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Unsaid but Not Forgotten
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.
ABSTRACT
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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.
INTRODUCTION
PHYSICIANS and their patients are gradually moving away from a paternalistic
model of medicine1 to embrace a shared decision-making
approach.2 Collaborative decision making requires
openness, mutual information sharing, and clinical negotiation.3
Understanding patients' expectations and responding appropriately are fundamental
goals of clinical practice4 that can promote
patient satisfaction, encourage adherence to treatment plans, and deter malpractice
suits.5 Research shows that physicians' actions
are influenced considerably by their perceptions of patient preferences.6
Given that physicians' wield almost exclusive control over the order
sheet and prescription pad, the primary means by which patients exert influence
in the medical partnership is through requests for information and action.7 The questions patients ask and the resources they
solicit can reveal much about their psychological states, health-related perceptions,
treatment expectations, and life circumstances.7-8
Request fulfillment can increase patient satisfaction,7, 9
foster perceptions of physician attentiveness and communication competence,9 and may even enhance adherence and outcomes (R.L.K.,
R.A.B., R.A., E.K., D.T., and Steven Kelly-Reif, MD, unpublished data, 1999).9 In particular, patient requests are an integral part
of clinical negotiations, which can resolve differing views of the patient's
situation,10 lead to a mutually acceptable
treatment plan, and promote patient satisfaction.11
To date, far more attention has been given to what patients say during
clinical encounters (communication behaviors) than to what they do not say
(unexpressed desires).12-13 A
patient desiring action from the physician may remain silent for many reasons.
Desires might not be articulated owing to the sensitivity of the topic, beliefs
about what constitutes appropriate patient behavior, a poor relationship with
the physician, cultural gaps,14 time constraints
in the visit, or the physician's practice style. Whatever the reason, the
unvoiced need is not likely to be met, potentially resulting in poorer health
outcomes.12 Soliciting the patient's goals
and desires is deservedly recognized as a fundamental physician skill15 that can be taught,16
but it is a skill that is poorly demonstrated in many medical interviews.17-18
The concepts "agenda," "desire," and "request" are not synonymous. The patient's agenda is his or her goal (eg, "I want to determine
if I have a ruptured lumbar disk"), whereas a desire
is a means for satisfying that goal (eg, "I want my doctor to order a magnetic
resonance imaging"). Agendas are typically formulated prior to a visit, whereas
a desire can be held before or emerge over the course of the visit. A desire
becomes a request when it is verbalized to the physician.
Elsewhere we have examined requests and their fulfillment (R.L.K., R.A.B.,
R.A., E.K., D.T., and Steven Kelly-Reif, MD, unpublished data, 1999).7-8 We extend this line of work by focusing
on unspoken desires–requests that are never verbalized. Four issues
are addressed. First, we quantify the extent to which patients leave their
outpatient visits having remained silent about their wishes for medical information,
tests, referrals, and other kinds of physician action. Second, we identify
patient, physician, and practice factors associated with unvoiced desires
for care. Third, we investigate the effects of unexpressed desires on patients'
and physicians' evaluations of the office visit. Fourth, we examine the association
of patients' unvoiced desires with health outcomes and subsequent health care
utilization. To assess the generalizeability of our conclusions, we address
these issues in both primary care and specialty settings.
PATIENTS AND METHODS
This study is a component of the Physician Patient Communication Project,
a large-scale investigation carried out in Sacramento (California) County's
2 largest health care systems, the University of California, Davis, Medical
Group (UCDMG) and Kaiser-Permanente. The University of California, Davis,
Medical Group is a multispecialty group practice with explicit utilization
review where physicians are compensated according to a Resource-Based Relative
Value Scale (discounted fee-for-service) and specialists are salaried. Physicians
at Kaiser-Permanente, a group model health maintenance organization, are salaried,
with limited bonuses earned by those who meet utilization, quality, and patient
satisfaction targets. The study was reviewed and approved by the University
of California, Davis, Human Subjects Review Committee.
PHYSICIAN RECRUITMENT
Physicians were invited to participate in the study if they were practicing
family medicine, internal medicine, or cardiology and if they were providing
direct patient care at least 20 hours per week. At UCDMG, the group's associate
medical director identified suitable practice sites and helped to recruit
several physicians from each site. At Kaiser-Permanente, potentially eligible
physicians were recruited by mail and through interpersonal contact. Efforts
were made to balance the cohort for sex, ethnicity, and physician experience.
