What is the best way to establish a shared agenda for a visit with a patient with COPD, hypertension, and hyperlipidemia after hospitalization?

Establishing a Shared Agenda in Post-Hospitalization Medication Reconciliation

The best approach to establishing a shared agenda with this COPD patient is to say: "I'm hoping that we can review any medication changes that happened as a result of your recent hospital stay, but before we do that may I ask if there are other issues you would like to discuss so that we can decide how to spend our time today?"

Rationale for This Approach

This approach is optimal for several reasons:

1. Acknowledges the primary purpose of the visit (medication reconciliation) while recognizing the patient may have additional concerns

2. Elicits the patient's agenda early in the encounter, which research shows is critical but often overlooked in clinical practice 1, 2

3. Creates a collaborative framework for prioritizing discussion topics, which improves patient outcomes and satisfaction

4. Prevents "doorknob moments" where patients bring up important concerns at the end of visits 3

Why Other Approaches Are Suboptimal

The other options have significant flaws:

• "Let's plan to review medication changes... then discuss other issues if there is time left" - This approach relegates patient concerns to secondary status and may discourage the patient from mentioning important issues

• "Because our appointment was originally scheduled for reviewing medications... I'll pass along other concerns to your PCP" - This approach dismisses patient concerns and fragments care

• "Would it be OK with you if we reviewed medication changes?" - While respectful, this approach fails to explicitly invite the patient to share their concerns

Importance of Agenda Setting in COPD Care

For COPD patients post-exacerbation, proper agenda setting is particularly important:

• COPD exacerbations are associated with increased morbidity and mortality 4
• Comprehensive education with action plans and case management reduces hospitalizations and ED visits 4
• Pulmonary rehabilitation is strongly recommended after hospitalization for COPD exacerbation 4

Best Practices for Agenda Setting

1. Ask about the patient's concerns early in the visit - research shows clinicians often interrupt patients after only 11 seconds 1

2. Use open-ended questions that invite discussion of "concerns" rather than just "questions" 2

3. Negotiate priorities together when time constraints exist 3

4. Acknowledge time limitations transparently but avoid making the patient feel rushed

5. Document concerns that cannot be addressed during the current visit and create a plan for follow-up

Common Pitfalls to Avoid

• Interrupting the patient before they finish stating their concerns (most uninterrupted patients take only 6 seconds to state their concern) 1

• Focusing exclusively on the medical agenda without addressing the patient's priorities

• Allowing "late agenda items" to emerge at the end of visits, which disrupts visit flow 3

• Failing to explicitly negotiate priorities when time is limited

By using the recommended approach to agenda setting, you establish a patient-centered foundation for the visit that acknowledges both the medical necessity of medication reconciliation and respects the patient's autonomy and concerns following their COPD exacerbation.