Editor's note: Kathryn Ticknor is senior analyst, linguistic insights and analytics at Verilogue Inc., a Horsham, Pa., research firm.

Last year, 81.2 percent of patients in the United States made an estimated 1.2 billion visits to physician offices and hospitals, an annual rate of over four visits per person.1 Yet the average length of these visits is just over 10 minutes – roughly equivalent to the time we spend in the shower each morning before rushing off to work.

With such a huge number of visits and such a short time, it’s little wonder that a recent study of cancer patients revealed that 29 percent of patients reported not receiving enough information about cancer treatments, 48 percent reported problems in getting health information and 25 percent said they were not involved in decisions as much as they desired.2

Yet at the same time, studies also show that the average patient asks five or fewer questions during visits with their doctor, and a high proportion ask no questions at all.3 Additional research suggests that patients not taking their medications as prescribed, costing the U.S. health care system an estimated $337.1 billion in avoidable medical spending every year.4

And so the stories conflict. On one hand, patients report high levels of dissatisfaction and a desire to be more involved in their care. On the other, patient participation during office visits is minimal, accompanied by vast amounts of financial waste due to non-compliance with their doctor’s orders.

Physicians and patients use different frameworks

Although it may seem as if doctors and patients are on the same page in the exam room, linguistic analysis shows quite the opposite. Patients and physicians operate using two different mental frameworks of what constitutes a doctor visit.

Mental frameworks are our socially, culturally and individually developed conceptions of “what exactly we’re doing here.” They provide us with the rules to play by during an interaction. For patients, this is personal. Their mental framework is largely that of a relational exchange. Our goal by going to the doctor is to establish/maintain trust with health care providers and understand our condition and the impact of it (and treatment side effects) on our quality of life.

For physicians, this is professional. Physicians’ mental framework is based on an information exchange. Physicians’ goals for office visits are to acquire information, share information and initiate, modify or stop treatment.

It’s as if two players agreed to “hit the courts” at an appointed time but one showed up holding a tennis racket, the other a basketball.

These different mental frameworks lead to different objectives for the visit and different communication strategies throughout:

• Patients are unsure of their role in decision-making and are uncertain of how to show ownership of their condition. After all, they’re there to consult an expert.

• Patients’ input in decision-making is often limited across therapeutic categories, leaving few opportunities to ask questions. Certainly not while taking deep breaths and saying “Ah.”

• When physicians don’t position treatment as a collaborative decision, patients are less likely to raise concerns, not wanting to be interpreted as “talking back” or non-compliant.

• While patients are financially responsible for treatment, cost discussions are largely initiated and guided by physicians – as if openly discussing money matters wasn’t already difficult enough when you’re dressed in little more than a paper towel.

Homing in on what patients are communicating indirectly can reveal much of where shared decision-making is currently limited and where education needs to be refocused in order to dispel the myth of the passive patient and achieve true patient-centricity at the point of care.

Signaling information gaps

Implicit questions are a speaker’s way of signaling information gaps, like regular questions but with a key difference: they don’t sound like questions. They are most often structured as declarative sentences, without the subject-verb inversion of regular questions. They also lack the regular, upward intonation arc most American English speakers use to give questions their recognizable sound. In a patient’s mind, implicit questions wave the same red flags of confusion that other questions do but on the surface, implicit questions may be too subtle to go noticed by a physician.

Test yourself: Out of these four quotes, how many questions were asked?

Patient 1: No it’s just this, in my head I don’t know whether it’s the medication or, or what it is.

Patient 2: It says take these tablets when your doctor tells you to. And I don’t know when to take them.

Patient 3: What does that [number] mean? Is that high?

Patient 4: I know some foods have sodium in them but I don’t actually use salt in, you know, I don’t put salt on a meal.

If you said two, you might have been a physician in the study. But you would be incorrect. The right answer is five.

As readers we can quickly skim for the written symbol of a question mark but in spoken interaction, we don’t have the benefit of visible punctuation. We listen instead for verb-subject order (“Is that high” vs. “That is high”) and the classic who, what, where, when and whys.

But Patients 1 and 2 each used a w-question. So what did the doctors miss?

First, Patient 1 and 2’s questions sounded like statements: They had a normal, subject-verb word order. Vocally, the questioning intonation curve that signals “This is a question” to a listener is missing. Instead, the speakers tend to trail off, further masking their misunderstandings.

Physicians are less likely to hear they’ve been “tagged” to respond, especially while multitasking to keep electronic medical records, checking for drug interactions or attempting to move along to the patients in the packed waiting room. Even when patients use the phrase “I don’t know,” as Patients 1 and 2 did, physicians were unable to hear the questions.

Each patient quoted above held a misunderstanding regarding treatment – and knew it. Yet despite asking their doctors for clarification, their questions were not addressed. Suddenly our conflicting data starts to take shape.

