BACKGROUND: Exploring all patient's requests during a medical encounter represents a difficult task. In some encounters, the patient raises a new problem just at the end of the visit, which has been called the ''by-the-way'' syndrome. Little is known about the content of the questions asked and physician response. We aimed to analyze this syndrome, physician response to it and the predictors of its apparition.
METHODS: We videotaped a gender-stratified random sample of 24 encounters in a primary care outpatient clinic. Patients were aged 19-90 and 50% were women. We performed a qualitative and quantitative analysis of patient-physician encounters and examined the predictors of the apparition of the ''by-theway'' syndrome, defined as a new problem raised by the patient during the closure of the encounter. The content of the ''by-the-way'' syndrome and physician response were classified in three categories: biomedical, psychosocial and biopsychosocial by two independent investigators (kappa=0.82 and=1.0 for the category of the question and response respectively).
RESULTS: The ''by-the-way'' syndrome occurred in 37.5% (9/24) of office visits. The content of this syndrome was biopsychosocial in 67% of encounters, psychosocial in 22% and biomedical in 11%, while physician responses were mostly biomedical (67%). In 78% of encounters, the content of physician response was not concordant with patient's question. To a patient who said he was ''anxious about an eventual positive response to an HIV test'' (biopsychosocial question), the physician did not give any response to the anxiety and added she ''never gives the results by phone'' (biomedical only answer). The visits with a syndrome were not shorter than those without (34 vs. 24 minutes; p=0.08). Questions about the patient's agenda at the beginning of the office visits was not significantly associated with the apparition of such a syndrome (44% in the group with the syndrome vs. 67%, p=0.29), but questions about patient's own agenda during the continuation of the encounter was (22% vs. 67%, p=0.04).
CONCLUSIONS: The ''by-the-way'' syndrome is mainly of biopsychosocial or psychosocial content, while physician response is usually biomedical. Asking a question about the patient's own agenda during the continuation of the office visitmight decrease the apparition of this syndrome. Teaching should focus on a more appropriate physician response to the ''by-the-way'' syndrome.