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Length of patient's monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care
Israel Rabinowitz, Rachel Luzzati, Ada Tamir and Shmuel Reis BMJ 2004;328;501-502 doi:10.1136/bmj.328.7438.501

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Correction

A correction has been published for this article. The contents of the correction have been appended to the original article in this reprint. The correction is available online at: http://bmj.com/cgi/content/full/328/7450/1236-b

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Primary care
the prognosis for familial hypercholesterolaemia has improved with more effective treatment.2 Nevertheless variability in the rating applied was considerable, and patients could usefully be advised to shop around for the most competitive premium. The results of the survey, however, are reassuring and should encourage relatives of probands to be tested rather than being deterred by concerns about life assurance.
We thank the life assurance companies for participating in the study. Contributors: HAWN and DM designed the study, TH conducted the survey, HAWN undertook the analysis, SEH and HAWN wrote the paper. All authors participated in the interpretation and critical revision of the paper. HAWN is the guarantor. Funding: This work was supported by a grant from the British Heart Foundation (PG2000/015) and was carried out in part with support from the Department of Health and the Department of Trade and Industry for the IDEAS Genetics Knowledge Park. Competing interests: None declared.
1 2 Mayor S. UK insurers agree five-year ban on using genetic tests. BMJ 2001;323:1021. Scientific Steering Committee on behalf of the Simon Broome Register Group. Mortality in treated heterozygous familial hypercholesterolaemia: implications for clinical management. Atherosclerosis 1999;142:105-12. Neil HAW, Hammond T, Huxley R, Matthews DR, Humphries SE. Extent of underdiagnosis of familial hypercholesterolaemia in routine practice: prospective registry study. BMJ 2000;321:148. Stone NJ, Levy RI, Fredrickson DS, Verter J. Coronary artery disease in 116 kindred with familial type II hyperlipoproteinaemia. Circulation 1974;49:476-488. Neil HAW, Mant D. Cholesterol screening and life assurance. BMJ 1991;302:891-3.

Excess mortality rating (%)

250

1990 ratings 2002 ratings before statin treatment 2002 ratings after starting statin treatment

200

150

100

50

0 Life assurance companies

Percentage excess mortality ratings applied by life assurance companies in 1990 and 2002, before and after starting statin treatment

mean excess rating increased from 89% (SD 52) in 1990 to 158% (SD 40) in 2002 (difference 69%, 95% confidence interval 41 to 97; P < 0.000, paired t test), but fell to 56% (SD 43) on treatment (102%, 79 to 126; P < 0.000), which was 33% lower (5 to 61; P = 0.022) than the original rating in 1990.

Comment
The increase in mortality rating in the second survey, together with the substantial reduction in the excess applied to patients taking statins show that underwriters now assess risk more realistically and recognise that
4 5

(Accepted 2 October)

Length of patients monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care
Israel Rabinowitz, Rachel Luzzatti, Ada Tamir, Shmuel Reis

The patients opening statement in a consultation (the patients monologue) is an important part of history taking, and doctors are encouraged not to interrupt the patientbut they often do,1 2 probably because they think that the patients monologue is time consuming. When uninterrupted, patients conclude their monologue in less than 30 seconds in primary care and about 90 seconds in consultant settings.15 We assessed encounters in primary care that included a new clinical problem, recording the length and rate of completion of patients monologues before and after instructing doctors not to interrupt.

Methods and results

We recorded consecutive encounters between eight family physicians and their patients on two days in six family clinics in northern Israel. All doctors were videotaped on both days. They had been told that the study focused on the doctor-patient interaction. Patients were given this explanation via a written notice on the door of the consulting room and also orally by the
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doctor when required. At the start of the second day the doctors were handed a written note that said: When the patient starts speaking, please do not interrupt him or her until you are satisfied that he or she has finished. All practices had stable lists, and patients were seen by their regular doctors. The eight doctors were a convenience sample (five men; mean age 39.7 (range 35 to 44) years); all had completed the residency programme in family medicine. The sex and age of patients seen on days 1 and 2 was similar. In total, 235 consultations (omitting two refusals) were recorded; 21 were excluded due to foreign languages, office procedures, and technical difficulties. Of 214 (91%) encounters we viewed, 112 (52%) involved a new clinical problem. We examined these for length of patients monologue, whether the monologue was completed, performance and length of physical examination, ordering of accessory tests (or referrals to specialists), prescriptions, and total encounter time. Statistical analysis used 2 and t tests, with significance

