Journal Information
Vol. 109. Issue 10.
Pages 855-857 (December 2018)
Vol. 109. Issue 10.
Pages 855-857 (December 2018)
Opinion Article
DOI: 10.1016/j.adengl.2018.04.022
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The Hidden Agenda
La agenda oculta
E. Martínez-Garcíaa,
Corresponding author

Corresponding author.
, A. Buendía-Eismanb
a Servicio de Dermatología, Hospital Costa del Sol, Marbella, Málaga, España
b Facultad de Medicina, Universidad de Granada, Granada, España
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Patients seek medical care for many different reasons. At first glance, it might appear that the reason why patients consult a doctor is obvious: they are experiencing the signs or symptoms of disease. Similarly, patients’ expectations when they visit a doctor may also seem patently obvious: they want to obtain a diagnosis and treatment. However, when patient motivations and expectations are studied in greater depth, we find that this apparently simple question is much more complex than might be expected at first sight.

The patients who consult us have many doubts, fears, and expectations, and some of these concerns may never be expressed if we do not proactively elicit them. In 1981, Barsky1 gave a name to this assortment of questions and concerns that patients do not express openly; he called it the hidden agenda. While these issues may not come to light during the consultation, the patient will not forget them, and the dermatologist's failure to address them may have considerable impact on the patient's satisfaction with the care they receive and on the effectiveness of the treatments prescribed.

At the beginning of the visit, patients state the reason (or reasons) why they decided to consult a doctor (in the case of public medicine, we usually also have a referral report from a colleague). This is the declared, or visible, agenda. However, the doubts, fears, worries, and expectations that patients sometimes choose not to reveal may never emerge unless we take appropriate steps to elicit this information; they constitute the patient's hidden agenda.

Patients who notice the recent onset of a severe and disabling symptom almost invariably seek medical care. In such cases, the motivation for the consultation is obvious. However, most of our patients have mild or moderate symptoms which, in many cases, they have experienced for months or even years. It is in this situation that the motivation for a consultation can be more ambiguous and more difficult to elicit.

There are many examples of dermatological conditions for which a significant proportion of those affected do not consult a doctor. Acne is a case in point: while it is a common problem—particularly among adolescents and young adults—the majority of those affected (90%) are never treated.2,3 Similarly, a significant proportion (66%) of patients with chronic hand eczema never consult a dermatologist.4 These statistics show that the presence of symptoms is not the only thing that leads the patient to seek medical care. For example, research has shown that one factor which favors the decision to seek care is a higher educational and socioeconomic level.5

In addition to the presence of symptoms and socioeconomic status, certain psychological factors also favor the decision to seek an appointment with a dermatologist at a particular time. These include emotional stress and life crises, which influence the decision to seek care in 2 ways: first, stress can trigger the onset of or exacerbate numerous diseases6; second, stress intensifies and amplifies fears about bodily symptoms that might otherwise be ignored.7

Psychological conditions are particularly important in dermatology because an estimated 30% of our patients suffer some kind of psychological or psychiatric comorbidity.8 In some patients, these comorbidities are mild and unrelated to the dermatological problem. In others, however, the psychological symptoms are predominant and determine the course of the skin disease and the effectiveness of treatment. The examples are numerous, including such conditions as excoriated acne, trichotillomania, and nail biting.9 The dermatologist who is capable of detecting these undisclosed psychological disorders can help relieve the patient's suffering and improve the prognosis.

Social isolation is another hidden motive that leads patients to seek medical care. Dermatological diseases, partly due to their significant visual impact, can affect the patients’ self-esteem, making it difficult for them to interact with others.10 Sometimes, individuals who lack social support go to the dermatologist in search of advice and comfort; they want to feel that someone cares for them and is concerned about their well-being. In part, this happens because it is relatively simple, even for socially isolated people, to establish a doctor-patient relationship. Patients trust that a doctor will understand their concerns and will not be prejudiced or ridicule their complaints.

The need for information about a symptom or symptoms is also an important trigger in the decision to seek medical care. The presence of a physical symptom with no obvious diagnosis, apparent cause, or clear mechanism can give rise to feelings of uncertainty, anxiety, and impotence in the patient. In the absence of clear and reliable information, people often suspect that their symptoms are caused by the disease everyone dreads.11 Patients who feel that their health is threatened—by a symptom or a diagnosis—will actively build cognitive models to understand the mechanism of the disease. The patient's mental representation of the disease will condition the way they deal with the situation. Interestingly, 2 patients with the same illness may have very different perceptions of their disease and this will condition their disease-related behaviors and coping strategies, which in turn will influence prognostic factors, such as adherence to treatment.12 This logic underscores the value of investigating the patient's viewpoint on his or her disease.

Fears and anxieties are also important factors in every dermatology consultation. Patients come to the dermatology office with numerous concerns, many of which are related to fear: fear of cancer, fear of their symptoms and their persistence, fear that their condition will get worse, fear of an unsightly appearance.13 Patients may not openly express these fears, but it is the dermatologist's job to proactively elicit them.

