UC Davis

Objective: To understand how and when patients initiate additional concerns in general surgery visits. Methods: 175 video-recorded visits of a general surgery practice in rural Texas were collected, coded, and analyzed using Conversation analysis. Results: Patients initiated 377 additional concerns, with 2 or more concerns raised in 80 visits, and 1 concern raised in 37 visits. Three methods of initiation were identified: fitted-to-topic (66%), fitted-to- activity (14%), and disjunctive (20%). Sixty percent of patient-initiated concerns occurred i) before the physical examination, compared to 14% after the physical exam, and ii) in pre-operative visits. Conclusions: In contrast to the research on acute, primary care visits, patients in general surgery visits do not wait to present “door knob concerns.” Instead, patients in general surgery visits are more likely to initiate concerns early in the visit. Patients most frequently find and create opportunities to introduce new concerns by fitting them to the ongoing talk or activity. Practice implications: Physicians should spend more time on the physical exam, as this phase creates a unique opportunity for patients to initiate concerns.