Clalit Health Services and Department of Family Medicine, B Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Israel Rabinowitz family physician Rachel Luzzatti family physician Shmuel Reis family physician continued over
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Department of Community Health and Epidemiology, B Rappaport Faculty of Medicine Ada Tamir statistician Correspondence to: S Reis, Departments of Medical Education and Family Medicine, B Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, POB 9649, Bat-Galim, 31096 Haifa, Israel reis@ tx.technion.ac.il

Characteristics of consultations before and after doctors were instructed not to interrupt the patients opening statement
Variable No (%) of encounters with new clinical problem Length of patients monologue (seconds) Mean (SD) Median (range) No (%) of monologues completed Physical examinations: No (%) of encounters Mean (range; SD) length (seconds) No (%) of encounters with tests or referrals No (%) of encounters resulting in diagnosis No (%) of encounters resulting in prescription Mean length (range; SD) of encounter (minutes) Geometric mean (minutes) 53 (91) 89 (5-215; 62) 18 (31) 56 (97) 30 (52) 10.5 (1-33.5; 5.9) 8.9 45 (83) 88 (5-296; 84) 21 (39) 52 (96) 24 (44) 9 (2-25; 2.7) 7.8 26 (28.5) 15 (1-120) 18/56 (32) 28 (26.9) 21 (2-123) 32/49 (65)* Day 1 (before instruction) 58 Day 2 (after instruction) 54

*P<0.001. Completion of monologue could be determined in only 105 encounters. (In a subgroup of 75 encounters in which patients were aged 10 years or over (mean age 43.8; median 40.0; SD 22.4), in 12/38 (32%) encounters on day 1 and 25/37 (68%) encounters on day 2 the monologues were completed; P<0.01 ( 2 and regressions, controlling for doctor).)

level of 0.05. As patients are nested within physician, we used linear and logistic regression as well. Monologues averaged 26 seconds on day 1 and 28 seconds on day 2 (table). After the intervention, twice as many monologues were completed, and six doctors accounted for this increase (90/112 (80%) encounters). A physical examination was performed in 88% of encounters; it averaged a minute and a half. Tests or referrals were requested in a third, a diagnosis was given in almost all, and prescriptions were issued in half the encounters. These figures did not change significantly after the intervention, nor did the length of the consultation.

Different languages and cultures seem to have no effect on average length of monologue (Slovenia, 28 seconds3; United States, 23 seconds;2 Israel 27 seconds). Lengthier monologues have been reported in specialist settings (Switzerland, 90 seconds5). The significant increase in the proportion of completed monologues is compatible with the observation that completed monologues are just marginally longer than interrupted ones.2 This is probably due to the natural brevity of patients monologues.
Contributors: RL and IR wrote the protocol, collected and analysed data. AT gave statistical advice and supervised the analysis. IR wrote the first draft of the paper. All authors contributed revisions of drafts of the paper. SR supervised the whole process, wrote the final draft, and will act as guarantor. Funding: No external funding. Competing interests: None declared. Ethical approval: Helsinki Committee (IRB) of the Emek Medical Center, Afoula, Israel.
1 2 3 4 5 Frankel M. The effect of physician behavior on collection of data. Ann Intern Med 1984;101:692-6. Marvel MK. Soliciting the patients agenda: have we improved? JAMA 1999;281: 283-7. Svab I. The time used by the patient when he/she talks without interruptions. Aten Primaria 1993;11:175-7. Blau JN. Time to let the patient speak. BMJ 1989;298:39. Langewitz W. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002;325:682-3.

Comment
Allowing patients to complete their monologue requires little time and does not disrupt the other components of the clinical encounter. In consultations with a new clinical problem (that is, those aiming to reach a diagnosis), the number of completed monologues doubled when doctors were told not to interrupt. The difference in monologue length between day 1 and day 2 is better represented by the median (15 and 21 seconds respectively) than by the mean (26 and 28), because the mean is affected by a number of relatively lengthy monologues. A similar difference was reported by Marvel.2

(Accepted 13 October 2003)

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the differences between hospitals in their in-hospital death rates. Calculation of in-hospital death rates, aggregated across a wide clinical spectrum, including a mixture of admissions for treatment, cure, and palliative and terminal care, gives rates that are difficult to interpret as quality measures.
We thank Pamela Evans for typing the manuscript. Contributors: MJG proposed the study; VS analysed the data. Both designed the study, wrote the manuscript, and will act as guarantors. Funding: VS is funded by the Research and Development Directorate of the Department of Health and Social Care (South). MJG holds a grant from the Department of Health for the Oxford site of the National Centre for Health Outcomes Development (NCHOD). The funding body had no role in the design or writing of the work covered by this report. Competing interests: None declared. Ethical approval: Not needed.