PATIENT RECRUITMENT
English-speaking patients 18 years or older were sampled from among
patients scheduled to see a participating physician during screening periods
held from February 1, 1999, through November 22, 1999. A sampling frame of
potentially eligible patients was created from appointment lists obtained
1 to 2 days prior to the visit and then randomly sampled until daily quotas
were met. Patients were eligible for study if they could complete a written
questionnaire with minimal assistance and if they were willing to provide
written informed consent. In an effort to focus on problem-based visits, we
also imposed the eligibility requirement that a patient needed to report a
new or worsening problem or be concerned about having a serious disease (79%
were enrolled in the study because of a new or worsening health condition).
Of 2606 patients contacted by telephone during the enrollment period,
737 were ineligible, usually because they neither had a new or worsening condition
nor were worried about having a serious undiagnosed condition. An additional
677 declined to participate, most often before their eligibility could be
ascertained. In total, 80.4% of patients known to be eligible agreed by telephone
to participate and 84.5% (n = 909) of these completed patient questionnaires
at the index visit. We were able to administer by telephone 2-week follow-up
questionnaires to 97.6% (n = 887) of the patients who completed index visit
questionnaires.
DATA COLLECTION
Data were collected from patients at 4 time points. Participating patients
completed a brief telephone screening questionnaire administered 1 to 2 days
prior to the index visit, a self-administered questionnaire immediately before
the index visit, a self-administered questionnaire immediately after the visit,
and a telephone follow-up questionnaire approximately 2 weeks after the index
visit. For 99.3% of the patients, physicians completed postvisit encounter
forms that included questions on visit type, chronic conditions, treatments,
patient behavior, and visit demandingness and satisfaction.
MEASURES: PATIENT QUESTIONNAIRES
Unspoken Desires
Patients indicated in the immediate postvisit questionnaire if they
had asked their physician for medical information, a physical examination,
a diagnostic test or procedure, new medications, a specialist referral, physical
therapy or medical equipment, assistance with paperwork, or any other form
of resource or help. Patients who did not voice a particular type of request
were asked if such a request was one that they wanted to make, but did not.
Their responses to these questions were analyzed separately, but also summed
to create an unexpressed desires index (potential range, 0-8).
Patient Evaluations
Immediately after the index visit and at the 2-week follow-up, patients
rated their satisfaction with the care they received on a widely used instrument
composed of five 5-point agreement scales.19
These items were averaged to create a satisfaction with care score (
= .8820 on both occasions; range, 1-5 [least
to greatest satisfaction, respectively]). Endorsement of the physician was
measured after the index visit and at the follow-up visit by averaging responses
on three 5-point agreement scales that addressed the patients' willingness
to make a special effort to see the index physician again, their eagerness
to recommend the physician to a friend, and their intention to follow the
physician's advice ( = .90 and .89 after the index visit and at the
follow-up visit, respectively; range, 1-5 [least to strongest endorsement,
respectively]). At the follow-up visit, patients also reported via single
5-item agreement scales the extent to which their physician made them feel
well taken care of and did everything possible on their behalf (range for
both items, 1-5 [least to most positive evaluation, respectively]).
Health Care Utilization
At the 2-week follow-up, postvisit use of health care was assessed in
2 ways. First, patients indicated (yes/no-question format) if they had gone
to an emergency department, had been an overnight hospital patient, made contact
by telephone or in person with the index physician, or had any contacts with
another physician concerning the index visit problem since the visit. Their
responses were used to create a health system contacts index that reflected
the number of affirmative responses to these questions (range, 0-4 [4 = high
usage]). Second, patients who reported that they had postvisit contact with
the index physician were asked in a subsequent series of questions if they
had requested further medical information, tests, or procedures; specialist
referrals; physical therapy or medical equipment; new medications; or assistance
with paperwork. Responses to these questions were used to create a postvisit
requests index, which was the number of yes responses to these queries (range,
0-6 [6 = high usage]).
Health Concerns, Status, and Outcomes
Patients' health concerns were measured by averaging responses on three
5-point items that asked about symptom bothersomeness, health worries, and
concerns about having a serious condition not yet diagnosed. These items were
administered immediately after the index visit ( = .68) and at the
2-week follow-up visit ( = .72) (range, 1-5 [5 = greatest concern]).
