Unmasking the patient's hidden agenda

Ian Gilson, FACP, a primary care internist from a multidisciplinary clinic in Milwaukee, told us about a 44-year-old married professional woman scheduled as his last appointment on a Monday evening. She had a history of asthma and depression, and came in nearly one year after her last appointment because she was running out of her asthma medication and SSRI. The depression was chronic and had been quite well controlled on fluoxetine, a “legacy prescription” given to her years before she came under Dr. Gilson's care.

When Dr. Gilson asked about her depression, the patient curtly said she was “so-so.” He told us that her tone gave a clear message: “Let's move on.” Dr. Gilson then explored how she was coping with her asthma; she said she was doing well on her current medications. He raised again the issue of her single daily cigarette, which was a long-standing topic of conversation.

Normally, the visit would have ended there, with Dr. Gilson renewing her prescriptions and scheduling a follow-up appointment. “But something about that reply of ‘so-so’ bothered me,” he said. Dr. Gilson has a special interest in mental health, and three days before he saw this patient, he had led a focus group on suicide prevention in primary care medicine. “The consequences of severe depression were very much in my mind,” he said.

Retrieving thoughts about a situation based on a recent experience or a dramatic memory is termed an “availability bias.” This shortcut or heuristic likely evolved as a way to adapt successfully to decision making under time pressure and uncertainty. The availability shortcut in thinking can lead us astray, as we have written, but it can also work to our advantage in certain situations.

Dr. Gilson, then, was especially primed to pay particular attention to his patient's mood. She had signaled strongly that she didn't want to discuss her depression further. So he took another approach: He gave her a PHQ-9 form, which has questions that provide insight into the severity of depression and risk of suicide. “I left her alone in the room with the form for a few minutes,” Dr. Gilson said. “When I returned I was surprised to see a high depression score, including anhedonia and self-worth, but I was most alarmed to see her score on question 9, self-harm thinking of suicide more often than not.”

Debra Roter, PhD, a professor of health policy and management at Johns Hopkins University, works with Judith Hall, PhD, a professor of social psychology at Northeastern University. They have analyzed literally thousands of videotapes and live interactions between patients and doctors of many types. Their work provides deep insight into physician-patient communication. They are particularly focused on how a doctor responds to his patient's emotions, and how this response guides the types of questions he asks, and in what tone.

Drs. Roter and Hall conclude that the physician should seek “patient activation and engagement.” As Dr. Roter explained in How Doctors Think, the idea is to make the patient feel free, if not eager, to speak and participate in dialogue. Many patients are gripped by fear and anxiety; some also carry shame about their disease. Dr. Roter emphasized that even if the doctor asks the right questions, “The patient may not be forthcoming because of his emotional state. The goal of a physician is to get the story, and to do so he has to understand patients' emotions” (How Doctors Think, pages 17-18).

Dr. Gilson gave his patient time alone with the PHQ-9 form, which seemed to allow her to focus on her feelings. Her written answer served as an opening to an in-depth discussion that uncovered what was hidden. “She had suicidal ideation for months, imagining asphyxiation or taking a drug overdose. I also learned that she had a history of suicide attempts as an adolescent, and was feeling detached from her husband and her child.”

Dr. Gilson recommended she increase her dose of fluoxetine, which she did, and referred her urgently to a psychiatric nurse practitioner skilled in treating refractory depression. The patient left a message the next day thanking him for the referral.

Dr. Gilson was primed to pay attention to the answer of “so-so” delivered in a tone meant to change the subject. He was able to prompt and encourage this woman to open up to him despite the fear and anxiety that likely inhibited her initially. “It is fortunate that I gave her the PHQ-9 form and paid attention to the result. It was key to probably aborting a potential suicide.”

The timing of the patient's visit was also fortunate. “Had I been running behind, as I so often am, and had she not been one of the last patients in the evening, I may well have skipped it and missed a crucial diagnosis.” We have written before about how time pressure increasingly affects how we all deliver care.

It is not only psychiatric symptoms that patients may be reluctant to discuss due to fear and anxiety. In our own practices, we have been struck by how often patients may mention, almost in passing, a lump in the breast or the chest pain they had climbing stairs as they are leaving the appointment, with “one foot out the door.”

Physicians need not only to be attuned to the reality that patients may have a hidden agenda, but also to have various strategies to try to unmask that agenda and the time to address issues raised. This can be especially difficult in a busy primary care practice. Despite this challenge, it is deeply gratifying to the clinician to uncover a patient's hidden agenda. “I've been practicing for a long time,” Dr. Gilson told us, “and I still love to do it.”