Medical students' agenda-setting abilities during medical interviews.

PURPOSE: Identifying patients' agendas is important; however, the extent of Korean medical students' agenda-setting abilities is unknown. The study aim was to investigate the patterns of Korean medical students' agenda solicitation.
METHODS: A total of 94 third-year medical students participated. One scenario involving a female patient with abdominal pain was created. Students were video-recorded as they interviewed the patient. To analyze whether students identify patients' reasons for visiting, a checklist was developed based on a modified version of the Calgary-Cambridge Guide to the Medical Interview: Communication Process checklist. The duration of the patient's initial statement of concerns was measured in seconds. The total number of patient concerns expressed before interruption and the types of interruption effected by the medical students were determined.
RESULTS: The medical students did not explore the patients' concerns and did not negotiate an agenda. Interruption of the patient's opening statement occurred in 4.62±2.20 seconds. The most common type of initial interruption was a recompleter (79.8%). Closed-ended questions were the most common question type in the second and third interruptions.
CONCLUSION: Agenda setting should be emphasized in the communication skills curriculum of medical students. The Korean Clinical Skills Exam must assess medical students' ability to set an agenda.

INTRODUCTION

Agenda setting can be defined as the reaching of a mutual agreement by a patient and doctor regarding what to discuss during the consultation. Upfront agenda setting is one of the most important factors in the effective management of clinical encounters [1]. Doctors are required to listen attentively, survey all the patient’s concerns, and negotiate an agenda in order to enable the identification of reasons for the patient’s visit to the doctor [2]. Setting an agenda while applying attentive listening may decrease concerns that could emerge later, ensure efficient time management, and minimize the risks of important problems being missed [1,3]. Agenda setting should be performed before focusing on a specific agenda [4].

The listening skills that should be used in the initial stages of a consultation differ significantly from those used to gather information. When taking patient history, facilitation using repetition (repeating the patient’s sentence), paraphrasing (expressing the patient’s statements in a different way), and interpretation (presenting the meaning of what the patient is saying) constitute effective listening skills [2]. In contrast, when setting an agenda, those techniques, as well as closed questions, non-interrogative verbal responses, and comments aimed at encouraging a patient to speak about a certain topic, constitute interruption when patients are stating their concerns [4].

Generally, patients have between one and six concerns per visit [1,5], and the first stated concern is not always the patient’s principal concern [6]. Patients primarily complete their statements of concern within 60 seconds [4]; therefore, during the initial phase of the interview, which typically takes 1 minute, it is recommended that the doctor postpone diagnostic questioning in favor of questions that facilitate open-ended responses and repeated prompts to assist the patient in identifying more concerns [1,7].

However, incomplete interviews are common in the medical field [6]. Patients finish their initial opening statement of concern in only 23% to 28% of medical visits [3,4]. The mean time within which doctors allow patients to complete their opening statements is approximately 18 to 23 seconds. The most common obstacles to statement completion include closed-ended questions, absence of solicitation (i.e., not asking further about patients’ concerns), and the physician’s statements (i.e., physicians’ interruption of patient statements and redirection of patients toward the doctor’s concerns) [3]. Most redirections (54% to 76%) occur after the first concern has been stated [3]. The likelihood of returning to the agenda completion is very low once the focus of the discussion is on a specific concern [3].

Training in communication skills should be persistently implemented from undergraduate and extend throughout the physician’s professional life. To teach agenda setting, educators should know the students’ skill levels (good/poor) across this area of communication. However, few studies have reported medical students’ abilities regarding agenda setting. In addition, previous research has not focused on specific agenda-setting skills in detail. Furthermore, no research has been conducted on either the mean time that medical students allocate to patients to complete their opening statements or the patterns of interruption by medical students in patients’ completion attempts.

Therefore, medical students’ agenda solicitation patterns were investigated using the following research questions: (1) How many medical students explore patient concerns and negotiate an agenda? (2) How long do the students listen attentively at the beginning of the encounter? (3) What type of responses do the students give after the patient’s initial statement of concern?

SUBJECTS AND METHODS

1. Participants

The agenda-setting skills of medical students at Inje University College of Medicine (Korea) were examined during the first college semester in 2012. Ninety-five students in their third year were included. Our medical school has a four-year curriculum for medical degrees. This comprises 2 years of the preclinical course and 2 years of clinical clerkships. A formal communication program for first-year students has been in existence since 2012; this means that the students in this study did not practice communication under a formal course.

