Levenstein et al13introduced the concept of a “patient agenda” as playing a pivotal role in physician understanding. The physician’s agenda is the explanation of the patient’s illness in terms of a taxonomy of disease and prescription of treatment as necessary. In a disease-centered model, only this agenda is addressed. However, in a patient-focused model, the patient’s agenda should be elicited and addressed as well. Patients may not actively voice their agendas, and the physician needs to be receptive to cues from patients and to enact behavior that encourages them to express their feelings, beliefs, and concerns. However, physicians are not always skilled in eliciting patients’ agendas. For example, Barry et al14 interviewed 35 patients prior to a primary care consultation to determine their agendas and evaluated the consultation as to whether the patients’ agendas were actually voiced. There was a total of 188 agenda items expressed in the preconsultation interviews, 73 of which were unvoiced during the interview (38.8%). All patients had more than one agenda item, and most had five or more items, and only four patients (11.4%) voiced all of their agenda items.14 The frequency of voiced vs unvoiced agenda items is shown in Figure 1
.,14 Most of the unvoiced agenda items were psychosocial, but some patients failed to mention symptoms and other biomedical information.14 This failure to recognize or to coax agendas from patients was not without consequences. Fourteen of the 35 consultations had problem outcomes, and at least one of the problems for each of these consultations was related to an unvoiced agenda item (eg, unwanted prescriptions, nonuse of prescriptions and nonadherence to treatment).,14 Patients may not be comfortable voicing their agendas for a number of reasons; they may feel intimidated, fear that they are not showing respect by questioning diagnoses or medication, or feel that their opinions are not valued in the consultation. They may also not want to be seen as malingering or as being “neurotic” about their health. Therefore, physicians need to cultivate an open, nonjudgmental approach, and actively seek patients’ agendas. This may increase consultation time in the short term, but may improve patient satisfaction, health outcomes, and reduce resource use in the longer term.