To the consultation, the patient brings ideas, concerns, expectations, feelings and emotions related to his health problem. These areas are often grouped together and called the “Patent’s Agenda”. Some of these emotional concerns may be explicit “Open Agenda”, but a large part may never be expressed openly if doctors do not proactively elicit them. In 1981, Barsky, an American psychiatrist, gave a name to this assortment of hidden concerns; he called it the “Hidden Agenda”. An important objective of a medical consultation is to understand as much as possible these hidden emotions. Unless the doctor is able to fathom these, the patient may only be left with therapy that will treat his most obvious symptoms but not resolve the underlying problems.

1. 7

2. Lecture Outline
 Definition of the Hidden Agenda
 The Biomedical Vs. Biopsychosocial
Model
 Health, Disease and Illness
 Family Physician & The Hidden Agenda
 Reasons behind Hidden Agendas
 How to uncover Hidden Agendas

3. Introduction
 To the consultation, the patient brings ideas, concerns, expectations, feelings and
emotions related to his health problem. These areas are often grouped together and
called the “Patent’s Agenda”.
 Some of these emotional concerns may be explicit “Open Agenda”, but a large part
may never be expressed openly if doctors do not proactively elicit them.
 In 1981, Barsky, an American psychiatrist, gave a name to this assortment of hidden
concerns; he called it the “Hidden Agenda”.
 An important objective of a medical consultation is to understand as much as possible
these hidden emotions.
 Unless the doctor is able to fathom these, the patient may only be left with therapy
that will treat his most obvious symptoms but not resolve the underlying problems.

4. The Patient’s Agenda

5. Definition of the Hidden Agenda
The term Hidden Agenda
refers to the covert conscious
or unconscious ideas,
concerns, expectations, fears,
and feelings that underlie a
patient’s request for a medical
consultation

6. Roots of the Problem
 With the latest medical advances, doctors turn more and
more to machines, and consequently, their basic intuitive
human abilities decline and the skill to recognize the
patient’s hidden feelings and concerns is correspondingly
diminished.
 In specialist practice, the focus of attention in the
consultation is on the BIOMEDICAL aspects of the
patient’s illness ignoring the PSYCHOSOCIAL factors
involved in the pathogenesis of the disease.
 Such an approach results in an imposition on a frustrated
patient the doctor’s own agenda and views instead of an
understanding of the patient’s perspective on his health
problem.

7. The Biomedical Vs. Biopsychosocial Model
 The biomedical model attributes a key role to
biological factors, and pays less attention to the
possible effects of psychological or social
influences.
 The model focuses on the physical processes
that affect health (e.g., biochemistry, physiology,
and pathology of diseases).
 According to this model, good health is the
freedom from pain, disease, or defect.
 In this model, each illness has one underlying
cause, and once that cause is removed, the
patient will be healthy again.
 As a result, the patient plays a relatively passive
role, whereas physicians assume responsibility
for fixing the problem, which is biologically
based.
The main determinants of health
Biological Factors
Endogenous
Age
Sex
Weight
Genetic
Immunity
Exogenous
microorganisms

8. The Biopsychosocial Model
 The Biopsychosocial Model views illness as
caused by a multitude of converging Biological,
Psychological, and Social factors emerging
from both outside and inside the person.
 As a result, patients are asked to actively
collaborate with their physicians instead of
playing a passive role.
 The Biomedical Model limits the role of the
physician to the diagnosis and treatment of
DISEASES. While, The Biopsychosocial Model
expands the role of the physician to that of
coping with ILLNESS and searching for
conditions that contribute to the patient’s
suffering.

9. Health, Disease and Illness
 HEALTH is a state of complete Physical,
Mental, and Social well-being, and not
merely the absence of disease or infirmity.
 DISEASE refers to an abnormal,
pathological state that affects the
structure and/or function of body organs
and systems.
 ILLNESS refers to the subjective sense of
feeling unwell (e.g., discomfort, tiredness,
and general malaise) that often motivates
a person to consult a physician.

10.  Patients routinely bring more than one concern
to the interview.
 Importantly, the order in which patients present
their problems is not related to their clinical
importance, they may withhold the main concern
until later in the visit when the patients have
gained confidence in the doctor.
 Unfortunately, many doctors falsely assume that
the first concern or symptom mentioned is the
main one.
 Further, doctors interrupt early in interviews, and
therefore this approach leads to failure in
discovering The Patient’s Full Agenda.
THE Doctors’ Weak Points

11. Family Physician & The Hidden Agenda
 Family physicians, in their daily work, see
problems that are often undifferentiated and
encounter patients with vague distress or with
symptoms for which no physical basis can be
found.
 Family physicians are in the best position to
observe the close and complex relationship
between physical illness and the inner
disharmony of the mind and the emotions.
 The adoption of a comprehensive
Biopsychosocial Approach will enable the
family physician to recognize the Hidden
Agenda of his patients.

