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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients seek medical care for many different reasons&#46; At first glance&#44; it might appear that the reason why patients consult a doctor is obvious&#58; they are experiencing the signs or symptoms of disease&#46; Similarly&#44; patients&#8217; expectations when they visit a doctor may also seem patently obvious&#58; they want to obtain a diagnosis and treatment&#46; However&#44; when patient motivations and expectations are studied in greater depth&#44; we find that this apparently simple question is much more complex than might be expected at first sight&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patients who consult us have many doubts&#44; fears&#44; and expectations&#44; and some of these concerns may never be expressed if we do not proactively elicit them&#46; In 1981&#44; Barsky<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> gave a name to this assortment of questions and concerns that patients do not express openly&#59; he called it the hidden agenda&#46; While these issues may not come to light during the consultation&#44; the patient will not forget them&#44; and the dermatologist&#39;s failure to address them may have considerable impact on the patient&#39;s satisfaction with the care they receive and on the effectiveness of the treatments prescribed&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">At the beginning of the visit&#44; patients state the reason &#40;or reasons&#41; why they decided to consult a doctor &#40;in the case of public medicine&#44; we usually also have a referral report from a colleague&#41;&#46; This is the declared&#44; or visible&#44; agenda&#46; However&#44; the doubts&#44; fears&#44; worries&#44; and expectations that patients sometimes choose not to reveal may never emerge unless we take appropriate steps to elicit this information&#59; they constitute the patient&#39;s hidden agenda&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Patients who notice the recent onset of a severe and disabling symptom almost invariably seek medical care&#46; In such cases&#44; the motivation for the consultation is obvious&#46; However&#44; most of our patients have mild or moderate symptoms which&#44; in many cases&#44; they have experienced for months or even years&#46; It is in this situation that the motivation for a consultation can be more ambiguous and more difficult to elicit&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">There are many examples of dermatological conditions for which a significant proportion of those affected do not consult a doctor&#46; Acne is a case in point&#58; while it is a common problem&#8212;particularly among adolescents and young adults&#8212;the majority of those affected &#40;90&#37;&#41; are never treated&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#44;3</span></a> Similarly&#44; a significant proportion &#40;66&#37;&#41; of patients with chronic hand eczema never consult a dermatologist&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> These statistics show that the presence of symptoms is not the only thing that leads the patient to seek medical care&#46; For example&#44; research has shown that one factor which favors the decision to seek care is a higher educational and socioeconomic level&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition to the presence of symptoms and socioeconomic status&#44; certain psychological factors also favor the decision to seek an appointment with a dermatologist at a particular time&#46; These include emotional stress and life crises&#44; which influence the decision to seek care in 2 ways&#58; first&#44; stress can trigger the onset of or exacerbate numerous diseases<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a>&#59; second&#44; stress intensifies and amplifies fears about bodily symptoms that might otherwise be ignored&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Psychological conditions are particularly important in dermatology because an estimated 30&#37; of our patients suffer some kind of psychological or psychiatric comorbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> In some patients&#44; these comorbidities are mild and unrelated to the dermatological problem&#46; In others&#44; however&#44; the psychological symptoms are predominant and determine the course of the skin disease and the effectiveness of treatment&#46; The examples are numerous&#44; including such conditions as excoriated acne&#44; trichotillomania&#44; and nail biting&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> The dermatologist who is capable of detecting these undisclosed psychological disorders can help relieve the patient&#39;s suffering and improve the prognosis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Social isolation is another hidden motive that leads patients to seek medical care&#46; Dermatological diseases&#44; partly due to their significant visual impact&#44; can affect the patients&#8217; self-esteem&#44; making it difficult for them to interact with others&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> Sometimes&#44; individuals who lack social support go to the dermatologist in search of advice and comfort&#59; they want to feel that someone cares for them and is concerned about their well-being&#46; In part&#44; this happens because it is relatively simple&#44; even for socially isolated people&#44; to establish a doctor-patient relationship&#46; Patients trust that a doctor will understand their concerns and will not be prejudiced or ridicule their complaints&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The need for information about a symptom or symptoms is also an important trigger in the decision to seek medical care&#46; The presence of a physical symptom with no obvious diagnosis&#44; apparent cause&#44; or clear mechanism can give rise to feelings of uncertainty&#44; anxiety&#44; and impotence in the patient&#46; In the absence of clear and reliable information&#44; people often suspect that their symptoms are caused by the disease