At the 2-week follow-up visit, patients also made a direct rating of symptom
improvement on a single 5-point scale (1 = much worse; 5 = much better). Physical
functioning, role–physical functioning, and general health perceptions
were assessed with instruments taken from the Medical Outcomes Study Short
Form-36 survey21; the first 2 of these were
also assessed at the 2-week follow-up visit. These measures were scored such
that higher scores indicate better functioning and more positive self-evaluations
of general health (range, 0-100). The reliabilities exceeded .93 for
the physical functioning measure, .86 for the role–physical functioning
instrument, and .81 for the general health perception instrument.
PHYSICIANS' POSTVISIT EVALUATIONS
Following each visit, the physician rated on 2 single-item 5-point scales
their impressions of how demanding the visit was for the amount of effort
required and how satisfying it was in comparison with the typical visit (range,
1-5 [5 = far more demanding or satisfying than typical]).
CONTROL VARIABLES
We also assessed 3 other variables for statistical control. Previsit
trust in the physician seen during the index visit, used as a proxy for the
quality of the prior relationship, was assessed by averaging responses on
9 items developed for this study. This instrument was developed based on results
from previous patient focus groups and piloted for clarity and acceptability
prior to being used in the current study. The wording of some of the items
was patterned after items appearing in 2 published instruments.22-23
These items asked patients to judge their level of trust in their physician's
honesty, competency, and agency (the extent to which the physician acts in
their interests at all times) on 5-point response scales, where 5 indicates
complete trust ( reliability = .90).24
Because trust could not be assessed for those 195 patients (21.5% of the sample)
who had no prior experience with the index physician, we created a 4-category
trust variable that classified patients into low, moderate, or high (relative)
trust groups of nearly equal size or into a fourth category labeled "no prior
relationship." These 4 categories were represented as 3 dummy-coded covariates
in our analyses. Visit length was estimated in minutes after the outpatient
visit by physicians; such estimates have been found in our data to be highly
correlated with actual visit length.8 Number
of requests made by patients was also controlled for on the assumption that
the patient with a long list of expectations might have less of an opportunity
to verbalize 1 or more of those expectations. This variable was assessed by
asking patients after the outpatient visit to report within 8 categories of
resources those for which a request had been made (eg, medical information,
referrals, tests or procedures, and others).
STATISTICAL ANALYSES
Basic descriptive statistics were used to describe the sample. Primary
analyses were corrected for the clustering of patients within physicians using
the Stata 6.0 svytab, svylogit, svymean, and svyreg (Stata Statistical Software:
Release 6.0; Stata Corp, College Station, Tex) procedures for complex surveys.
In these analyses, the physician was identified as the cluster (primary sampling
unit) and a 6-level stratification variable was created by crossing specialization
(internal medicine, family practice, and cardiology) with site (UCDMG or Kaiser-Permanente).
Probability weights were assigned to the patients in a cluster to account
for differences among physicians in the number of patients enrolled in the
study from their practice and the number of patients they see regularly. Specifically,
a weight was assigned to each patient within a cluster (ie, physician practice)
by (1) multiplying for each physician the number of patients seen weekly on
an outpatient basis by sample size and (2) dividing this value by the product
of the number of patients seen weekly by all physicians in the study and the
number of patients enrolled in the study by the index physician. By so doing,
observations obtained from very busy practices were given greater influence.
Weights produced by this method ranged from 0.18 to 1.90 (mean weight, 1.0).
RESULTS
PHYSICIAN AND PATIENT CHARACTERISTICS
Physicians
A total of 45 physicians were enrolled in the study, 22 from UCDMG (29%
of eligible physicians) and 23 from Kaiser-Permanente (15% of eligible physicians).
Sixteen practiced general or family medicine, 18 general internal medicine,
and 11 cardiology. The mean (SD) age was 44 (8.3) years, 14 (31%) were female,
and 13 (29%) were nonwhite. Participants were affiliated with their current
institution for a mean (SD) of 8.3 (6.3) years, had held their medical degrees
an average (SD) of 17 (9.1) years, and reported spending an average of 39
hours per week in direct patient care; 43 (96%) were board certified. Data
were collected at 6 UCDMG locations and 5 Kaiser-Permanente sites.
