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Patients' Unvoiced Desires in Office Visits

Robert A. Bell, PhD; Richard L. Kravitz, MD, MSPH; David Thom, MD, PhD; Edward Krupat, PhD; Rahman Azari, PhD

Arch Intern Med. 2001;161:1977-1984.

Objectives  To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests.

Patients and Methods  Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians.

Results  Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use.

Conclusions  Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.

From the Departments of Communication (Dr Bell) and Statistics (Dr Azari), University of California, Davis; University of California, Davis, Center for Health Services Research in Primary Care, University of California, Davis, Medical Center (Drs Kravitz and Azari); Division of Family and Community Medicine, Stanford University Medical School, Stanford, Calif (Dr Thom); and Massachusetts College of Pharmacy and Allied Health Services, Boston (Dr Krupat).

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