Third-year medical students were chosen for two reasons. First, there was concern that final-year students are too familiar with the format of the Clinical Skills Examination in the Korean Medical Licensing Exam. It was assumed that they would be more likely to display only the behaviors that are evaluated in the exam, even though they knew the importance of agenda setting. Second, the ability of first- and second-year students to control the interviews is less likely to be well developed [8]. These students may not have sufficient clinical reasoning ability to see a patient within 15 minutes.

Of the 95 medical students who participated in this investigation, one was omitted from analysis due to a missing file. Therefore, the final sample size was 94, comprising 68 male and 26 female students. The average age was 24.40 years (±2.12). There was no age difference between the male and female groups.

2. Standardized patient case development

The station is a 15-minute interaction with a 32-year-old woman with abdominal pain. The medical students’ task was to build initial rapport, solicit an agenda, take relevant histories, and perform focused physical examinations.

The instruction for students before entering the exam room includes the patient’s age, gender, and vital signs, and for the student to determine whether the patient had visited the emergency room or not. The instruction did not describe the patient’s primary concern. The patient’s initial statement was formulated such that it would take 40 seconds. There were four concerns that were to be presented to the doctor within 40 seconds. The patient’s first concern, presented in 10 seconds, was about dark-colored urine. The second concern was abdominal pain, presented in the next 10 seconds. Two further statements of concern were a headache and a psychosocial concern regarding the stomach cancer that the patient’s mother had.

A family medicine doctor was the primary case writer. He wrote the roles for the standardized patient based on his experiences with common medical complaints. Two communication skills educators and one standardized patient trainer reviewed the script.

Before the video recording, informed consent was obtained from both the medical students and the standardized patients. The medical students were informed that the purpose of the exercise was to assess their communication skills. We obtained approval to undertake this study from the Institutional Review Board Committee of Inje University in Busan, Korea.

3. Data collection and analysis

Medical students were video-recorded while interviewing a standardized patient. The segment of the encounter in the current study focused on the solicitation of the chief complaints and current concerns. The identity of the students and interview order were hidden from raters to prevent the halo effect.

1) Evaluation of the tasks for the initiation of the discussion

The evaluation form was constructed based on the Calgary-Cambridge Guide to the Medical Interview: Communication Process. The focus of the analysis was on the initiation stage of the medical interview, includeing the identification of reasons for consultation. The rating form included three tasks for agenda setting; these tasks were rated as yes (1) or no (0) (Appendix 1). Two experienced standardized patients were trained as raters for 2 hours. The video recordings were independently reviewed and scored using the evaluation checklist. If the two raters disagreed in their judgment of a medical student’s performance, the two communication educators reviewed and scored the interview in order to gain additional insight and clarity.

IBM SPSS Statistics version 19.0 (IBM Corp., Armonk, USA) was used for descriptive statistics; the data are shown as the mean and standard deviation for the sum of all task items, as well as frequencies and percentages for categorical data.

2) Timing and content of the medical students’ redirection to the patient’s initial statement

The duration of the patient’s initial statement without redirection was measured in seconds, starting from the end of the medical student’s soliciting question to the point of redirection. The time was measured by a research assistant and the exact timing was verified by two investigators.

The interviews in which the medical students solicited the patient’s agenda in the initial stage were transcribed. The two investigators reviewed each video recording and transcript of the patient encounter. The total number of patient concerns expressed before interruption was evaluated. The first, second, and third questions posed by the students were coded. The categories and number of questions were coded as closed-ended (e.g., “When do you feel a stomachache?”), elaborating (e.g., “Tell me more about your stomachache”), recompleters (repetition or paraphrasing of what the patient said; e.g. “stomachache”), a statement (e.g., “That sounds serious”), open-ended (e.g., “Tell me more” or “Anything else?”), and others, as used in previous studies [3,4].

RESULTS

1. Tasks for agenda setting

All medical students asked appropriate opening questions to identify the patient’s problems and concerns. However, the students did not screen all of the patient’s concerns or confirm the list of concerns before focusing on a specific concern. In addition, none of the medical students negotiated an agenda with the patient.

2. Timing and content of the medical students’ redirection to the patient’s initial statement

The patient’s 40-second initial statement of their concerns was not completed in any of the interviews conducted by the medical students. These students interrupted the opening statement after 4.62±2.20 seconds. All students interrupted the patient during or after the statement of the first concern (Table 1). Among all of the responses, the two most common interruptions were recompleters and closed-ended questions. Two of the students used more open-ended inquiries to explore a greater number of concerns after the first interruption; however, they used closed questions in response to the patient’s reply.

Table 1.