Walsall Bolton Heatherwood Medway Royal Bournemouth Sandwell Tameside George Elliot Princess Alexandra, Harlow Essex Blackpool Sheffield Teaching Royal Surrey Weston Royal West Sussex Royal Devon Airedale Royal United, Bath Plymouth Bedford 40 45 50 55 60 65 70 80 90 100 110 120 130

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Percentage

HSMRs

Percentages of deaths occurring in NHS hospitals for catchment areas of hospitals (vertical line is percentage for England) and hospital standardised mortality ratios (HSMRs) as published (black) and after adjustment (red). Hospitals are plotted in ranking order of published HSMRs1

The good hospital guide. 6 April 2003. www.timesonline.co.uk (accessed 1 Aug 2003). Ellis R. The Good Hospital Guide 2002. A deadly lottery: you are twice as likely to die at the worst hospitals. Mail on Sunday 2002 March 10. Jacobson B, Mindell J, McKee M. Hospital mortality league tables. BMJ 2003;326:777-8. Review of the registrar general on deaths in England and Wales, 2000. Norwich: Stationery Office, 2000. (DH1, No 33.) Hospital guide. www.drfoster.co.uk (accessed 1 Aug 2003).

(Accepted 17 December 2003) doi 10.1136/bmj.38058.517118.47

Statistics on place of death (NHS hospital, hospice, home, etc) of residents of different areas are published routinely.4 These were available for two of the three years on which the published hospital league tables were based (1999 and 2000). We used hospital episode statistics to identify the individual health authorities that corresponded most closely to the catchment area of the 20 selected hospitals, and we used the published figures on place of death to calculate the percentage of deaths of residents of each catchment area that occurred in NHS hospitals. We then adjusted the published HSMRs to allow for geographic differences in the percentages of deaths occurring in hospital in the hospitals catchment areas. We did this by scaling down the values when proportionately more deaths of residents occurred in NHS hospitals compared with England as a whole and scaling up those when proportionately fewer deaths occurred in hospital. For instance, for every 1000 deaths of residents of Walsall Health Authority, on average 623 occurred in NHS hospitals. For England overall, the average was 546. We reduced the published HSMR for the Walsall hospitals, 126, by the scaling factor 0.88 (546/623), which gave an adjusted HSMR of 110. The percentages of deaths of residents of health authorities that occurred in NHS hospitals varied from less than 45% in Plymouth and West Sussex to over 60% in Walsall and Sandwell (figure, and see table on bmj.com). In most cases the adjustment brought the HSMRs closer together and closer to 100. It also changed the rankings.

Corrections and clarifications

Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial Two errors crept into table 2 of the full version (on bmj.com only) of this paper by Janet James and colleagues (22 May, p 1237). Firstly, the parentheses should be around the second set of values (which are the percentages) not the first set of values (which are the numbers). Secondly, the control girls consumed 95 (not 5) glasses of carbonated drinks in three days. The authors also want to make clear that data in the table relate to overweight children who fall between the 91st and 98th centiles and to obese children above the 98th centile. Minerva Minerva was reminded by a reader that she had forgotten to insert a reference for one of the items in the issue of 24 April (p 1024). The reference for the final item (about fatigue in patients with primary biliary cirrhosis) is Gut 2004;53:587-92. Length of patients monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care In this Primary Care paper by Israel Rabinowitz and colleagues (28 February, pp 501-2), a misspelling of the surname of the second author (Rachel Luzzati) persisted to publication. There is only one t in Luzzati (not two). This has been corrected on bmj.com. Integrating health care for mothers and children in refugee camps and at district level The name of the first author in reference 8 was wrongly spelt in this Education and Debate article by Assad Hafeez and colleagues (3 April, pp 834-6). The correct spelling is Rahman.

Comment
Geographical differences in the provision of facilities for the dying are a plausible explanation for some of
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