everyone dreads&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> Patients who feel that their health is threatened&#8212;by a symptom or a diagnosis&#8212;will actively build cognitive models to understand the mechanism of the disease&#46; The patient&#39;s mental representation of the disease will condition the way they deal with the situation&#46; Interestingly&#44; 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&#44; which in turn will influence prognostic factors&#44; such as adherence to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> This logic underscores the value of investigating the patient&#39;s viewpoint on his or her disease&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Fears and anxieties are also important factors in every dermatology consultation&#46; Patients come to the dermatology office with numerous concerns&#44; many of which are related to fear&#58; fear of cancer&#44; fear of their symptoms and their persistence&#44; fear that their condition will get worse&#44; fear of an unsightly appearance&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> Patients may not openly express these fears&#44; but it is the dermatologist&#39;s job to proactively elicit them&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">It is normal for people to be scared or worried about a health problem&#46; However&#44; if their fear becomes excessive or irrational&#44; it can lead to depressive or anxiety disorders&#44; which may eventually prove more dangerous than the problem that gave rise to the fear in the first place&#46; Patient&#39;s fears must be taken into account because&#44; when not addressed&#44; they tend to multiply and become magnified&#44; thereby blocking the therapeutic process &#40;patients may reject treatments or diagnostic tests based on unfounded fears&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> In many cases&#44; the patient&#39;s fears and worries can be resolved in a single visit&#46; In the most serious cases&#44; when a patient has deep-seated fears or phobias&#44; it may be necessary to involve a specialist therapist&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In addition to their fears&#44; the patient&#39;s wishes&#8212;in other words&#44; the expectations they have when they consult a doctor&#8212;are another important facet of the hidden agenda&#46; These expectations can be generic &#40;for example&#44; the patient wants to be listened to and to feel they are being cared for&#41;&#46; Patients may also have specific expectations&#44; such as the desire to undergo a particular diagnostic test or procedure&#46; Some patients openly state their expectations at the outset and can sometimes even formulate their wishes in a way that makes the dermatologist uncomfortable&#46; 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&#46; However&#44; for better or for worse&#44; most patients are not so explicit&#44; and in some cases they may even be reluctant to say what they expect from their visit to the dermatologist&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Patients&#8217; satisfaction with the health care they receive is determined by the doctor&#39;s ability to meet their expectations&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> and the first step in that process is obviously to discover what these are&#46; Even when the dermatologist cannot meet the patient&#39;s expectations&#44; talking about these during the visit can be helpful because it allows the clinician to explain why the patient&#39;s objective is unrealistic or erroneous&#46; 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&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Once we recognize the existence of a hidden agenda &#40;doubts&#44; fears&#44; anxieties&#44; expectations&#41;&#44; the dermatologist&#39;s task becomes clear&#58; to bring this agenda to light&#46; Unfortunately&#44; this is not as simple as it might seem&#46; The difficulty in exploring the hidden agenda is usually attributed wholly to the patient&#44; who may be reluctant to share his or her psychosocial problems&#44; worries and expectations with the doctor&#46; 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&#46; However&#44; once we as dermatologists are aware of these difficulties&#44; our attitude and good doctor-patient communication skills will provide a solid basis for exploring the reasons &#40;not apparent at the outset&#41; why the patient is seeking our help&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">There is no clearly established guideline on how to elicit information about the patient&#39;s hidden agenda&#46; However&#44; there are strategies that can be help us to do this&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Research has shown that doctors tend to interrupt the patient&#39;s initial description of their concerns after an average of 23<span class="elsevierStyleHsp" style=""></span>seconds&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> Normally&#44; once the patient has asked a question or expressed their first concern&#44; we tend to redirect the conversation to focus on the medical history and explore the first problem reported&#46; This approach&#8212;in which the doctor takes control early in the visit&#8212;tends to obscure the patient&#39;s hidden agenda because in this situation patients tend to adopt a passive role&#46; Once they are interrupted&#44; patients rarely complete their opening statement&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The reasons why the dermatologist redirects the patient at this early stage&#44; starting the search for key signs and symptoms&#44; are well known to all of us&#46; Since we know that the time allocated for each consultation is short&#44; we tend to guide the patient in the direction which&#44; in our opinion&#44; will be the most productive for understanding the problem and resolving their symptoms&#46; However&#44; there are good reasons why we should consider an alternative approach&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">When patients are not interrupted&#44; they generally