Agenda setting in psychiatric consultations: an exploratory study.

Patient-centeredness has been recognized as a critical component of quality in primary health care (Mead & Bower, 2000) but is only recently beginning to be recognized and studied in mental health care, which has not kept pace with the broader medical field’s focus on partnership (Adams & Drake, 2006). Such an approach, in which consumers become active participants in their own care, is essential to facilitating recovery for persons with severe mental illness (Karnieli-Miller & Salyers, 2010; Torrey & Drake, 2010). The term “patient-centered care” was first introduced by Levenstein, McCracken, McWhinney, Stewart, and Brown (1986) in a family medicine context and built on the conceptual framework of Engel’s (1977) biopsychosocial model. In the context of mental health services, the equivalent terminology for patient-centered care is consumer-directed or consumer-centered care, which we use hereafter in this paper. Consumer-centered care takes into account individual consumers’ social and psychological needs, regards consumers as unique individuals who assign personal meaning to their illness(es), and fosters the concept of shared power and responsibility between health care providers and consumers (Mead & Bower, 2000). One area of consumer-centered care that has received a good deal of attention is shared decision making (SDM). The literature on SDM focuses almost exclusively on decisions about treatment options and the extent to which patients are aware and can make informed treatment choices (Joosten et al., 2008; Charles, Gafni, & Whelan, 1997). Far less attention has been paid to other opportunities for being consumer-centered. One such opportunity is the first few moments of a medical or psychiatric visit in which consumers and providers collaboratively discuss the topics or agenda to be covered. These early agenda setting decisions set the stage for what is to come in the visit and can affect the course, direction, and quality of care, including treatment decisions. The opening moments of many types of social interactions are important. For example, Malcolm Gladwell in his book, Blink (2005), asserts that on the basis of the first 30 seconds of a casual social interaction, raters can predict a variety of outcomes, for example, teaching effectiveness (Ambady & Rosenthal, 1993). Clinical interactions are no different. In studies of non-verbal behavior, researchers have found that the tone of voice used by a clinician early in the visit predicts satisfaction and follow up to treatment recommendations (Milmoe, Rosenthal, Blane, Chafetz, & Wolf, 1967; Roter, Hall, Blanch-Hartigan, Larson, & Frankel, 2011). Likewise, using “thin slice analysis,” a technique for sampling discourse at fixed intervals (typically every 20–30 seconds), researchers have been able to correctly identify physicians who have, and have not, been sued for medical malpractice (Ambady et al., 2002). Agenda setting can take a variety of forms. For example, physicians can “control” the agenda by asserting what topics will be covered without soliciting input from the patient. Conversely, consumers can sometimes control the agenda by stating the topic(s) they want to cover at the outset of the visit. A consumer who does not wait for a greeting or solicitation of a “reason for the visit” from the physician but launches into the main concern is an example of a consumer-controlled approach to setting the agenda. Finally, agendas can be set collaboratively with each party contributing ideas about what is important to cover in the visit and negotiating whether and when these ideas will be discussed. This style of agenda setting comes closest to being consumer-centered because it is based on shared power and control (Mead & Bower, 2000). Evidence suggests that collaboratively setting an agenda at the beginning of a clinic visit increases consumer-centeredness in a number of ways. Consumer (and physician) satisfaction increase (Roter et al., 1997; Williams, Weinman, & Dale, 1998), there is less premature hypothesis testing on the part of the physician (Beckman & Frankel, 1984), consumers feel empowered, and the approach yields more information from which physicians can make appropriate diagnosis and treatment recommendations. In addition, early agenda setting results in fewer “hidden” concerns at the end of the visit, resulting in a more efficient overall visit (Beckman, Frankel, & Darnley, 1985). Finally, agenda setting at the beginning of the visit has been associated with clinical outcomes such as the resolution of chronic headache at one year follow up (The Headache Study Group of the University of Western Ontario, 1986). Despite the documented benefits of increasing consumer-centered care, agenda setting may be challenging to accomplish in a busy clinical environment where time and throughput are paramount. In particular, issues of time and communication constraints have been highlighted in psychiatric care (Torrey & Drake, 2010). Time pressures may lead physicians to assert control over the visit in the belief that this is the most efficient way to “get the work done.” Likewise, being busy may lead physicians to forego checking for patient comprehension of recommended treatments and other decisions made during the visit (Braddock, Edwards, Hasenberg, Laidley, & Levinson, 1999). In primary care, evidence of physicians’ exerting early control over the visit agenda comes from studies indicating that physicians interrupt patients within 18–23 seconds of their opening statement in response to a solicitation of agenda items (Beckman & Frankel, 1984; Marvel, Epstein, Flowers, & Beckman, 1999). This research has also documented a statistically significant relationship between early interruption and “late breaking” concerns that are raised at the very end of the visit (Beckman et al., 1985). Although agenda setting has been explored in primary healthcare (Mauksch, Hillenburg, & Robins, 2001; Brock et al., 2011), little attention has been devoted to this practice in mental health care. In pediatrics and geriatrics, where patients may not be able to speak for themselves or have cognitive impairments, the evidence suggests that greater inclusion of the patient in communication/interaction (both verbal and non-verbal), is associated with more positive outcomes (Greene, Majerovitz, Adelman & Rizzo, 1994; Pantell, Stewart, Dias, Wells & Ross, 1982). Given the widespread acceptance of a recovery-oriented model for persons with severe mental illness, some of whom may have cognitive impairment or difficulty articulating their concerns, one would expect to find many of the elements of agenda setting present in visits between health care providers and consumers with severe mental illness. The purpose of the current study was to examine the extent and quality of agenda setting in a sample of mental health consultations.