogers EL, O'Connor PG. Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med. 2002;17(3):173–9.

    PubMed  PubMed Central  Article  Google Scholar 

  59. 59.

    Colburn JL, Jasinski DR, Rastegar DA. Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients treated by resident and attending physicians in a general medical clinic. J Opioid Manag. 2012;8(3):153–60.

    PubMed  Article  PubMed Central  Google Scholar 

  60. 60.

    Fiebach NH, Wong JG. Taking care of patients in resident clinics: where do we stand? J Gen Intern Med. 2001;16(11):787–9.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  61. 61.

    Agnoli A. Cancer Screening Among Women Prescribed Opioids: A U.S. National Study. Ann Fam Med. 2019;18(1):59–65.

  62. 62.

    Butchart A, Kerr EA, Heisler M, Piette JD, Krein SL. Experience and management of chronic pain among patients with other complex chronic conditions. Clin J Pain. 2009;25(4):293–8.

    PubMed  PubMed Central  Article  Google Scholar 

  63. 63.

    Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–6.

    PubMed  PubMed Central  Article  Google Scholar 

  64. 64.

    West CP. Physician well-being: expanding the triple aim. J Gen Intern Med. 2016;31(5):458–9.

    PubMed  PubMed Central  Article  Google Scholar 

  65. 65.

    Haas LJ, Glazer K, Houchins J, Terry S. Improving the effectiveness of the medical visit: a brief visit-structuring workshop changes patients' perceptions of primary care visits. Patient Educ Couns. 2006;62(3):374–8.

    PubMed  Article  PubMed Central  Google Scholar 

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Acknowledgements

Authors gratefully acknowledge the contributions of Gary Weinberg, who recruited participants and collected the video data. Authors also thank the patients and physicians who participated in this study.

Funding

Original data collection was supported by National Institutes of Health grants KL2TR000134 and UL1TR000002 and by the University of California Davis Department of Internal Medicine. For secondary analyses, Dr. Henry was supported by National Institutes of Health grant K23DA043052. Drs. Hood-Medland and White were supported by Health Resources and Services Administration grant T32HP30037 through the Quality, Safety, and Comparative Effectiveness Research Training (QSCERT) Program. Dr. Hood-Medland was also supported by National Institutes of Health grant UL1TR001860. Dr. White was also supported by Agency for Healthcare Research and Quality grant T32HS022236. Views expressed in this manuscript are solely those of the authors. Funders had no input into the preparation or approval of this manuscript.

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Contributions

EAHM, AECW, RLK, and SGH contributed to the research design, to the analysis of the results, and to the writing of the manuscript. SGH collected these data. EAHM and AECW coded the visits. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Anne E. C. White.

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Ethics approval and consent to participate

Written consent for participation was obtained from all participants. The University of California Davis Institutional Review Board approved the study.

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Not applicable as no personal information is provided in the manuscript.

Competing interests

The authors have no competing interest for disclosure.

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Prior Presentations:

International Conference on Communication in Healthcare

October 28, 2019

San Diego, CA

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Hood-Medland, E.A., White, A.E.C., Kravitz, R.L. et al. Agenda setting and visit openings in primary care visits involving patients taking opioids for chronic pain. BMC Fam Pract 22, 4 (2021). https://doi.org/10.1186/s12875-020-01317-4

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Keywords

  • Primary care
  • Chronic pain
  • Opioid analgesics
  • Physician-patient communication
  • Agenda setting
  • Conversation analysis
  • Mixed-methods