complete the statement of their reasons for seeking care after about 28<span class="elsevierStyleHsp" style=""></span>seconds &#40;only 5<span class="elsevierStyleHsp" style=""></span>seconds more than when they are interrupted&#41;&#44; and the longer we let them talk&#44; the more concerns and fears they are likely to reveal&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> We tend to assume that the patient will mention the most important or most annoying problem first&#44; but this is often not the case&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> If we focus immediately on exploring the first problem mentioned by the patient&#44; 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 &#8220;Since I am here&#46;&#46;&#46;&#8221;&#46; Creating a situation that will favor the expression of all of their ideas&#44; worries&#44; and expectations does not necessarily take more time&#46; In fact&#44; the inverse is true&#58; 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&#44; therefore&#44; give rise to an unproductive doctor-patient relationship that in the end takes up more time&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Pre-visit questionnaires are a very helpful tool for exploring the patient&#39;s hidden agenda&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> Our research group used pre-consultation questionnaires and our results&#44; currently in press&#44; support the use of these tools as a cost-effective method for improving dermatologist-patient communication&#46; These questionnaires also encourage patients to adopt a proactive role and help them to put their ideas in order&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Sometimes&#44; a patient may have conditions&#44; concerns&#44; or expectations that cannot be dealt with during the time allotted for the consultation&#46; In such cases&#44; the physician should negotiate with the patient to agree which problems to focus on during the visit and&#44; if necessary&#44; schedule another appointment to properly assess other issues that have emerged&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">When patients are asked to list their main complaints about doctors&#44; the most common negative characteristic cited is the doctor&#39;s inability to listen to them and&#47;or to understand their concerns&#46; People prefer to be cared for by doctors who know how to listen&#44; advise&#44; and educate them&#46; When we see a patient&#44; therefore&#44; one of our main objectives should be to elicit their hidden agenda&#44; to listen actively&#44; and to let them see that we have understood their concerns&#46; This approach has been shown to improve clinical results and patient adherence to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mart&#237;nez-Garc&#237;a E&#44; Buend&#237;a-Eisman A&#46; La agenda oculta&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;855&#8211;857&#46;</p>"
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Opinion Article
The Hidden Agenda
La agenda oculta
E. Martínez-Garcíaa,
Autor para correspondencia
eliseo3@gmail.com

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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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients seek medical care for many different reasons&#46; At first glance&#44; it might appear that the reason why patients consult a doctor is obvious&#58; they are experiencing the signs or symptoms of disease&#46; Similarly&#44; patients&#8217; expectations when they visit a doctor may also seem patently obvious&#58; they want to obtain a diagnosis and treatment&#46; However&#44; when patient motivations and expectations are studied in greater depth&#44; we find that this apparently simple question is much more complex than might be expected at first sight&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patients who consult us have many doubts&#44; fears&#44; and expectations&#44; and some of these concerns may never be expressed if we do not proactively elicit them&#46; In 1981&#44; Barsky<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> gave a name to this assortment of questions and concerns that patients do not express openly&#59; he called it the hidden agenda&#46; While these issues may not come to light during the consultation&#44; the patient will not forget them&#44; and the dermatologist&#39;s failure to address them may have considerable impact on the patient&#39;s satisfaction with the care they receive and on the effectiveness of the treatments prescribed&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">At the beginning of the visit&#44; patients state the reason &#40;or reasons&#41; why they decided to consult a doctor &#40;in the case of public medicine&#44; we usually also have a referral report from a colleague&#41;&#46; This is the declared&#44; or visible&#44; agenda&#46; However&#44; the doubts&#44; fears&#44; worries&#44; and expectations that patients sometimes choose not to reveal may never emerge unless we take appropriate steps to elicit this information&#59; they constitute the patient&#39;s hidden agenda&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Patients who notice the recent onset of a severe and disabling symptom almost invariably seek medical care&#46; In such cases&#44; the motivation for the consultation is obvious&#46; However&#44; most of our patients have mild or moderate symptoms which&#44; in many cases&#44; they have experienced for months or even years&#46; It is in this situation that the motivation for a consultation can be more ambiguous and more difficult to elicit&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">There are many examples of dermatological conditions for which a significant proportion of those affected do not consult a doctor&#46; Acne is a case in point&#58; while it is a common problem&#8212;particularly among adolescents and young adults&#8212;the majority of those affected &#40;90&#37;&#41; are never treated&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#44;3</span></a> Similarly&#44; a significant proportion &#40;66&#37;&#41; of patients