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Archived Comments for: Open and hidden agendas of "asymptomatic" patients who request check-up exams

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  1. Patient-Physician Communication: How to Address Hidden Agendas of "Asymptomatic" Patients Who Visit a Doctor for Periodic Health Examinations

    Christian T. K.-H. Stadtlander, Microbiologist & Epidemiologist

    17 May 2011

    Hunziker et al. [1] discussed an important issue that relates to patient-physician communication and, in turn, to the development of a trusting relationship. The authors conducted a follow-up study of 66 patients who visited an outpatient clinic for a general, preventive check-up (i.e., a periodic health examination [PHE]), and who initially declared to be "asymptomatic." The authors observed that the majority of the patients had actually "hidden agendas," which means, they mentioned during the consultation specific symptoms, health concerns, or psychosocial problems. It is believed that these initially undisclosed issues were the primary reasons for the patients' requests for routine check-ups.

    Communication is an important part for a successful relationship, including the patient-doctor relationship. Treece [2] pointed out that the word "communication" comes from the Latin word "communis" and means "common." Thus, in communication, we attempt to establish a commonness by sharing information, attitudes, ideas, and understanding. Interpersonal communication can take on different forms: for example, verbal or nonverbal; on a one-to-one basis or in group interactions. We can only say that the communication was successful when 1. The message was understood (i.e., the patient and the doctor recognize its true meaning); 2. The message accomplished its purpose (i.e.,the patient gets proper medical treatment for his concerns); and 3. The sender and the receiver (patient and doctor) of the message maintain a favorable relationship [2].

    Hunziker et al. [1] videotaped all consultations and analyzed the interactions for cues (verbal and nonverbal hints) that might provide relevant information about hidden agendas. Although I believe patient "interview" videotapes can be helpful for the portrait of the patient and the reconstruction of the patient-doctor dialogue, I wonder if patients reacted "naturally" when being videotaped. Visual and audio recording of a person can cause in some great anxiety (e.g., a feeling of being documented, perhaps even of being "caught on camera"); this can have an influence on the interpretation of the data. Furthermore, it would be interesting to know what the observer(s)' frame of mind was. Investigators generally enter their research projects with certain preconceptions, assumptions about the subjects, and the setting they are studying. Bogdan and Biklen [3] summed it up as follows: "Like everyone else, qualitative researchers have opinions, beliefs, attitudes, and prejudices, and they try to reveal these in their notes by reflecting on their own way of thinking."

    There is another, closely related issue. Hunziker et al. [1] provided a list of baseline patient characteristics (gender and age; marital-, employment-, and disability-status; and nationality). These data are important as they indicate that the patients came from different backgrounds. For example, patients had different nationalities: Swiss, German, Italian, Turkish, and other. Since each nationality typically relates to a certain type of culture (i.e., "a learned set of shared interpretations about beliefs, values, and norms, which affect behavior" [4]), it would be interesting to know from what culture(s) the researchers came and what factors (e.g., intercultural differences; anxiety levels; cultural biases; cultural differences in persuasion, etc.) might have influenced the cross-cultural communication between the patient and the physician. There is always a risk that improper cross-cultural communication leads to misunderstanding caused by misperception, misinterpretation, and misevaluation [5].

    In conclusion, the study by Hunziker et al. [1] provides valuable information about the "hidden agendas" patients seem to have when visiting a doctor for PHE. I fully agree with the authors that recognizing and identifying hidden agendas is not easy and that paying attention to behavioral and verbal cues can lead to successful communication and proper medical treatment. Along the same line, Larsen, Risor, and Putnam [6] developed an interesting nine-step model (called P-R-A-C-T-I-C-A-L), starting with how the patient has prepared for the visit (Prior to consultation: the patient's story) and ending with time for reflection (Leave from consultation: did I remember everything?). The authors believe that using this model can help determine the real content of the patient's visit by balancing the patient's views of an illness ("voice of the lifeworld") with the physician's views ("voice of medicine"), thus making the consultation a more productive and enjoyable process for both. I think this model can be quite useful for addressing both, open and hidden agendas.


    1. Hunziker S, Schlaepfer M, Langewitz W, Kaufmann G, Nuesch R, Battegay E, Zimmerli LU: Open and hidden agendas of "asymptomatic" patients who request check-up exams. BMC Family Practice 2011, 12:22.

    2. Treece M: Successful Communication for Business and the Professions. 6th edition. Needham Heights, Massachusetts: Allyn and Bacon; 1994.

    3. Bodgan RC, Biklen SK: Qualitative Research for Education: An Introduction to Theories and Methods. 5th edition. Boston, Massachusetts: Pearson Education; 2007.

    4. Lustig MW, Koester J: Intercultural Competence: Interpersonal Communication across Cultures. 3rd edition. New York, New York: Addison Wesley Longman; 1999.

    5. Adler NJ: International Dimensions of Organizational Behavior. 4th edition. Cincinnati, Ohio: South-Western; 2002.

    6. Larsen J-H, Risor O, Putnam S: P-R-A-C-T-I-C-A-L: a step-by-step model for conducting the consultation in general practice. Family Practice 1997, 14(4):295-301.

    Competing interests

    The author declares no competing interests.