This is NOT good news for Patient Engagement

David Newman-Toker toker at JHU.EDU
Fri Aug 3 19:50:50 UTC 2018

I guess I’ll push back a little on this, Mark. I have always been a little concerned that people spontaneously equate “interrupting” with “not listening,” or, worse yet, “not caring.” I can see the logic of these ideas being associated, and I’m sure that some clinicians interrupt their patients thoughtlessly because they have their own agenda and don’t care what the patient is interested in telling them. However, I’m not sure this concept really applies when it comes to good diagnosis. A typical diagnostic encounter in my clinical domain goes something like this…

DNT (asks an open ended question): “So, tell me what happened when you first got your dizziness symptoms?”

Patient: “Well, I was at home this morning. I got dizzy, so my husband called 911. Then the ambulance arrived, and they put me in the back, and then they put in an IV, and gave me some fluids. Then I arrived at the emergency room and Dr. Smith told me I had an ear infection. He gave me a medicine… I can’t remember the name, but I think it started with an ‘M’. Then they admitted me to the hospital because I was too sick to go home….”

DNT (interrupting after ~10-20 seconds of the patient’s story above): “Ok, hold on a minute. Let’s go back a bit to the part where you first got dizzy… Where were you? What were you doing?” … (waits for answers) … “Did you feel unsteady on your feet? How did you get from the hall to the kitchen… Did you crawl? Hold on to the wall?” … (waits for answers)… “Were you sick to your stomach? Did you vomit?” … and so on …

I just think that active listening to the patient’s story means redirecting them to the information that is most pertinent diagnostically… and that often means interrupting frequently with more narrowly-focused or closed-ended questions than the ones you began with. In my view, this is what patients should be looking for in a caring, thoughtful diagnostician. That’s because it is very rare for a (lay) patient to be able to so cogently and concisely tell their illness history that it simply rolls out perfectly over 5-10 minutes while the clinicians politely takes notes for the record in complete silence. I just think there is another side to this issue of “patient engagement” and dialogue.

For what it’s worth, patients can readily tell the difference between someone who interrupts because they want to understand what happened… and someone who interrupts because they don’t care what the patient has to say.


David E. Newman-Toker, MD PhD
Professor of Neurology, Ophthalmology, & Otolaryngology<>
Director, Division of Neuro-Visual & Vestibular Disorders<>
Director, Armstrong Institute Center for Diagnostic Excellence<>
Core Faculty, Brain Injury OutcomeS (BIOS) Clinical Trials Unit<>
President-Elect, Society to Improve Diagnosis in Medicine<>

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From: Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG>
Sent: Friday, August 3, 2018 2:46 PM
Subject: [IMPROVEDX] This is NOT good news for Patient Engagement

There have been earlier studies showing that clinicians tend to interrupt the patient at the start of the encounter.  At a time when patient engagement and partnership are strongly being endorsed, one would have thought we’d be doing better by now.  I guess not !

Here’s a quote from a new study, attached:  “The patient’s agenda was elicited in 36% of the clinical encounters. Among those in which the agenda was elicited, patients were interrupted seven out of ten times, with a median time to interruption of 11 s.”


Mark L Graber, MD FACP
President, SIDM
Senior Fellow, RTI International
Professor Emeritus, Stony Brook University, NY
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