It is normal for people to be scared or worried about a health problem. However, if their fear becomes excessive or irrational, it can lead to depressive or anxiety disorders, which may eventually prove more dangerous than the problem that gave rise to the fear in the first place. Patient's fears must be taken into account because, when not addressed, they tend to multiply and become magnified, thereby blocking the therapeutic process (patients may reject treatments or diagnostic tests based on unfounded fears).14 In many cases, the patient's fears and worries can be resolved in a single visit. In the most serious cases, when a patient has deep-seated fears or phobias, it may be necessary to involve a specialist therapist.

In addition to their fears, the patient's wishes—in other words, the expectations they have when they consult a doctor—are another important facet of the hidden agenda. These expectations can be generic (for example, the patient wants to be listened to and to feel they are being cared for). Patients may also have specific expectations, such as the desire to undergo a particular diagnostic test or procedure. Some patients openly state their expectations at the outset and can sometimes even formulate their wishes in a way that makes the dermatologist uncomfortable. This is the case when a patient immediately requests tests or treatments that may or may not be indicated depending on their medical history and the results of a physical examination. However, for better or for worse, most patients are not so explicit, and in some cases they may even be reluctant to say what they expect from their visit to the dermatologist.13

Patients’ satisfaction with the health care they receive is determined by the doctor's ability to meet their expectations,15 and the first step in that process is obviously to discover what these are. Even when the dermatologist cannot meet the patient's expectations, talking about these during the visit can be helpful because it allows the clinician to explain why the patient's objective is unrealistic or erroneous. This explanation can also open the door to a productive conversation that provides a starting point for the process of finding alternatives that the patient may find acceptable.

Once we recognize the existence of a hidden agenda (doubts, fears, anxieties, expectations), the dermatologist's task becomes clear: to bring this agenda to light. Unfortunately, this is not as simple as it might seem. The difficulty in exploring the hidden agenda is usually attributed wholly to the patient, who may be reluctant to share his or her psychosocial problems, worries and expectations with the doctor. Patients find it embarrassing to describe certain symptoms and this may lead them to defer reporting them or to fail to mention them at all. However, once we as dermatologists are aware of these difficulties, our attitude and good doctor-patient communication skills will provide a solid basis for exploring the reasons (not apparent at the outset) why the patient is seeking our help.16

There is no clearly established guideline on how to elicit information about the patient's hidden agenda. However, there are strategies that can be help us to do this.

Research has shown that doctors tend to interrupt the patient's initial description of their concerns after an average of 23seconds.17 Normally, once the patient has asked a question or expressed their first concern, we tend to redirect the conversation to focus on the medical history and explore the first problem reported. This approach—in which the doctor takes control early in the visit—tends to obscure the patient's hidden agenda because in this situation patients tend to adopt a passive role. Once they are interrupted, patients rarely complete their opening statement.

The reasons why the dermatologist redirects the patient at this early stage, starting the search for key signs and symptoms, are well known to all of us. Since we know that the time allocated for each consultation is short, we tend to guide the patient in the direction which, in our opinion, will be the most productive for understanding the problem and resolving their symptoms. However, there are good reasons why we should consider an alternative approach.

When patients are not interrupted, they generally complete the statement of their reasons for seeking care after about 28seconds (only 5seconds more than when they are interrupted), and the longer we let them talk, the more concerns and fears they are likely to reveal.17 We tend to assume that the patient will mention the most important or most annoying problem first, but this is often not the case.18 If we focus immediately on exploring the first problem mentioned by the patient, we run the risk that the rest of the problems will emerge at the very end of the visit in the form of the dreaded sentence beginning “Since I am here...”. Creating a situation that will favor the expression of all of their ideas, worries, and expectations does not necessarily take more time. In fact, the inverse is true: a lack of mutual understanding between the dermatologist and the patient makes it more difficult to define a shared objective for the consultation and will, therefore, give rise to an unproductive doctor-patient relationship that in the end takes up more time.19

Pre-visit questionnaires are a very helpful tool for exploring the patient's hidden agenda.13 Our research group used pre-consultation questionnaires and our results, currently in press, support the use of these tools as a cost-effective method for improving dermatologist-patient communication. These questionnaires also encourage patients to adopt a proactive role and help them to put their ideas in order.

Sometimes, a patient may have conditions, concerns, or expectations that cannot be dealt with during the time allotted for the consultation. In such cases, the physician should negotiate with the patient to agree which problems to focus on during the visit and, if necessary, schedule another appointment to properly assess other issues that have emerged.

When patients are asked to list their main complaints about doctors, the most common negative characteristic cited is the doctor's inability to listen to them and/or to understand their concerns. People prefer to be cared for by doctors who know how to listen, advise, and educate them. When we see a patient, therefore, one of our main objectives should be to elicit their hidden agenda, to listen actively, and to let them see that we have understood their concerns. This approach has been shown to improve clinical results and patient adherence to treatment.20

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Please cite this article as: Martínez-García E, Buendía-Eisman A. La agenda oculta. Actas Dermosifiliogr. 2018;109:855–857.

Copyright © 2018. Elsevier España, S.L.U. and AEDV
Actas Dermo-Sifiliográficas (English Edition)

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