Opinions Wanted: How Do You Prioritize Your Patient’s Concerns?

Okay reader(s) out there, send in your best approach to this dilemma: You’re meeting a new patient for a physical. He also wants to address the following laundry list of concerns: heart palpitations, a mysterious migratory rash, nocturia for the past five years, a family history of prostate cancer, and toenail fungus. How do you prioritize these concerns? How do you (politely) explain that you only have a certain amount of time to address his concerns? Do you inform him that a physical exam appointment is an opportunity to focus on preventive health but doesn’t usually leave enough time for every concern and ailment?

I’ve been struggling with this issue lately. I’m trying to build up my practice and therefore am seeing a lot of new patients. I also know that word of mouth is important to my success, so I don’t want to be too rigid in approaching my patients. However, after spending a couple of nights finishing charts well into the time I should already be home, I need a new approach. Two recent examples come to mind.

The first is a patient who came in for a pre-operative exam. Since he has significant co-morbidities, it was not a clear-cut pre-op clearance. He also wanted to address an acute shoulder injury. I finished the pre-op exam and told him that I didn’t have time to address his shoulder pain as another patient was waiting for me, but since my next patient was my last patient of the day, I would be willing to return to the exam room if he was willing to wait. He was, and I extended my day, my medical assistant’s day, and the X-ray technician’s day in order to address this concern.

The second patient was a new patient who came in for a 20-minute evaluation of allergy symptoms that actually was a much more complex respiratory issue. Additionally, she was having episodes of a shooting sensation going down her left leg. When I tried to defer this issue to the next appointment, she angrily declared that the only reason she made the appointment was because she was worried about her leg. I offered to finish up with my next patient and then come back in the exam room during my lunch hour to evaluate her additional concern.

Both patients appreciated my limited amount of time and were willing to wait. But, somehow, this still doesn’t satisfy. I feel at some point, I should be able to declare the visit complete and ask them to make another appointment to address other issues. In the era of co-pays and packed schedules, I think a lot of patients just do not want to go through the bother of scheduling another appointment and try to pack in every concern they’ve had into the visit.

I’ve tried having patients complete a list in the waiting room of all the things they want to discuss. This worked pretty well, as I could quickly just glance at the list - if it had one line filled out, I could take my time. If the list continued onto the back of the paper, I knew that agenda-setting was the first priority. I’ve tried to rephrase my standard closer from “is there anything else” to “is there something else” after reading that this approach resulted in fewer “oh, by the ways.” Things that haven’t worked include standing up, walking to the door, or reaching for the doorknob. These actions seem to only put more pressure on the patient to cram in as many final concerns as possible.

I’m open to other suggestions…

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