Patients
Among 909 patients completing baseline questionnaires, the mean (SD)
age was 57 (15.3) years, 56.1% were female, and 81.0% were white. Seventy-seven
percent reported completing at least some college, and 30.2% had at least
a bachelor's degree. About half (45.3%) were employed at least part-time,
60.4% were married, 19.1% reported annual household incomes of less than $20 000,
and 96.0% had health insurance. Slightly more patients came from Kaiser-Permanente
(51.3%) than from UCDMG (48.7%). Physicians reported that 13.0% of these visits
were for comprehensive evaluation, 71.8% were follow-up visits for a patient
known to the physician, 5.3% were urgent care appointments with a colleague's
patient, and the remaining 9.9% were for other purposes.
Not surprisingly, cardiology and primary care patients differed significantly
in many ways. Cardiology patients tended to be older, on average (64 vs 55
years, P<.001), and were more likely to be male
(57% vs 40%, P<.001), married (71% vs 57%, P<.001), and a member of the lowest household annual
income group of under $20 000 (28% vs 17%, P
= .003). Physicians reported significantly more chronic medical conditions
for cardiology patients than for primary care patients (1.9 vs 1.3 conditions, P<.001) and cardiology patients rated themselves to
be less healthy on all of the Medical Outcomes Study Short Form-36 survey21 measures (all P values <.001).
Cardiology visits were longer than primary care visits by about 3 minutes
(20 vs 17 minutes, P<.001) and were rated by physicians
as being more effortful (P = .02). These 2 groups
did not differ on the patient and physician visit satisfaction measures, but
cardiology patients did rate their physicians more positively on the endorsement
and trust measures (both P values <.001).
PREVALENCE OF UNEXPRESSED DESIRES
We initially examined the prevalence with which patients reported unspoken
desires for each of the 8 prespecified categories. The top data series in Figure 1 shows the percentage of all patients
who reported at least 1 unvoiced desire for that category. Patients were most
likely to report an unvoiced desire for a specialist referral (3.4% of patients)
and least likely to report an unvoiced desire for paperwork assistance (0.2%).
The bottom data series in Figure 1
shows the percentage of patients who desired a particular resource but did
not request it. (For example, among just those 317 patients who said they
were interested in getting a test or procedure, 95.6% mentioned it to their
physicians and 4.4% remained silent.) Desires for referrals and for physical
therapy or medical equipment were least likely to be conveyed to the physician
(16.5% and 8.2% of desiring patients, respectively). In contrast, a desire
for medical information was seldom left unsaid (2.7%).
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Prevalence of unvoiced desires. The top data series shows the percentage
with an unvoiced desire for each of 8 types of resources for all patients.
The bottom data series shows the percentage for just those patients who desired
each of these resources but who did not request it. Entries have been sorted
by prevalence.
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A total of 91.1% of the patients reported no unvoiced desire, 6.8% reported
1 unvoiced desire, 0.7% reported 2 unvoiced desires, and 1.4% reported 3 or
more unvoiced desires. Given the skewed nature of this distribution, we created
a dichotomous variable for subsequent analyses by classifying patients into
1 of 2 groups: those who reported no unvoiced desires (91.1%, coded as 0)
and those who reported at least 1 unvoiced desire (8.9%, coded as 1).
CHARACTERISTICS OF PATIENTS WITH UNVOICED DESIRES
Patient, physician, and practice behaviors associated with unvoiced
desires were initially examined in a series of univariate analyses using the
Stata svytab (cross-tabulation) procedure. After weighting and correction
for design effects, 4 patient characteristics were found to be associated
with the tendency to leave wishes unvoiced: younger age, female sex, nonwhite
ethnicity, and being unmarried. In addition, patients with lower trust in
the treating physician were more likely to remain silent (Table 1). Unvoiced desires were more common in visits of intermediate
length than in shorter and longer visits, but this effect failed to reach
significance (P<.06). We anticipated that patients
with long agendas would be more likely to leave a request unvoiced owing to
the time constraints of the visit. In fact, those patients with 1 or more
unvoiced requests did not differ significantly from patients with no unvoiced
requests on the number of requests made of their physicians (1.56 vs 1.50
requests, P = .18).
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Table 1. Patient, Physician, and System Characteristics Associated
With Estimated Prevalence of Having 1 or More Unvoiced Desire for Information
or Physician Action*
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The svylogit multivariate procedure was used to assess the independent
effects of these variables. Unspoken desires were more common among patients
who were younger, less educated (high school education or less), unmarried,
and less trusting of the treating physician (all P
values <.04). The difference in prevalence found in the univariate analyses
for patient sex and race were not identified when covariates were considered.
Other analyses, not reported, found no effect on unvoiced desires of patient-physician
congruence on age, sex, or ethnicity.