Implicit questions may, in fact, be more common than direct questions. They appear in several forms, but in most cases they are structured as – and sound like – a statement, resulting on them being lost on the listener. These statements contain two types of requests for physician input: a request to “confirm or deny” information the patient believes to be true or a “request for more information” on a subject of which the patient lacks sufficient understanding.

“Confirm or deny” questions may most often start with the ubiquitous “So . . . . ” and consist of a patient demonstrating their understanding of an element of their care but of which they are uncertain. A metastatic melanoma patient, discussing the start of an immunotherapy treatment with his oncologist asks “I’ll go bald and everything, huh?”5 This implicit question reflects a common misconception about immunotherapy which, unlike chemotherapy, does not cause one’s hair to fall out.

“Request for more information” questions, while similar, have an illocutionary intent of eliciting more information about an existing topic of discussion from a doctor:

Patient A: You said I was going to have to go back on [medication] later or something.

Patient B: You mentioned both bleeding and clotting, which seems a little bit oxymoronish.

As with implicit questions that seek to confirm or deny, implicit requests for more information identify key areas of misunderstanding. But with the latter, the patient often doesn’t know what other information to ask for, only that they need more of it. Will they have to go back on medication soon or later? What medication? And why? What will cause Patient B to bleed and clot at the same time? Should she be concerned? Think back to Patient 4 above, who stated with confusion, “I know some foods have sodium in them but I don’t actually use salt in, you know I don’t put salt on a meal.” She was implicitly asking for more information than she provided.

Implicit questions can also indicate that a patient a) wants more information but doesn’t know where to start to ask; or b) is uncomfortable admitting to not understanding what is being discussed. By using an implicit question format, the patient may hope to gather the information currently missing without directly admitting they don’t follow.

Physicians may miss the mark

In some cases a physician may think he or she is picking up on the patient’s implicit question but miss the mark. In the example below, a patient expresses a concern that she is having irregular periods. She adds that she and her husband and interested in starting a family as soon as possible:

Patient: Yeah, I mean everything’s good. I just, you know, I really came because today because I’m, you know, I want to have kids and I just -
Doctor:  Sure.
Patient:  My periods being irregular and stuff like that . . .

Her indirect question here draws a link between her irregular menstrual cycle and a fear that this is an indication she will have difficulty conceiving.

What happens when her physician is presented with this indirect question? In response, this OB/GYN meticulously explains numerous causes of infertility:

Doctor: I know your concerns are you’re going to be getting married in the near future and, you know, you’re kind of wondering if there’s any infertility or, you know, fertility problems and so I think, you know, my assessment from talking to you is that your periods have been irregular and sometimes heavy and you haven’t conceived or maybe there was no birth control used, so it could be a lot of things, like I mentioned. It could be the husband’s sperm count being low, the wife not ovulating, the tubes not opening, but there’s other diseases people can have, like thyroid disease, diabetes, um, or polycystic ovarian disease where the, your ovaries have eggs but they’re not being released, okay? There’s like it’s a big capsule against the, uh, ovaries. Different things, of course, could be treated. Even if we found a problem doesn’t mean we can’t treat it so that you could successfully get pregnant, but I need to work it up, so what we’re going to do is, I, I gave you some lab forms, so in the lab work that, um, that I gave you, we’re going to rule out things like thyroid disease, diabetes, uh, we’re going to check your hormone levels, including, you know, FSH and LH, which tells if your ovaries are working and testosterone level, which is kind of a male hormone to some people that have polycystic ovarian disease make a lot of, so we’re going to try to fit the reason. And I know you’re a little bit heavy. That’s what made me think about this, which may be the reason. If there’s a medical reason, it could be the reason that that’s contributing, even though you’re eating properly, you know?

Patient: Mm-hmm.

Doctor: Um, so what I’ll do is, if you’ll please go to the lab one the, the, for, um, I think you could, uh, is it Labcorp or Quest.

Patient: Yeah.

Doctor: Whichever it was, says, go to one near your home, whenever.  But it should be a fasting test, okay?

Patient: Mm-hmm.

Doctor: And what’ll happen is, when I get the lab work, it probably takes about a week to get back, okay?  So I will call you within a week or my nurse, you know, explaining what the tests meant and what we should do about it, okay?  So I know we haven’t come to an answer today.

Patient: Mm-hmm.

Doctor: Okay?  Um, is it, do you understand that?

Patient: Yeah.

Doctor: Okay, hon, and I think you were thinking a little bit about some of these things yourself, right?

Patient: Yeah.

Doctor: So I’m not, like, coming out of left field.

Patient: No, no, yeah, I’ve looked up, I’ve read about it and -
Doctor: Right.

Patient: And I just -

Doctor: Also, now, I’m going to just change because I don’t have the information to see if we need to do more testing or whatever but I will explain that as we get into it.

This physician’s intentions were right on target: he identified what he believed was the underlying question – what causes infertility – and launched into a highly informational response. What the patient’s implicit question was actually asking – whether irregular periods were a possible symptom of infertility – is not addressed. The patient is left with much to remember but little understanding of relevancy.

