Background: Although studies have demonstrated that physicians often fail to elicit the full spectrum of patient concerns, few studies have described the ways in which physicians elicit concerns and the extent to which they set an explicit agenda. Methods: We performed a qualitative analysis of audio recorded, transcribed routine patient-provider encounters from the Enhancing Communication and HIV Outcomes (ECHO) Study. We developed themes related to whether and how providers elicit patient concerns and then set an agenda for the visit. We developed a coding scheme that we applied to a random selection of 2 encounters per provider (33 providers, 66 encounters total). Findings: In 41/66 encounters, providers opened the visit with a general question (“How are you doing?”). Seven visits opened with a leading question (“Everything’s okay?”) and 1 with the provider explicitly asking which concerns s/the patient wanted to discuss. Patients more often responded to these opening questions with brief positive statements (“Fine”, n=30) than with actual concerns (n=14). In 12 encounters (18%), the provider continued to elicit concerns until the patient stated that s/he had no further concerns (probe to exhaustion). In 30 encounters, there was no agenda statement. When an agenda statement was made, it most often (n=20) centered on physicians’ priorities. Rarely, there was an agenda statement made by the patient (n=3) or one that was collaboratively negotiated (n=3). In 53% of encounters (n=35), patients brought up new concerns later in their visit. Implications: Providers frequently use generic opening questions that may not be effective in eliciting patients’ concerns, and then do not continue to elicit further concerns. Negotiation of the visit agenda is rare, and new concerns continue to arise later in most encounters. Providers need further training to more effectively invest in the beginning of each encounter. Word Count 293 KEY WORDS HIV - communication - decision-making preferences  

1. Agenda-setting in Routine Ambulatory Encounters: The Practical Limits of Patient Autonomy Zackary Berger, MD, PhD Mary Catherine Beach, MD, MPH Johns Hopkins University Baltimore, MD United States

2. Who controls the conversations?

4. What is ‘supposed to’ happen? Allow patient to tell story Don’t interrupt Probe to exhaustion ‘Is there anything else?’ Set explicit agenda

5. Study Purpose To determine the ways in which physicians elicit patient concerns and set an explicit agenda for the visit

7. Opening of the Visit

8. Patient Response

9. Further Solicitation of Concerns

10. Agenda Statements

11. Summary Providers frequently use generic opening questions these are not effective in eliciting concerns then do not typically continue to probe further Patients response to generic opening questions suggest that they function as a social exchange rather than genuine exploration of patient priorities

12. Summary Agendas are not often explicitly stated When an agenda is stated, it tends to center on physicians’ priorities Negotiation of the visit agenda between patient and provider is rare

13. Conclusion Patients cannot possibly be empowered to engage effectively in a routine outpatient encounter if they are not given the explicit opportunity to state their priorities and they have no idea what the agenda for the visit might entail

14. Recommendations Needed: Interventions to educate physicians and patients about how to most effectively discuss/express concerns and set an explicit visit agenda Physicians ought to be aware that a question such as ‘How are you?” is not always interpreted by the patient as an opportunity to express their concerns Patients should be empowered to express their concerns and negotiate the agenda