title: "Oh, by the way ...": the closing moments of the medical visit.
abstract: OBJECTIVE
  To define and describe the communication between physicians and patients in the closing phase of the medical visit. To identify types of communication throughout the visit that are associated with the introduction of a new problem during the closing moments of the visit or with longer closures.
  
  
  METHODS
  Audiotaping of office visits. Tapes were analyzed using a modified Roter Interactional Analysis System (RIAS). The coders' definition of closure was compared with the opinion of communication experts.
  
  
  METHODS
  Outpatient offices of practicing physicians.
  
  
  METHODS
  Eighty-eight patients visiting 20 primary care physicians participated. Physicians were selected by a letter from the Oregon Board of Medical Examiners. The mean number of years from graduation was 16 (range 3-47). One physician per site participated.
  
  
  METHODS
  Frequencies of physician and patient communication behaviors and global affect scores were calculated and correlations were drawn using t-test and chi-square analyses.
  
  
  RESULTS
  The physicians initiated the closing in 86% of the visits. The physicians clarified the plan of care in 75% of the visits and asked whether the patients had more questions in 25% of the cases. The patients introduced new problems not previously discussed in 21% of the closures. New problems in closure were associated with less information exchanged previously by physicians and patients about therapy (t = -3.28, p = 0.002; t = -2.26, p = 0.03), fewer orientation statements by physicians (t = 1.86, p = 0.001), and higher patient affect scores (t = 0.252, p = 0.016). Long closures (> 2 minutes) correlated with physicians' asking open-ended questions (0.2438; p = 0.019), laughing (0.3002; p = 0.005), showing responsiveness to patients (0.3996; p < 0.001), being self-disclosing (0.3948; p < 0.001), and engaging in psychosocial discussion with patients (0.2410; p = 0.020).
  
  
  CONCLUSIONS
  This study is the first description of how physicians and patients communicate during the closing of office visits. Notably, the patients raised new problems at the end of the visit in 21% of the cases. The findings suggest ways physicians might improve communication in the closing phase of the medical interview. Orienting patients in the flow of the visit, assessing patient beliefs, checking for understanding, and addressing emotions and psychosocial issues early on may decrease the number of new problems in the final moments of the visit.
authors.affiliation: Good Samaritan Hospital, Oregon Health Sciences University, Portland 97210.
authors.forename: J
authors.initials: J
authors.lastname: White
authors.forename: W
authors.initials: W
authors.lastname: Levinson
authors.forename: D
authors.initials: D
authors.lastname: Roter
mesh_terms: D003142:Communication; D004502:Education, Medical, Continuing; D005194:Family Practice; D005260:Female; D006801:Humans; D007388:Internal Medicine; D008297:Male; D008875:Middle Aged; D009819:Office Visits; D017060:Patient Satisfaction; D010817:Physician-Patient Relations; D013637:Tape Recording; D013997:Time Factors