Observational study on the timing and method of interruption by hospital consultants during the opening statement in outpatient consultations
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* Inge Mulder-Vos
* Ellen M Driever
* Paul L P Brand

## Abstract

**Objective** To analyse verbal interruptions by Dutch hospital consultants during the patient’s opening statement in medical encounters.

**Design** Cross-sectional descriptive study.

**Setting** Isala teaching hospital in Zwolle, the Netherlands.

**Participants** 94 consultations by 27 consultants, video recorded in 2018 and 2019.

**Main outcome measures** Physicians’ verbal interruptions during patients’ opening statements, rate of completion of patients’ opening statements, time to first interruption and the effect of gender, age and physician specialty on the rate and type of physicians’ verbal interruptions.

**Results** Patients were interrupted a median of 9 times per minute during their opening statement, the median time to the first interruption was 6.5 s. Most interruptions (67%) were backchannels (such as ‘hm hm’ or ‘go on’), considered to be encouraging the patient to continue. In 52 consultations (55%), patients could not finish their opening statement due to a floor changing interruption by the consultant. The median time to such an interruption was 31.4 s, on average 20 s shorter than a finished opening statement (p=0.004). Female consultants used more backchannels (median 9, IQR 5–12) than male consultants (median 7, IQR 2–11, p=0.028).

**Conclusions** Hospital-based consultants use various ways to interrupt patients during their opening statements. Most of these interruptions are encouraging backchannels. Still, consultants change the conversational floor in more than half of their patients during their opening statements after a median of 31 s.

*   EDUCATION & TRAINING (see Medical Education & Training)
*   GENERAL MEDICINE (see Internal Medicine)
*   HISTORY (see Medical History)

### STRENGTHS AND LIMITATIONS OF THIS STUDY

*   To our knowledge, the first study of interruptions by hospital-based consultants during their patients’ opening statements.

*   Distinguished between different types of interruptions based on their effects.

*   Comparison to earlier studies complicated by adapted definition of interruption used in this study.

*   Limited generalisability because study was performed in one hospital only.

## Introduction

Despite increasing attention to patient-centred communication, patients still complain that doctors do not listen enough, insufficiently address their concerns and interrupt them when they present their concerns or complaints.1 2 A major cause for these shortcomings could lie in the time pressure consultants perceive and in the subsequent strategies they have developed to cope with this, for example, controlling the length of the consultation by interrupting patients.3 4 By limiting patients in the time and space given to discuss their complaints, consultants risk missing out on crucial information. Research has shown that patients commonly have multiple complaints to discuss,5 6 and that, when interrupted, they take on a more passive role,7 potentially causing important information to remain unmentioned. In addition, although intended to reduce the time spent in consultation, there are two reasons why interruptions may also have the opposite effect. First, interruptions may lead to ‘doorknob complaints’ being presented towards the end of the consultation.5 8 9 Second, the use of interruptions by physicians has also been shown to increase the amount of time patients use, possibly in an attempt to regain some level of control in the conversation.10

The opening of the consultation lays the foundation of a trusting patient–physician relationship, which can contribute to improving patients’ health.11–13 The opening statement is commonly the only time in the consultation when patients are given the ‘floor’.14 15 Patients appreciate being given the opportunity to explain their complaints in their own words.14 Interrupting the patient’s opening statement can harm the process of building this relationship of mutual trust,16 17 limit the already asymmetric position of the patient in the consultation,18–20 and may come across as rejection to patients who already indicate that fear of rejection is a reason for them not to share everything they would like to.21

Research, mostly in the general practice setting, has shown that physicians interrupt their patients’ opening statements in 70% of consultations and very early into the consultation, on average after 12 s.8 22–26 Little is known about interruptions in consultations by hospital-based consultants, who constitute the majority of physicians. In addition, most interruption studies have been performed more than 10 years ago. Given the increased attention to patient-centred communication in medical curricula and the lay press, the available literature may therefore not represent current medical practice regarding the interruption of patients during their opening statement. Finally, the currently available literature on interruptions in medical consultations rarely distinguishes between different types of interruptions, which may be relevant because recent studies have shown that not all interruptions have a negative effect,27–30 and that some interruptions may also have supportive and affirming functions in the consultation.30–32

This study aimed to analyse hospital consultants’ verbal interruption behaviour during the opening statement of their patients, considering various forms of interruptions and their effects on the doctor–patient consultation.