Types of Medical Students’ Responses to the Patient’s Statement of Concerns

First responses		Second responses		Third responses
Type	No. (%)	Type	No. (%)	Type	No. (%)
Recompleter	75 (79.8)	Closed-ended	56 (59.6)	Closed-ended	54 (57.4)
Closed-ended	47 (62.7)	Statement	18 (19.1)	Recompleter	24 (25.5)
Total	94 (100.0)	Total	94 (100.0)	Total	94 (100.0)

Among the first interruptions, the most frequent barrier to completion was recompleters (79.8%), followed by closed-ended questions (14.9%). Closed-ended questions were in relation to two issues; namely, onset (n=11) and nature (n=3). One response was classified into the “other” category. The response was, “By the way, what is your name and how old are you?”

Among the second interruptions, the most frequent was closed-ended questions (59.6%), followed by statements (19.1%). Among the third interruptions, the most frequent was closed-ended questions (57.4%), followed by recompleters (25.5%).

When a recompleter was used as the first interruption, closed-ended questions (62.7%) were the second response, and recompleters (42.5%) were the third response (Table 2). Moreover, in case of other responses except recompleters as the second, students mostly used closed-ended questions as the third response.

Table 2.

Types of Medical Students’ Second and Third Responses in Case of a Recompleter as a First Question

Second response		Third response
Type	No. (%)	Type	No. (%)
Closed-ended	47 (62.7)	Recompleter	20 (42.5)
		Closed-ended	17 (36.2)
		Statement	8 (17.0)
		Elaborating	2 (4.3)
Statement	16 (21.3)	Closed-ended	14 (87.5)
		Statement	1 (6.3)
		Open-ended inquiry	1 (6.3)
Recompleter	8 (10.7)	Closed-ended	8 (100.0)
Elaborating	3 (4.0)	Closed-ended	2 (66.6)
		Recompleter	1 (33.3)
Open-ended inquiry	1 (1.3)	Closed-ended	1 (100.0)
Total	75 (100.0)

When closed-ended questions were used as the first interruption, recompleters (42.9%) and closed-ended questions (42.9%) were equally used as the second response (Table 3). The most frequently used third response was closed-ended questions.

Table 3.

Types of Medical Students’ Second and Third Responses in Case of a Closed-Ended First Question

Second response		Third response
Type	No. (%)	Type	No. (%)
Recompleter	6 (42.9)	Closed-ended	3 (50.0)
		Statement	2 (33.3)
		Recompleter	1 (16.7)
Closed-ended	6 (42.9)	Closed-ended	3 (50.0)
		Statement	2 (33.3)
		Recompleter	1 (16.7)
Statement	1 (7.1)	Closed-ended	1 (100.0)
Elaborating	1 (7.1)	Closed-ended	1 (100.0)
Total	14 (100.0)

DISCUSSION

The present study demonstrated the limited agenda-setting abilities of medical students in Korea. The students did not explore the patient’s concerns and did not negotiate an agenda. The medical students took specific history from patients’ first concern. In addition, the time taken by the students to listen to the patient’s statement was under 5 seconds. Repetition of the patient’s statement was also predominant in the first response; however, closed-ended questions featured increasingly in the second and third responses.

These findings are similar to those in previous studies [3,4]. However, Korean medical students’ competency in setting an agenda proved lower than that of medical students in other countries, as shown by the research. This finding can be partly attributed to Korean culture and Korea’s medical system.

First, in many traditional medical schools in Korea, the teaching of communication skills remains limited in duration and scope. Educators have recently developed communication education programs [9]; however, these need more time to be more fully established. In addition, some students have exhibited skepticism toward the learning of communication skills [10]. The situation at Inje University College of Medicine is very similar to those in other Korean contexts, as discussed previously. That is, formal communication courses had not yet been established and some students exhibited skepticism toward communication education.

Second, it is common in Korean training hospitals for physicians, including residents, to have under 5 minutes of contact with individual patients. While the fee-forservice system is applied for paid doctors, the fee ceiling is low. Therefore, hospital income depends on the number of patients seen by the hospital’s physicians within a certain period. Poor quality and inefficient communication subsequently occurs between doctors and patients due to physicians being pressed for time. Korean medical students continuously observe short encounters between doctors and patients. Consequently, these students are more likely to allocate short consultation periods to patients and practice time efficiency.

