Patients and providers feel stressed when they don’t have enough time to accomplish their goals for the visit.  Time management strategies are especially important when patients are very talkative or tangential.

When interacting with a talkative or tangential patient taking time to try and understand why this may be happening can guide the techniques you use during the encounter.  This may be your patient’s typical communication style or maybe the patient is feeling nervous,  anxious or worried. Spending time getting to know the patient  and their needs can  guide the communication techniques which may be most effective.

Assuming the medical issue is not imminently life threatening,  consider changing the goal of the interaction to address emotional needs first with the plan of  having the patient return soon to further discuss the medical details.

Traditional teaching around patient-centered communication emphasizes the use of open-ended questions, invitations to share in an uninterrupted way, active listening and eventually moving toward more directed, closed ended questions.  This technique may be less effective with talkative and tangential patients.  Finding a way to continue to listen actively and empathically while obtaining information efficiently is important.  Taking a more directed approach to information gathering is often necessary.

Agenda setting early on is a helpful technique .  Before exploring a particular concern elicit a comprehensive list of patient concerns (without allowing them to dive deep into details at this point) and then spend  time negotiating up front which issues can be addressed adequately and safely  during the time you have together.  Acknowledge upfront the need for follow up visits to further address their other concerns.  Although one may worry that the use of agenda setting will length an encounter, studies have shown that providers who use an establishing focus protocol do not lengthen the time of the visit and patients are more satisfied and perceive that more of their concerns were elicited and prioritized.  If you are interested in learning more about agenda setting feel free to read this article.

Aligning with the patient early on by asking them to share the responsibility of effective time management can be helpful.  “Today we have decided to focus on these two issues.   I am hoping we can work together to stay focused on these two issues so I can get the information needed to provide you good care.”  You may need to remind the patient of this agreement if the conversation goes off track.  Agenda setting and sharing the responsibility of maintaining focus and efficiency may help patients learn to prioritize and structure their information for future encounters.

Rather than remaining too open-ended in your questioning try tailoring your approach to include subtle strategies such as reformulating the question, listing several options, specifying the type of answer needed or clarifying the purpose of a question. If this does not work you may need to be even more directive and explicit in the information that you need and transition to using closed-ended questioning techniques.

The use of summary statements can help to clarify details that may have been challenging to follow.  Making the subtle adjustment of providing a ‘closed-ended’ rather then ‘open-ended’ summary can clarify details while trying to avoid patient interruptions and the invitation to share more details unless absolutely needed.

Sometimes despite all these techniques, the provider will still need to interrupt. Empathic interrupting lets the patient know that you take the problem seriously while enabling you to refocus the attention on the current problem.   Non-verbal gestures may be used to create this interruption however it is important to recognize that we do not all share the same interpretations of certain gestures and they may not be understood or appreciated.  Use them mindfully and with caution.  You  may need to be more explicit.   “What you just brought up is really important.  Shall we get to that topic next week when I see you back in clinic.  I would like to continue to address X at this time so we can get you the care you need.” 

With the use of these techniques you can work toward creating a therapeutic space for both patient and provider.

Tools to use to redirect and focus

  • Collaborate to set the agenda. This is important for all visits but it’s critical for people who tend to be talkative. If you establish the goals and the time available at the start, you can refer back to the agenda if you need to redirect or interrupt.  
    • Thank you for that list of questions and concerns. In the time we have together today, I think we can do a good job on 2 or 3 of them. Let’s schedule a follow up visit so we can address the others soon. 
    • I can see that’s important, but I’m afraid if we spend time on it now we won’t get to…
  • Reflection & summary:  A patient who is talking at length may be signaling that the topic is emotionally important to them.  Acknowledging that you’ve heard them with reflection & summary can help move the conversation forward.
  • Redirection:  When a patient is loquacious or tangential, it’s an appropriate use of power to bring them back to the reason for the visit. Respond to something they’ve said when they pause to breathe, then ask if you can change direction.  
    • I appreciate hearing about that – would you mind if I move us back to the cough?  
  • Non-verbals: Generally, in our culture, if you look the speaker in the eye and smile or clear your throat most people will recognize that you wish to speak. Try this first!  Physical gestures like holding up a hand or a brief touch on the arm or hand can be used to interrupt a long narrative, but use with caution and respect.   
  • Verbal interruption: Just like different people have different notions of what constitutes adequate personal space, we have different notions of how long a pause is needed before another can begin speaking without being impolite. Watch your patient’s response and cues, and modify your approach as needed.  
    • I’m sorry for interrupting but I want to be sure I understand… 
  • Change question type: You can also try using more closed ended questions to elicit important details more concisely

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The Foundations of Clinical Medicine Copyright © by Karen McDonough. All Rights Reserved.