## Methods

We analysed a sample of consultations from an existing repository of 781 videorecorded consultations with 41 consultants at Isala Hospital, Zwolle, The Netherlands, an 1100-bed general teaching hospital serving a mixed urban–rural population of approximately 600 000 people.33

Consultations in which new patients (or caregivers with children aged 12 years or younger) were given the opportunity to discuss their opening statement were included. Consultations with a significant language barrier were excluded. The gender and age of included patients and consultants were collected, as well as the medical specialty of consultants. These were used to investigate the relationship between such patient and physician factors and the occurrence of interruptions.

Every utterance of the consulting physician during the patient’s opening statement was considered and will be referred to as an ‘interruption. Therefore, it was deemed possible that these so-called interruptions had a negative, neutral or positive effect and calling it an ‘interruption’ was merely a methodical act, not a judgement in itself. This also meant that for an utterance to be called an ‘interruption’, it was not our requirement that it had overlap with an utterance of the other speaker. The opening statement was defined as the time during which the patient discussed his or her reason for coming, starting with the patient’s first words on this subject, and ending when the consultant received or took the floor. We used Edelsky’s definition of floor as ‘the acknowledged what’s-going-on within a psychological time/space. What’s going on can be the development of a topic or a function (teasing, soliciting a response, etc) or an interaction of the two. It can be developed or controlled by one person at a time or by several simultaneously or in quick succession.’25 An opening statement was considered completed when (A) the patient communicated its completion (eg, ‘*that’s it*’ or ‘*that’s why I’ve come here*’), (B) responded positively to the consultant’s closing question (eg, patient: ‘*I guess I wanted to know whether it could be treated*.’, consultant: ‘*That seems like a reasonable question, right?*’, patient: ‘*Yes, I think so too*.’) or (C) when the consultant took over the floor (eg, patient: ‘*And that was only the beginning, because…*’, consultant: ‘*Have you been experiencing palpitations?*’).

We distinguished interruptions by which the consultant took the floor from the patient (floor changing interruptions) from interruptions in which the floor remained with the patient (opening statement interruptions). Opening statement interruptions were classified as ‘backchannels’ (utterances such as ‘hm-hm’, ‘yes’ or ‘go on’, which most communication researchers consider to be non-intrusive encouragements for the patient to continue speaking,10 31 and non-backchannels (eg, utterances prompting a change of subject, a correction, a clarification or a reflection on patients’ accounts of their symptoms, see figure 1 and table 1).

![Figure 1](http://bmjopen.bmj.com/http://bmjopenuat.stage.highwire.org/content/bmjopen/13/9/e066678/F1.medium.gif)

[Figure 1](http://bmjopen.bmj.com/content/13/9/e066678/F1)

Figure 1 
Classification of types of interruptions by consulting physicians during the patient’s opening statement.

View this table:
[Table 1](http://bmjopen.bmj.com/content/13/9/e066678/T1)

Table 1 
Definitions of types of interruptions

The time to interruption was measured as the time between the start of the opening statement and the first interruption of that type, by using the video time stamp.

Statistical analyses were performed using non-parametric methods, due to non-normally distributed continuous variables, in SPSS Statistics V.27. Based on previous studies assessing how often patients can complete their opening statement without interruptions,9 23–26 aiming for a power of 0.8 (with an alpha set at 0.05), we calculated the required number of consultations at 66 using a binomial test. To allow for consultations to be excluded for technical failures or practical reasons (eg, extensive small talk or intrusions at the beginning of a consultation, disturbing the presentation of an opening statement), we aimed to include at least 90 consultations, which we randomly selected from the consultations which met our inclusion and exclusion criteria listed above.

### Patient and public involvement

Patients and public were not involved in the design and conduct of the study.

## Results

### Demographics

Most of the 781 consultations in the repository were follow-up consultations of patients with a chronic disease. There were 212 consultations with a new patient, 122 of which met the inclusion and exclusion criteria. A total of 94 consultations by 27 consultants (maximum 4 per consultant) from 15 disciplines (see table 2) were randomly selected for analysis from these 122. Patients’ ages ranged from 0 to 88 (median 41) years; 54% were women. Consultants’ ages ranged from 36 to 63 (median 47) years; 34 were women (36%).