PATIENTS' AND PHYSICIANS' VISIT EVALUATIONS
Patients' postvisit evaluations of their encounters were examined by
comparing the group of patients with no unexpressed desires to those patients
with at least 1 unexpressed desire, after correcting for design effects and
adjusting means for patient age, sex, race, previsit general health perceptions,
prior relationship quality, and the number of self-reported requests (Table 2). After adjusting for these variables,
we found that patients with unvoiced desires were less satisfied with the
care they received when assessed immediately after the index visit and less
likely to endorse their physicians; these effects persisted for the duration
of the 2-week follow-up period. In addition, 2 weeks after the index visit,
those with an unvoiced desire felt less well taken care of and were less likely
to feel that their physician did everything possible for them. With regard
to physicians' ratings, visits in which patients reported 1 or more unvoiced
desires were judged to be significantly more demanding (Table 2). No significant effect was found for physicians' visit
satisfaction.
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Table 2. Patient and Physician Visit Evaluations*
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The possibility that these results might vary as a function of physician
specialty was examined. For the endorsement measure at follow-up and physicians'
ratings of visit demandingness measure, significant effects (P<.05 criterion) were found for at least 1 of the 2 dummy variables
created to represent the interaction between the unvoiced desires grouping
variable and the 3-level specialty categorical variable. Subsequent analyses
revealed that the difference between patients with voiced and unvoiced desires
on the endorsement measure at follow-up was substantially greater in family
practice settings (r = -0.64, P<.001) than in internal medicine (r = -0.20, P = .25) and cardiology settings (r
= 0.01, P = .97). As for the demandingness measure,
the effect of unvoiced desires on physicians' ratings of the effort required
of them was greater for cardiologists (r = 0.60, P = .02) than for internal medicine (r = 0.31, P = .06) and family practice physicians
(r = 0.20, P = .18).
HEALTH CARE UTILIZATION AND CLINICAL OUTCOMES
The effect of having unvoiced desires on postvisit health use and clinical
outcomes was examined, again correcting for design effects. In these analyses,
utilization and outcome measures were adjusted for patient age, sex, race,
previsit general health perceptions, prior relationship quality, visit length,
and the number of requests. Analyses of health concerns, physical functioning,
and role–physical functioning measures were further adjusted for their
baseline values. The only significant effect was obtained for patients' direct
rating of symptom improvement at follow-up. Patients with an unvoiced desire
reported the least amount of symptom improvement (3.4 vs 3.8 on a 5-point
scale, P = .02). They also reported more health concerns,
lower physical functioning, and more physical limitations (ie, worse role–physical
functioning measure), but these effects failed to reach significance. There
was no evidence that these results varied as a function of physician specialty.
COMMENT
In this sample, fewer than 1 in 10 patients reported that there was
something they wanted to ask of their physicians but did not. It would seems
as if unvoiced requests are less common than hidden agendas, which have been
estimated to be present in perhaps 30% to 50% of the visits.13
Our finding is not necessarily at odds with this estimate because patients
can ask for all that they desire while remaining mute on their goals for the
visit. The prevalence of unvoiced desires differed dramatically as a function
of the nature of the resource requested. For instance, patients almost always
asked for the medical information they wanted, but were more hesitant to ask
the physician for referrals and for physical therapy or medical equipment.
Patients may appropriately assume that it is the physician's responsibility
to answer their questions. A desire for a referral, however, might be kept
private owing to a fear that it would be construed by the physician as a challenge
to his or her medical competence. Alternatively, the high incidence of unvoiced
desires for specialty care may reflect patients' awareness of the role of
managed care in the referral process. For whatever reasons, research has shown
that desires for specialty care often remain unexpressed by patients and unrecognized
by physicians.25
The multivariate analyses suggest that trust, a key component of which
is clear and complete communication,24 may
encourage patients to present their desires to physicians. Conversely, individuals
with a high school education or less were more likely to report unspoken desires.
This effect may be owing to less awareness among these patients about alternative
treatment options. Desires were also much more likely to remain unspoken by
unmarried individuals and by the youngest patient group (aged, 18-29 years).
We speculate that unmarried patients may be less likely to be accompanied
by family or friends who could serve as intermediaries, encouraging the patient
to voice concerns and requests. The finding for age could possibly reflect
greater intimidation among younger patients. Unfortunately, we do not have
the data to test these possibilities. The univariate analyses suggested that
female and minority patients were more likely to remain silent about their
desires, but this effect did not hold up when covariates were considered.