with chronic hand eczema never consult a dermatologist&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> These statistics show that the presence of symptoms is not the only thing that leads the patient to seek medical care&#46; For example&#44; research has shown that one factor which favors the decision to seek care is a higher educational and socioeconomic level&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition to the presence of symptoms and socioeconomic status&#44; certain psychological factors also favor the decision to seek an appointment with a dermatologist at a particular time&#46; These include emotional stress and life crises&#44; which influence the decision to seek care in 2 ways&#58; first&#44; stress can trigger the onset of or exacerbate numerous diseases<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a>&#59; second&#44; stress intensifies and amplifies fears about bodily symptoms that might otherwise be ignored&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Psychological conditions are particularly important in dermatology because an estimated 30&#37; of our patients suffer some kind of psychological or psychiatric comorbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> In some patients&#44; these comorbidities are mild and unrelated to the dermatological problem&#46; In others&#44; however&#44; the psychological symptoms are predominant and determine the course of the skin disease and the effectiveness of treatment&#46; The examples are numerous&#44; including such conditions as excoriated acne&#44; trichotillomania&#44; and nail biting&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> The dermatologist who is capable of detecting these undisclosed psychological disorders can help relieve the patient&#39;s suffering and improve the prognosis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Social isolation is another hidden motive that leads patients to seek medical care&#46; Dermatological diseases&#44; partly due to their significant visual impact&#44; can affect the patients&#8217; self-esteem&#44; making it difficult for them to interact with others&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> Sometimes&#44; individuals who lack social support go to the dermatologist in search of advice and comfort&#59; they want to feel that someone cares for them and is concerned about their well-being&#46; In part&#44; this happens because it is relatively simple&#44; even for socially isolated people&#44; to establish a doctor-patient relationship&#46; Patients trust that a doctor will understand their concerns and will not be prejudiced or ridicule their complaints&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The need for information about a symptom or symptoms is also an important trigger in the decision to seek medical care&#46; The presence of a physical symptom with no obvious diagnosis&#44; apparent cause&#44; or clear mechanism can give rise to feelings of uncertainty&#44; anxiety&#44; and impotence in the patient&#46; In the absence of clear and reliable information&#44; people often suspect that their symptoms are caused by the disease everyone dreads&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> Patients who feel that their health is threatened&#8212;by a symptom or a diagnosis&#8212;will actively build cognitive models to understand the mechanism of the disease&#46; The patient&#39;s mental representation of the disease will condition the way they deal with the situation&#46; Interestingly&#44; 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&#44; which in turn will influence prognostic factors&#44; such as adherence to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> This logic underscores the value of investigating the patient&#39;s viewpoint on his or her disease&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Fears and anxieties are also important factors in every dermatology consultation&#46; Patients come to the dermatology office with numerous concerns&#44; many of which are related to fear&#58; fear of cancer&#44; fear of their symptoms and their persistence&#44; fear that their condition will get worse&#44; fear of an unsightly appearance&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> Patients may not openly express these fears&#44; but it is the dermatologist&#39;s job to proactively elicit them&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">It is normal for people to be scared or worried about a health problem&#46; However&#44; if their fear becomes excessive or irrational&#44; it can lead to depressive or anxiety disorders&#44; which may eventually prove more dangerous than the problem that gave rise to the fear in the first place&#46; Patient&#39;s fears must be taken into account because&#44; when not addressed&#44; they tend to multiply and become magnified&#44; thereby blocking the therapeutic process &#40;patients may reject treatments or diagnostic tests based on unfounded fears&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> In many cases&#44; the patient&#39;s fears and worries can be resolved in a single visit&#46; In the most serious cases&#44; when a patient has deep-seated fears or phobias&#44; it may be necessary to involve a specialist therapist&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In addition to their fears&#44; the patient&#39;s wishes&#8212;in other words&#44; the expectations they have when they consult a doctor&#8212;are another important facet of the hidden agenda&#46; These expectations can be generic &#40;for example&#44; the patient wants to be listened to and to feel they are being cared for&#41;&#46; Patients may also have specific expectations&#44; such as the desire to undergo a particular diagnostic test or procedure&#46; Some patients openly state their expectations at the outset and can sometimes even formulate their wishes in a way that makes the dermatologist uncomfortable&#46; 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&#46; However&#44; for better or for worse&#44; most patients are not so explicit&#44; and in some cases they may even be reluctant to say