View this table:
[Table 2](http://bmjopen.bmj.com/content/13/9/e066678/T2)

Table 2 
Specialty of the consultants in the 94 included consultations

### Interrater agreement

The first 10 consultations were analysed by two investigators, who independently classified all interruptions as outlined in figure 1. They agreed on floor change occurrence and on subtyping into backchannels and non-backchannels in 8 and 9 consultations, respectively.34 Differences between the two investigators were discussed and resolved by consensus. The remaining consultations were analysed by one investigator.

### Interruptions

Overall, 840 interruptions were recorded, 788 of which were non-floor changing and hence referred to as opening statement interruptions, a median of 7 per consultation (range 0–40)(figure 2), or 9 per minute (range 0–43) (figure 2). In only one consultation, the consultant made no interruptions during the patient’s opening statement, which the patient completed after 9.8 s.

![Figure 2](http://bmjopen.bmj.com/http://bmjopenuat.stage.highwire.org/content/bmjopen/13/9/e066678/F2.medium.gif)

[Figure 2](http://bmjopen.bmj.com/content/13/9/e066678/F2)

Figure 2 
Frequency plot of opening statement interruptions (A) and backchannels (B). Block bars represent the number of interruptions or backchannels per consultation, white bars represent the number of interruptions or backchannels per minute.

The non-floor changing opening statement interruptions were classified into five subtypes (table 3). Most interruptions were backchannels, with a median of 5 per consultation (range 0–29), or 8 per minute (range 0–35). Backchannel interruptions occurred in 89 consultations (95%).

View this table:
[Table 3](http://bmjopen.bmj.com/content/13/9/e066678/T3)

Table 3 
Frequencies and percentages of the types of interruptions

Opening statement non-backchannels (ie, elaborators, correctors or encouragers) occurred in 73 consultations (78%), with a median of 1 per consultation (range 0–11), or 2 per minute (range 0–22).

In 52 consultations (55%), the consultant interrupted the patient in such a way that the floor changed before the patient had signalled completion. Opening statements with a floor changing interruption lasted significantly shorter than those without (median 31.4 s, IQR 15.2–47.2 vs median 51.5, IQR 22.9–80.1 s, p=0.004).

### Relationship between interruptions and consulting physician and patient factors

We assessed the relationship between interruptions and physician factors such as age, gender and medical specialty, as well as between interruptions and patient factors such as age and gender. A statistically significant negative correlation was found between the age of consultants and the number of opening statement interruptions they made per minute (Spearman’s rank correlation coefficient ρ=−0.230, p=0.026). Female consultants used significantly more opening statement backchannels per minute (median 9, IQR 5–12) than male consultants (median 7, IQR 2–11) (p=0.028). There were no statistically significant relationships between physician or patient factors and the timing of opening statement interruptions.

The four paediatricians made considerably fewer floor changing interruptions (20% of opening statements ended with a floor changing interruption) than consultants of other specialties (62%, p=0.003). In the non-paediatric consultations, we found no significant relationship between floor changing interruptions and the consulting physician’s gender, age, or specialty, or the age and gender of the patient.

## Discussion

Although nearly all consulting physicians in this study interrupted their patients’ opening statements, they did so with a variety of interruptions (tables 1 and 3). Consultants interrupted their patients a median of 9 times per minute, and the median time to the first interruption was 6.5 s. However, one-third of these interruptions were backchannels like ‘hm-hm’ or ‘I see’, which encouraged patients to continue their opening statement. Still, the majority of opening statements (55%) were not completed due to a floor changing interruption made by the consultant. Such floor changing interruptions were associated with a (median 20 s) shorter opening statement. The median time to an interruption which caused a floor change was 31.4 s, considerably longer than previously reported in the literature.8 22 23 25