This study evidences the importance of encouraging patients to communicate
fully to physicians the information and interventions they hope to receive.
Unvoiced desires represent just one aspect of patients' evaluations of their
medical encounters, but an important one. Patients who withheld requests were
less satisfied with their care and their physician. These negative feelings
were persistent enough to be detected 2 weeks after the visit. While it is
true that some patients with unvoiced requests had less positive and possibly
less established relationships with their physicians to begin with, the effects
on patient evaluations of these unspoken requests held even when controlling
for baseline relationship quality and other factors.
The visits in which patients failed to convey their wishes were judged
by physicians to require more effort than the typical visit. This result may
seem ironic since the unspoken request is presumably unknown to the physician.
It is possible that the physician in such visits sensed that these patients
were "holding back" and felt frustrated as a result. Alternatively, unspoken
requests may be an indicator of unresolved tensions that make for a more challenging
consultation.
It makes intuitive sense that unvoiced desires compromise health care
quality by forcing the physician to treat a patient whose issues have not
been fully communicated,13 but this study provides
no compelling support for this hypothesis. For instance, we found no evidence
that unvoiced desires led to poorer treatment, resulting in greater health
care use after the index visit. Perhaps one should not be surprised to find
that patients who felt unable to express their desires at the index visit
did not seek care later from these same physicians. However, there was no
indication of postvisit contacts with sources of care other than the index
physician. There was also no evidence that unvoiced requests were simply expressed
later in postvisit contacts with the index physicians and their staffs.
In contrast, patients' reports of their health concerns and health status
were consistently more positive at follow-up for those patients who let the
treating physician know of their expectations for his or her behavior. The
only significant effect, however, was for patients' perceptions of symptom
improvement. It would appear that when patients keep their desires to themselves,
perceptions of quality of care are affected more than the care itself. One
possibility is that patients prioritize their requests, leaving to themselves
those that are less critical and less likely to be informative for the physician.
This study is not without limitations. It is possible that our sample
statistics do not represent the true incidence of unvoiced desires in the
patient population. First, by drawing patients from a health maintenance organization
and medical group, we recruited a sample of largely insured patients. These
individuals may feel comfortable asking for anything they think they might
need because they would not have to shoulder much of the financial burden
if these requests were fulfilled. Second, our eligibility requirement specified
that only those patients with a medical condition or health-related anxiety
could be enrolled in the study. These patients may have been especially motivated
to get to the bottom of their problem, leading to fewer unarticulated desires
for information and treatment. Conversely, by requiring that a patient have
a new or worsening condition to be eligible, our sample may overrepresent
patients with chronic conditions. It is unknown if such patients are more
or less likely to have unvoiced desires.
An additional limitation is that the prevalence of unvoiced desires
we report may reflect biases in our methods and sampling. For instance, some
patients may be hesitant to report that they did not "stand up for themselves"
by communicating their expectations to the physician owing to impression management
concerns. However, it is possible that patients "invent" unvoiced desires
in response to the questionnaire. Finally, our sample comes from a single
geographic region and a managed care market that may not represent the nation
as a whole.
Research on physician-patient interaction has focused extensively on
patterns of verbal and nonverbal behaviors exhibited in clinical encounters.
This study highlights the need for investigators of physician-patient communication
to give attention to both what is said by patients and what remains unspoken.
For practitioners, these findings suggest that a consideration of their relationship
with a particular patient is key in promoting patient openness about their
perceived needs. Silence is not always golden; what is left unsaid is not
necessarily forgotten by the patient.
AUTHOR INFORMATION
Accepted for publication January 9, 2001.
This investigation was supported in part by grant 03484 from the Robert
Wood Johnson Foundation, East Princeton, NJ (Dr Kravitz).
We gratefully acknowledge the assistance of the 45 participating physicians
and their patients. Thanks are also owed to Sara Lu Vorhes, Steven Kelly-Reif,
MD, and David Ormerod, MD, for assistance with physician recruitment and data
collection; to Christine Harlan for budgetary management; and to the staff
of the Patient-Provider Relationship Initiative (Bernard Lo, MD, director)
for technical assistance. Appreciation is also expressed to 3 anonymous reviewers
of this journal for their outstanding critiques.
Reprints: Robert A. Bell, PhD, Department of Communication, University
of California, Davis, Davis, CA 95616 (e-mail: rabell{at}ucdavis.edu).
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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