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What happens when a doctor closes the chart but the patient leaves without understanding what was actually said? Retired surgeon, independent physician, health care consultant, and patient advocate Alan P. Feren describes what he calls “unfinishedness,” the gap between administrative closure and true clinical closure that leaves patients disoriented and adrift. His episode is based on his KevinMD article, “Unfinishedness in medicine: When a good visit feels incomplete,” Feren shares the story of his mother-in-law, who was diagnosed with very early chronic lymphocytic leukemia but only heard the word “cancer,” never grasping that her condition called for watch and wait rather than alarm. She was dead within a year. He argues that physicians routinely achieve structural closure through documentation and prescriptions while failing to make their clinical reasoning visible and understandable to patients. You will hear why cognitive overload and system pressures cause well-meaning doctors to treat a finished chart as a psychological safety mechanism, what treatment burden means and why ignoring it undermines adherence, and how patients can ask orientation-based questions to close the gap themselves. Feren also explains how AI can serve as an add-on to clinical reasoning rather than a replacement. If you have ever left a doctor’s visit unsure what just happened, this episode gives you the language to change that.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Alan P. Feren, physician and patient advocate. Today’s KevinMD article is “Unfinishedness in medicine: When a good visit feels incomplete.” Alan, welcome back to the show.
Alan P. Feren: Thanks for having me again, Kevin.
Kevin Pho: All right, tell us what your latest article is about.
Alan P. Feren: Let me preface this by saying that modern medicine has done a great job with managing complexity, risk, and documentation. We have done probably a little less good of a job with helping patients understand and become oriented. By oriented, I mean knowing what is most likely, what remains uncertain, and what to do next. As a result of that, sometimes patients will leave the office with a prescription in hand and get their after-visit summary, but they still do not know exactly what their physician has really been thinking, what remains under consideration, and what to do next. So as a result, they are going to try to understand the thinking that the clinician had about what transpired during that visit. They will seek AI and internet sources, and they may come up with misinformation and disinformation, and ultimately not follow whatever the treatment plan is.
Kevin Pho: What are some of the reasons for that? Why do you think a lot of patients come away from their visit feeling unfinished?
Alan P. Feren: Let me give you a couple of quick definitions. First is orientation, which I think is really critical. That is when a patient leaves the office and is unsure about exactly what the clinical thinking was, which is what I call the internal reasoning that the physician has. They are not sure what remains uncertain or is still under consideration. Then they may not have a complete understanding of the treatment plan or may not be able to complete the treatment plan. There is something called treatment burden. This is whether or not a patient has the mode of transportation, has the financial wherewithal, has obstacles at home, or has a childcare or daycare issue that prevents them from being able to follow the treatment plan. If the medication regimen is three times a day and maybe they are forgetful, they cannot do it. So you have that treatment burden, and I think this is a key thing that a lot of physicians fail to recognize. They send the after-visit summary and just assume that the patient is going to follow exactly what they have said. If you do not understand what the treatment burden is, then it is very hard to ensure that the patient is going to follow whatever your treatment plan is.
Kevin Pho: In what ways does our current medical training or current medical system prioritize structural closure over what patients actually need? As a physician, talk to us about the time pressures that you face that prevent you from seeing or doing everything that is required or that you need to do during a particular visit.
Alan P. Feren: First of all, I recall having a very busy day and needing to get to the operating room sometime later that day. I walk in and am already fifteen minutes to half an hour behind. I know that I only have fifteen or twenty minutes to deal with that particular patient. Some patients can be a very quick issue. For other patients, like a newly diagnosed diabetic or a newly diagnosed patient in my specialty with vocal cord cancer and a family member in the room, it takes longer. You cannot just tell someone they have cancer and we are going to do a biopsy, or that they have a nodule and I am worried about cancer, and expect that they are going to leave the office and feel comfortable. So the system pressures really favor administrative closure over clinical closure. I think that is the point that you are driving at when you ask this particular question, Kevin. I think there are many instances where you are on that treadmill, which we have discussed in the past, and you need to get all the documentation right and fill out all the boxes. As a result, you have administrative closure, but you do not have clinical closure. I am sure you have felt the same thing that I have in my past where at the end of an appointment or at the end of the day, you are starting to think back about what happened with this particular patient. There is a sense of uneasiness that comes up, and you realize that the case really was not finished. The definition of unfinishedness is when that administrative closure happens, but the patient is not oriented. That is a simple way of looking at the two definitions of unfinishedness. One is an incomplete, closed, clinically appropriate patient encounter versus the administrative closure, which is very easy, particularly today with our EMRs.
Kevin Pho: In your article, you even escalate that. You said that sometimes cognitive overload leads well-meaning doctors to treat a finished visit as a psychological safety mechanism.
Alan P. Feren: That is absolutely true. I think that we are really pushed to our limits today. Throughput is really the key. There is a lot of thinking going on and a lot of cognitive overload. You have an inbox full of emails and text messages. Your portal is brimming with questions, and you are impatient to get through. This is not because physicians are uncaring; it is because of system pressures.
Kevin Pho: Can you tell us more about the harm that can occur through an unfinished visit, even though there is not necessarily a medical mistake that can occur? Tell us why this is so important and why this matters so much to patients.