The recent insight that interruptions come in different types complicates the interpretation of earlier studies of interruptions in consultations. In our study, we carefully distinguished between different types of interruptions, following recommendations from recent communication literature, and examined the effects of these interruptions on the floor of the conversation between patient and consultant. Our results nuance the assumption that all interruptions have a negative effect,27–29 and confirm earlier assertions that interruptions can also have supportive and affirming functions.31 32 The proportion of floor changing interruptions in our study (55%) was lower than was shown in three previous studies reporting incomplete opening statements in 68%–74% of consultations.8 22 25 On average, consultants interrupted patients later (at 31.4 s) than in previous literature (11–23 s),8 22 23 25 and the difference between a finished and prematurely interrupted (by floor changing interruption) opening statement was longer in this research (20 s) than previously reported (3.9–6 s).8 25

The differences between our results and those reported by previous literature are likely explained by different definitions used for ‘interruptions’. In contrast to earlier studies, in which interruptions were defined by form or content, we classified interruptions by their effect, that is, a floor change. For example, an ‘elaborator’ (eg, ‘So your question to me is…?’) was considered to end the opening statement in previous studies,8 22 25 whereas we only decided to record it as such when it also changed the floor. The differences may also be explained by a different research setting (hospital-based consults vs general practice) or could reflect the effects of patient-centred communication training.

Our results confirm previous literature on communication differences between male and female consultants and between consultants of different ages.29 30 35 Female consultants tend to use more backchannels than their male colleagues.26 27 29 36 Younger consultants made more opening statement interruptions than did older consultants, which has been interpreted in earlier studies as an effect of training level and experience.26 37 A surprising and new finding was that the paediatricians in this study made considerably fewer floor changing interruptions than the other consultants. This may be related to the triadic nature of paediatric consultations, involving the caregivers as a third party.38 It is also possible that paediatricians receive more training on involving both the child and the caregivers in the consultation, and hence provide more room for the patient and caregiver to present their opening statement without interruption. Further studies are needed to corroborate these findings.

### Implications

The results of this study paint a nuanced picture of how hospital consultants interrupt patients during their opening statements. Although interruptions occur very frequently, most of these are non-intrusive (eg, backchannels) and do not hinder the patient in presenting his or her opening statement.10 30 However, our study also shows floor changing interruptions in more than half of consultations, which do hinder the patient. The risks of such floor changing interruptions include a loss of patient trust,17 loss of information and paradoxical loss of time,7 10 for example, due to late arising complaints.5 8 9 Training physicians in communication skills should include attention to the adverse effects of interruptions other than backchannels, and studies are needed to explore the effect of interventions aimed at reducing physicians’ tendency to use floor changing interruptions in consultations with patients.

### Strengths and limitations

The main strength of this study is the nuanced and more detailed perspective on interruptions in medical consultations and their effects on patients. This study is also the first to analyse interruption practices of hospital-based consultants from various disciplines. We acknowledge the following limitations. First, by taking a more nuanced and detailed methodological approach to the study of interruptions, the comparison of our results with those of previous studies is complicated. Second, we did not collect data on the outcomes of the consultations or the patients’ satisfaction with the consultation or examine the consultants’ reasons for interrupting their patients. Third, we used data from one hospital only. The generalisability of our findings in different settings and countries should be examined in further research.

### Conclusion

Patients are regularly interrupted by consultants during the opening statement of consultations in medical specialist outpatient care. However, most interruptions are backchannels which appear to be encouraging rather than intrusive. Premature and undesired floor changing interruptions were observed in half of the consultations. Future research into interruptions during consultations requires nuance to account for the variation in different types of interruptions.

## Data availability statement

Data are available on reasonable request. All study data are available from the corresponding author on reasonable request.

## Ethics statements

### Patient consent for publication

Not applicable.

### Ethics approval

The hospital’s ethics review board approved this study (file number 200308). Participating patients and consultants gave written informed consent.

## Acknowledgments

We would like to thank Suzanne Schuurman, who independently classified interruptions as part of the interrater agreement assessment, for her contribution to this article.

## Footnotes

*   Twitter @paulbrandzwolle

*   Contributors IM-V contributed to study design, performed data collection and analysis, and wrote the initial report. EMD contributed to study design, data collection and data analysis, and edited the report. PLPB contributed to study design, supervised data collection and analysis, and edited the report. He is the guarantor of the study.

*   Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

*   Competing interests None declared.

*   Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

*   Provenance and peer review Not commissioned; externally peer reviewed.

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