Finally, a well-defined agenda is presented in the Korean National Clinical Skills Exam. In the exam, a standardized patient complains clearly about one major symptom in the initial statement. Students are asked to interview the patient—who has a predetermined primary concern—within a period of 10 minutes. It is the medical student’s responsibility to gather relevant history, examine specific physical signs, and discuss diagnostic and therapeutic plans with the patient. The doctor-patient interaction is assessed, but the items related to the initial stage include only the greeting, introductions, silence, and doctors’ nodding while listening. In the exam, it is assumed that the agenda has already been negotiated; therefore, the medical students are not required to explore and set the agenda. The students might acquire agenda-setting abilities during their clinical clerkships, but these cannot be evaluated in the current clinical skills exam. Consequently, medical students focus on the requirements for the exams, including history taking, which differs significantly from focused history taking [2].

However, any improvement strategies including prolonged training, long consultations and/or non-Korean cultures cannot guarantee good agenda-setting skills. In a Dutch study, the effect of a 4-year teaching program was found to be less relevant to the development of students’ exploration of reasons for the medical encounter [11]. Furthermore, in an Australian study, students displayed limited improvement during their clerkships, as demonstrated by their poor performance in agenda setting [12]. Time pressure, medical difficulties, and physicians’ clinical experience were not the causes of the low frequency of patients’ completion of their opening statements [13]. Although doctor visits lasting under 15 minutes are related to poor quality of communication [14], more time does not ensure better communication between a doctor and a patient [15]. Young doctors cannot spontaneously learn the basic communication skills in daily clinical work, despite their exposure to short postgraduate communication skills courses. Consequently, their deficient communication skills persist into their professional lives [16].

In light of this, how can medical students be encouraged to improve their ability to set agendas? The following four strategies are recommended: highlighting the importance of agenda setting in encounters with patients throughout the curriculum, modification of the instruction format of the clinical skills exam, faculty development, and reform of the Korean healthcare system to be more patient-centered. The emphasis on the importance of agenda setting and the clinical skills exam format is discussed in more detail in the paragraphs below.

First, it is proposed that, over the duration of the curriculum, medical students be trained to identify and negotiate the primary concern at the beginning of the doctor-patient encounter. In order to make differential diagnoses during their clerkships, medical students tend to focus more on medical information [17] rather than on upfront agenda setting. However, the students have little opportunity to obtain feedback on locating patients’ hidden agendas or they overuse inefficient closed-ended questions. Emphasis on agenda setting, with appropriate feedback, is desirable. Furthermore, a doctor’s ability to actively listen optimizes the exploration of reasons as to why a patient visits a doctor. It can be expected that, in a country such as Korea, where indirect communication is a virtue, hidden agendas are more difficult to determine than in countries where direct communication is more common.

It would be beneficial to identify the type of patients who tend not to communicate their agendas easily, or the types of agendas that cannot easily be determined. Younger, uneducated, and unmarried patients have been found to be less likely to trust doctors and express their desires [18]. Typically, patients do not express their concerns, including about possible diagnoses and prognoses, their anxieties about the side effects of treatments and unwanted prescriptions, and information about their social conditions [19]. Therefore, medical students should be trained to explore these issues and listen carefully to patients who cannot express their concerns easily.

Second, changes in the format of the Clinical Skills Exam in the Korean National Licensing Exam should be considered. Medical students’ agenda-setting abilities should be assessed. It is recommended that the exam instructions not indicate the patient’s primary concern. Currently, the instructions on the Medical Council of Canada Qualifying Examination Part II do not present and summarize the patient’s primary concern and agenda [20]. This appears to be a more appropriate method of assessing medical students’ ability to take medical history in the real world.

This study has two key limitations. The first limitation is that the medical students’ abilities were investigated in an exam setting, not in real settings. The second limitation is that only the sentences from the first to the third question were analyzed. That is, analysis was not conducted on the whole conversation; therefore, it is not known whether the medical students ultimately determined the patient’s real agenda.

In conclusion, Korean medical students have limited ability to explore patient concerns and to negotiate agendas during medical interviews. In addition, they interrupt the patient’s first statement in within 5 seconds, primarily using recompleters and closed-ended questions. In order to improve medical students’ ability to set agendas, communication skills focusing on upfront agenda setting, through active listening, should be taught. Moreover, the instruction format of the Clinical Skills Exam in the Korean National Licensing Exam should be changed to avoid explicating the patient’s chief complaint so as to facilitate assessment of agenda-setting ability.

Exploring concerns		Yes	No
1	To screen all of the patient’s concerns	1	0
2	To confirm the list of patient’s concerns	1	0
3	To negotiate an primary agenda before specific history taking	1	0

Timing and contents
4	End time of students’ question inquiring patient’s concern
5	Start time of students’ interruption
6	1st response
7	2nd response
8	3rd response