Alan P. Feren: Let me talk about the whole reasoning process. I divide clinical reasoning into internal reasoning, which is the mechanism that we use as physicians with our differential diagnosis. Then there is transparent reasoning, which is going through this clinical reasoning in a very short form with your patient. And then there is external reasoning, which is the use of AI to amplify our individual differential diagnoses. I consider AI as an add-on, not an instead-of. When you are not making your clinical reasoning visible to patients and understandable, and I am emphasizing understandable, then what happens is the patient really is not sure about what is being said and what they possibly need to do if things are starting to go off the rails. A good example for me was many years ago. My mother-in-law was diagnosed with very early chronic lymphocytic leukemia. She was asymptomatic. She came in and had a very high white blood cell count. What she heard was, “You have cancer.” What the physician did not tell her is, “This is a very early form of this particular cancer, and in early forms, it is a watch-and-wait situation.” Because she only heard the word cancer, she came home, lay on the couch, and within one year was dead. Both my wife and I feel that there was an error in not giving the diagnosis in a way that showed the clinical rationale and made that transparent and visible for her so that she understood. Yes, this can be a serious disease, and it is slowly progressive, but we are in a very early situation. We are going to watch and wait, and we are going to treat it in a targeted way when it starts progressing.
Kevin Pho: Do you have any ballpark data as to how often this happens? How often do patients leave their doctor’s visit with some questions, or have that visit feel unfinished from that patient’s perspective? How often does this approximately happen?
Alan P. Feren: I do not have a database that I can look at. I think it happens more often than we feel it does. I am sure you, Kevin, have come home at the end of the day and realized that maybe you could have done this or could have done that with such-and-such a patient. I recall a number of times where I used to dictate my charts at night before the advent of EMRs. While I would be dictating a chart, I would realize that there was something unfinished with that case. At that point, I made a phone call, which I realize is probably dating my practice days, but I made a phone call recognizing that the case really was incomplete and unfinished, and I needed to advise the patient.
Kevin Pho: Along with being a physician, you are also a patient advocate. What kind of advice can you give to patients when a physician completes their visit, but they still have questions or issues that they feel are unresolved?
Alan P. Feren: I think two things. I would like to emphasize the word orientation as I did earlier in our discussion. Ask orientation-based questions. What do you think is really going on with me? What still remains under consideration? What are the things I need to watch for or do if there is a change in my course? That needs to be absolutely clear. If it is not clear, then continue to ask questions to clarify exactly what is going on. Also, make sure that if you have a treatment plan and you know there is a barrier or an obstacle at home that is going to prevent you from adhering to that treatment plan, work that out at the time with the physician or their PA or assistant so that you can follow the advice. Physicians are really trying to do the best they can, but they need to know that information in advance.
Kevin Pho: From the busy clinician’s standpoint, tell us the first practical step that they can make tomorrow to ensure a visit reaches closure even before they start talking to patients.
Alan P. Feren: I think just a gentle reminder to themselves, a memo to self, to ensure that your clinical reasoning is made visible to that patient before they leave the treatment.
Kevin Pho: In terms of that transparency, it could be just talking it out before they do. It could be access to the note. What are some different ways they can do that?
Alan P. Feren: The after-visit summary has two components. It has what the treatment plan is, and then there are notes. Be sure that in the notes you include anything that would be relevant to that particular visit so that patients know that you were there and you were listening fully to whatever their clinical issue and presentation was for that visit.
Kevin Pho: Can you tell us a scenario or a success story of what that may look like in action? Maybe you could give a little hypothetical before and after about what a visit may look like before that closure, and then some adjustments and what that particular visit would look like after a closure. Just give us some examples so we can put some of these theories into action and illustrate that.
Alan P. Feren: Sure. Suppose you, Kevin, come in with a complaint of drainage from your ear, and you are examined by your clinician. The clinician identifies that there is an infection going on, asks questions about drug allergies, and whether or not that ear has been manipulated, for example, with a Q-tip or other instrument. Then they tell you that this is an external or outer ear type of infection, and it is very important to keep water out of the ear. They explain how you can do that because just telling a patient to keep water out of their ear is not a good suggestion. Take a cotton pad with Vaseline on it and put it in the ear when you are bathing or going to have water exposure, with no swimming, etc. Then you are discharged with a prescription for ear drops, generally not an antibiotic. Then ask the questions: “Do you understand these instructions? Is there a problem with you having access to getting those ear drops that I prescribed? Is there a problem keeping water out of your ear?” For example, maybe you are a lifeguard and you make a living by being in the water. So, ask to clarify whether or not there is a chance that these instructions cannot be followed. At the very end, explain the reasons why keeping water out of the ear is very important. It is because it exacerbates or increases the chance for recurrence or persistence. Ask, “Do you have any questions for me?” That would be a complete examination. That can be done in less than fifteen minutes. Obviously, this is a very non-complex but easy way. It is explaining the rationale, explaining your instructions explicitly, and making sure they do not have any questions for you at the very end. You can be assured that if there are no questions, there is no problem with access to the medications, and they do not seem to have any questions regarding being able to adhere to the treatment plan, that is a finished visit.
Kevin Pho: We are talking to Alan P. Feren, physician and patient advocate. Today’s KevinMD article is “Unfinishedness in medicine: When a good visit feels incomplete.” Alan, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Alan P. Feren: For physicians, take that extra couple of minutes to make your clinical reasoning transparent and visible to patients. Remember that before they leave your office and the clinical encounter, make sure that they understand what is most likely and what is still under consideration. Name that uncertainty, be very explicit about what your discharge instructions are, and ask whether or not they are able to follow them. For patients, make sure that you are oriented. Ask orientation-involved types of questions. What do I have? What else could this possibly be? What comes next? When should I call, when should I not call, and how best can I manage this based upon your instructions?
Kevin Pho: Alan, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.
Alan P. Feren: Thank you again, Kevin.