12. Reasons behind Hidden Agendas
1.Reassurance: A person who requests for a check-up for a
symptom that seems trivial or not respectable should alert the
doctor to explore the underlying reason, which may well be a
specific fear for which the patient seeks reassurance.
2.Problems of living: Persons who are burdened by problems of
living that have disturbed the equilibrium they have established
with their environment, may report physical health problems
rather than reveal the origin of their difficulties.
3.The need for a sick role: Many people who require certification
of ill-health begin the consultation with a description of
symptoms rather than initially demanding a sick certificate.

13. How to uncover Hidden Agendas
 The Patient’s Hidden Agenda need to be deciphered in
order to prevent patient dissatisfaction with the level of
care that is provided, to the scheduling of unnecessary
tests and follow-up consultations, or to the patients’
symptoms being left unevaluated and untreated.
 The understanding of the patient as a human being with
an illness requires an empathetic personal relationship
and the adoption of a Patient-Centered, Holistic approach.
 Importantly, there are three related communication skills
that may enable the doctor to recognize the hidden
agenda of his patients:
1. Attentive listening
2. Screening
3. Summarizing

14. Attentive Listening
 The doctor should allocate the first few minutes of the interview
to the patient, and concentrate on listening and facilitating
rather than questioning.
 Unfortunately, after the greeting, it takes the physician, on
average, about 18 seconds to interrupt the patient.
 Without interruption, patients spontaneously complete their
stories in under 2.5 minutes. That two minutes is rich in history,
and it is best to simply listen.
 The doctor needs to listen carefully to the patient’s verbal and
non-verbal cues.
 Attentive listening serves a number of purposes in medical
interaction:
 Allowing hearing the patient’s story.
 Demonstrating interest in, and respect for, the patient.
 Preventing making premature hypotheses.
 Reducing late-arising complaints.
 Providing reassurance and reducing anxiety.
 Helping to appreciate the patient’s perspective.

15. Screening
 After the patient has finished speaking, the doctor should
check that he has extract all the concerns the patient may
have.
 The “What else?” technique can help the doctor to uncover the
patient’s pertinent fears and anxieties up front and prevents
late-arising complaints.
 If the patient continues, the doctor must resume listening until
the patient stops again. Then, the doctor may repeat the
screening process until the patient says that he has finished.
 Additionally, the doctor can confront the patient by expressing
observed dis-ease like, “you look unhappy” or “something
seems to be in your mind”. Such an approach allows the
patient to admit to anxieties and share his emotions and fears
about an underlying problem.
What
else?

16. Summarizing
 At the end of the screening stage, the
physician must ensure that he
understands the patient’s real agenda
by Summarizing.
 Then, the doctor can start to explore
each area in more depth, secure that
he has a broad overview of the
patient’s problems and able to
undertake more effective diagnostic
reasoning.

17. Case Scenario
– Doctor: “Hello, Mr. Jamal. My assistant tells me you are here about your cold.”
– Mr. Jamal: “Yes, that's right.”
– Doctor: “I want to cover that in detail; however, I was wondering if you were hoping to cover any other
concerns today?”
– Mr. Jamal: “Yes, Doctor, I wanted to mention my sore shoulder.”
– Doctor: “I see. Your shoulder hurts. Anything else?”
– Mr. Jamal: “My blood pressure has been acting up.”
– Doctor: “OK. Any other concerns?”
– Mr. Jamal: “Well, I was a little concerned that the pressure in my chest might be from my heart and not only
this cold.”
– Doctor: “I can see how that might be a worry for you! We definitely need to discuss that. What else?”
– Mr. Jamal: “I think that is everything.”
– Doctor: “So, as I understand it, you have a cold with some chest pain that you have been worried about.
Your shoulder has been hurting too. And your blood pressure is of concern to both of us. In our time
allotted today, I would like to cover the most important items. I recommend we deal with the cold symptoms,
the chest pain and the blood pressure today. I'm concerned about the shoulder too. Would you consider
another appointment in the near future to cover it?”

18. Important Notes
 Already mentioned recommendations encourage but
do not guarantee early problem identification, and the
doctor must still remain open to late-arising
complaints.
 There are two warnings to mention:
1. The doctor must not be too obsessed with the
hidden agenda to the extent of ignoring biomedical
aspects of a complaint–trying to heal the patient
without curing him.
2. It is important to seek the patient’s concerns even
in a seemingly straightforward organic problem
like varicose veins, cholecystitis, or asthma.
Otherwise, the doctor may cure a patient without
healing him.

19. Further details about Hidden Agenda have been discussed in my
book "Essentials of Practicing Family Medicine".