This dialogue shows a classic example of the difference between a physician’s informational framework (“it could be the husband’s sperm count being low, the wife not ovulating, the tubes not opening, thyroid disease, diabetes, polycystic ovarian disease”) and a patient’s relational framework (I want to have kids). Due the patient’s indirect question format, she received a great volume of information but not an answer or explanation that addressed the root of her fears.

Frustration mounts

Patient frustration mounts when they don’t feel physicians are addressing their concerns. This frustration becomes particularly evident during the treatment decision-making process, when patients feel they are unable to get the information they need make decisions about the medications they take every day.

This glaucoma patient uses an indirect question style multiple times to express a concern over her current eye drop treatment, with little success reaching her doctor:

Patient: I think before I have a different type, it was a bigger bottle.

Doctor: Uh-huh.

Patient: Because it didn’t cost quite as much as this one, this is $100 for that little dude.

Doctor: Is that right?

Patient: Mm-hmm, and is there anything else –

Doctor: Okay.

Patient: I have still got stuff in here.

Doctor: Yeah, there is a different drop on the market, there is a generic drop on the market that we could try, okay. Let me see where your pressures have you today.

Patient: Well I read a lot and I asked you before.

Doctor: No, reading makes no difference, not at all.

Patient: Okay.

The physician’s first two responses – “Uh-huh” and “Is that right?” – are what linguists refer to as backchanneling, or listening cues – polite indications that he is listening. But they also show he interprets her comments regarding the size and cost of the bottle as statements, not implied confusion over a change in brand and cost of her medication. Trying a third time to express confusion over medication changes with a “request for more information” line of “I’ve still got stuff in here,” her concern is interpreted by the physician, who begins to pick up on an implicit “ask” surrounding cost issues and briefly mentions the existence of a generic. It isn’t until she signals her continued misunderstanding over the connection between reading (i.e., eye strain) and increased eye pressure (i.e., disease progression) with the phrase “I’ve asked you before” that the physician picks up on the fact that this patient is actually trying to ask questions.

A fascinating pattern

Even when patients ask questions in a clear, direct format, the institutional framework that works to minimize patient involvement comes into play. Patient discomfort with direct questions is evidenced by a fascinating pattern of apologizing for asking them.

Patient: I’m sorry I’m asking so many questions.

Even when physicians prompted their patients to ask them any questions freely, patients would apologize for questions related to proactive self-education done outside the office:

Doctor: What questions do you have for me?

Patient: Um, they said it was Stage 3 and I know a lot of doctors don’t like us going on the Internet and searching things and looking through things, but are there five stages to colon cancer?

Finally, and most strikingly, patients continue asking permission to ask a question, as in:

Patient: Can I ask you a question please?

The very acts of apologizing for and seeking permission to ask questions further highlights the conversational imbalance rooted at the linguistic level – a level that may be far more systemic than even the most comprehensive of legislation can hope to address.

Facilitate a more effective conversation

So how can we help facilitate a more effective conversation, reduce taxpayer burden and maximize the success of Patient Protection and Affordable Care Act programs such as Shared Decision Making? For physicians, the act of giving patients permission to ask questions can significantly open up the channels of communication. An Australian study showed that physician endorsement of patient questions positively correlated with the number of questions patients asked.6 By assuming patients will have questions, using the open-ended “What questions do you have for me?” rather than close-ended “Do you have any questions?” is more likely to optimize a response.

Physicians can avoid information-overload by following an ARC explanation model:

  • acknowledge the patient’s concern;
  • relate explanations to the concern; and
  • center education around the individual.

Patients can benefit from the work of groups such as the National Coalition for Cancer Survivorship, who are becoming more aware of how deceptively simple it may be to “Talk to your doctor.” The organization’s own Talking With Your Doctor guide includes a section on asking questions that specifically addresses potential reasons for a patient’s discomfort and provides a nitty-gritty guide for how, when and whom to ask effective questions.7

Misunderstandings in the exam room are certainly a danger of a language that rarely states exactly what it means. But patient-physician communication is critical in establishing good clinical relationships and improving medication adherence and patient satisfaction.8,9 

1 Stats from CDC:
2 Ayanian et al., 2005
3 Reviewed by IOM, 2008
4 Express Scripts Drug Trend Report:
5 All dialogues used with permission from Verilogue Inc.
6 Clayton et al., 2007
8 Bartlett, E.E., Grayson, M., Barker, R., Levine, D.M., Golden A., Libber, S. “The effects of physician communications skills on patient satisfaction; recall, and adherence.” Journal of Chronic Diseases. 1984;37(9-10):755-764.
9 Chang, J.T., Hays, R.D., Shekelle, P.G.; et al. “Patients’ global ratings of their health care are not associated with the technical quality of their care.” Annals of Internal Medicine. 2006;144(9):665-672.