what they expect from their visit to the dermatologist&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Patients&#8217; satisfaction with the health care they receive is determined by the doctor&#39;s ability to meet their expectations&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> and the first step in that process is obviously to discover what these are&#46; Even when the dermatologist cannot meet the patient&#39;s expectations&#44; talking about these during the visit can be helpful because it allows the clinician to explain why the patient&#39;s objective is unrealistic or erroneous&#46; 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&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Once we recognize the existence of a hidden agenda &#40;doubts&#44; fears&#44; anxieties&#44; expectations&#41;&#44; the dermatologist&#39;s task becomes clear&#58; to bring this agenda to light&#46; Unfortunately&#44; this is not as simple as it might seem&#46; The difficulty in exploring the hidden agenda is usually attributed wholly to the patient&#44; who may be reluctant to share his or her psychosocial problems&#44; worries and expectations with the doctor&#46; 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&#46; However&#44; once we as dermatologists are aware of these difficulties&#44; our attitude and good doctor-patient communication skills will provide a solid basis for exploring the reasons &#40;not apparent at the outset&#41; why the patient is seeking our help&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">There is no clearly established guideline on how to elicit information about the patient&#39;s hidden agenda&#46; However&#44; there are strategies that can be help us to do this&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Research has shown that doctors tend to interrupt the patient&#39;s initial description of their concerns after an average of 23<span class="elsevierStyleHsp" style=""></span>seconds&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> Normally&#44; once the patient has asked a question or expressed their first concern&#44; we tend to redirect the conversation to focus on the medical history and explore the first problem reported&#46; This approach&#8212;in which the doctor takes control early in the visit&#8212;tends to obscure the patient&#39;s hidden agenda because in this situation patients tend to adopt a passive role&#46; Once they are interrupted&#44; patients rarely complete their opening statement&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The reasons why the dermatologist redirects the patient at this early stage&#44; starting the search for key signs and symptoms&#44; are well known to all of us&#46; Since we know that the time allocated for each consultation is short&#44; we tend to guide the patient in the direction which&#44; in our opinion&#44; will be the most productive for understanding the problem and resolving their symptoms&#46; However&#44; there are good reasons why we should consider an alternative approach&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">When patients are not interrupted&#44; they generally complete the statement of their reasons for seeking care after about 28<span class="elsevierStyleHsp" style=""></span>seconds &#40;only 5<span class="elsevierStyleHsp" style=""></span>seconds more than when they are interrupted&#41;&#44; and the longer we let them talk&#44; the more concerns and fears they are likely to reveal&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> We tend to assume that the patient will mention the most important or most annoying problem first&#44; but this is often not the case&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> If we focus immediately on exploring the first problem mentioned by the patient&#44; 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 &#8220;Since I am here&#46;&#46;&#46;&#8221;&#46; Creating a situation that will favor the expression of all of their ideas&#44; worries&#44; and expectations does not necessarily take more time&#46; In fact&#44; the inverse is true&#58; 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&#44; therefore&#44; give rise to an unproductive doctor-patient relationship that in the end takes up more time&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Pre-visit questionnaires are a very helpful tool for exploring the patient&#39;s hidden agenda&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> Our research group used pre-consultation questionnaires and our results&#44; currently in press&#44; support the use of these tools as a cost-effective method for improving dermatologist-patient communication&#46; These questionnaires also encourage patients to adopt a proactive role and help them to put their ideas in order&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Sometimes&#44; a patient may have conditions&#44; concerns&#44; or expectations that cannot be dealt with during the time allotted for the consultation&#46; In such cases&#44; the physician should negotiate with the patient to agree which problems to focus on during the visit and&#44; if necessary&#44; schedule another appointment to properly assess other issues that have emerged&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">When patients are asked to list their main complaints about doctors&#44; the most common negative characteristic cited is the doctor&#39;s inability to listen to them and&#47;or to understand their concerns&#46; People prefer to be cared for by doctors who know how to listen&#44; advise&#44; and educate them&#46; When we see a patient&#44; therefore&#44; one of our main objectives should be to elicit their hidden agenda&#44; to listen actively&#44; and to let them see that we have understood their concerns&#46; This approach has been shown to improve clinical results and patient adherence to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mart&#237;nez-Garc&#237;a E&#44; Buend&#237;a-Eisman A&#46; La agenda oculta&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;855&#8211;857&#46;</p>"
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