How would you react if you sent your sputtering car to the auto mechanic, and they stopped trying to diagnose the problem after 15 minutes? You would probably revolt if they told you that your time was up and gave back the keys.
Yet in medicine, it's common for practices to schedule patient visits in 15-minute increments — often for established patients with less complex needs. Physicians face pressure to mind the clock while they examine you.
That’s not to say that your physician "clocks out" as soon as your 1 p.m. appointment hits 1:15, or that all appointments last that long. What it does mean is that patients and doctors may be deprived of the opportunity for more meaningful discussions about the underlying causes of their problems and plans to improve them. A woman in her 50s who presents with high blood pressure and obesity might need medicine. But a longer conversation about the stresses of being the primary caregiver to her father, who has Alzheimer's, could help provide strategies to help her look after herself.
When you see a new patient every quarter hour, there is often scant time to get to these root causes, to make accurate diagnoses, and develop the best treatment plans. And there is the danger that you miss a major diagnosis altogether.
The 15-minute appointment arose not out of evidence that it improves patient outcomes but out of production pressures — both the need to meet patient demand and to see enough patients to stay profitable.
Unpopular among patients, these production pressures have few fans among physicians either. A Mayo Clinic report stated that 54 percent of physicians meet the criteria for burnout in 2014 — up nearly 10 percent from three years earlier. Running on a treadmill all day in 15-minute sprints likely contributes to this phenomenon. Onerous documentation requirements and other pressures don't help, either.
Some patient problems could be solved in 5, 10 or 15 minutes, but others cannot. What if health care trusted its physicians enough to take the time they need with patients and no more — and then monitored and paid for results? Could we realize better care while reducing costs, because patients are getting the right diagnosis sooner, and not coming back after their problem has been missed and their condition has worsened?
It's not clear whether alternative payment models will achieve this. Concierge practices, in which patients pay a hefty annual fee in exchange for greater access to their physicians, may work well for those who can afford it. While this model is beyond the financial reach of many, a related model called direct primary care — or "concierge care for the masses" — is more accessible. Patients pay a monthly fee of anywhere from $25 to $85 to cover their primary care services, according to a Health Affairs report in December, and are encouraged to have insurance to cover more serious health issues. Patients and physicians might have 45 minutes to spend in an appointment. Because direct primary care usually does not bill insurance, it results in less checking boxes and more conversation.
A criticism of these models is that they may exacerbate the larger physician shortage, because physicians are responsible for significantly fewer patients than in a typical practice. Yet we need to evaluate their impact and see if their lessons might help us reclaim the patient-physician encounter.
This post first appeared in The Wall Street Journal's blog, The Experts.
Society wants great care but is unwilling to pay for it. As an anesthesiologist I see plenty of patients whose underlying disease is just not well controlled (e.g. A1c of 10.0). And this is in the perioperative period. These are good docs who are simply too time pressured to take the time it takes to teach the obese Type II diabetic how and what to eat. Mid levels are fine, mostly, but they lack the expertise physicians develop over a training period that is far more rigorous than that of a mid level. Yet society pays the doc the same as a mid level for an office visit. I wish I had a solution, but since we "providers" (I HATE that term) have given up control and patient advocacy, I have no idea what it is. And don't forget how much time we now spend doing data entry. That time comes at the expense of patient care. Give it a ponder- has the EMR helped or hindered care? Comments?
EMR in its current state is hindering healthcare but at the same time it has great potential to help and be a great asset to physicians and patients. It is here to stay so a very strong and influential partnership between physicians, medical system IT managers and the EMR vendors needs to bring the EMR technology originally developed in the 1980s into the 21st century. Or maybe create a consortium and use an open source model of development which has been very successful in software engineering circles which is both faster and more responsive to adapting to rapidly changing needs. It is appalling what is being offered today and what it can and needs to be. For example, my dog gets full color graphical results of blood tests while Meditech prints out human blood test results in text-only dot matrix format! You can fight City Hall and you can collaborate with Meditech and the other EMR providers to provide physician and patient centric EMRs or build a consortium that produces an EMR product that is efficient to fill out, highly effective to use and highly adaptable to need.
In your example of a doctor being too time pressured to teach diabetic patients, is best remedied with a more up-to-date approach, a multidisciplinary approach in which the patient is the focal point. The VA uses a wonderful multidisciplinary approach model called PACT (Patient Aligned Care Team) which includes the MD, nurse practitioner, registered nurse, and any other disciplinary member as needed. I understand your frustration that you HATE to be referred to as "provider" as I am a nurse practitioner and find it offensive to be referred to as a "mid-level".
This article seems a great argument for an revolution in healthcare systems rather than the small evolutionary models being mentioned here that do little for both the physicians or the patients interests in delivering and receiving quality healthcare. If the unanimous accord on Climate Change between 195 nations in Paris this past December can happen, so can a revolution in healthcare where optimism and collaboration and mutual interest by all parties -- physicians, patients, insurance companies, medical product developers including EHR, and governments -- can happen. Please see this TED talk on the inside story of the Paris agreement for inspiration for thinking in a new way about creating a healthcare system where physicians are energized once again and enriched by their meaningful role in healthcare.
The 15 minute visit, if not less for some providers started back in the 80's. I remember when I was a practicing adult NP in NYC, the attending physicians from the attached teaching hospital had to go with the new HMO with the scuttle going around then of five patients per hour. We know short visits and stressed practices are not new, and getting worse. There is a great deal that needs to be fixed in our current, often dysfunctional model of health care. 15 minutes is often not enough just for the physical aspect of the visit. What about the psychosocial concerns and education! Education, real, meaningful education, often is absent or a blip.Having just left home care nursing I saw example after example of patients whose needs outstripped the short visits some received. But, on the flip side, I saw physicians who give as much as they can, with the help of practice case managers and committed staff nurses who contact and follow up with patients. The visit is really but one aspect of care, however, that's where other needs are identified. If that fails patients can fall through the cracks with negative yet preventable outcomes.
As someone who works in suicide prevention and has treated suicidal patients for 30 years - and who trains medical students and psychiatry residents - it remains impossible for me to imagine how doctors working in the 15-minute model can possibly fully engage a suicidal patient and have a meaningful conversation about the only real existential question any of us humans ever face. Of all the risks mentioned thus far, failing to detect, assess, and manage suicide risk seems to me to be a high order of priority, particularly given the research that last professional contact before death by suicide is usually with a physician. Among older adults who take their own lives, fully 58% have seen their doctor in the past 30 days. And older people premeditate and plan their suicides with care, resulting in a high case fatality rate for attempts (1 in 4 dies on the first try vs. 1 in 25 across the age span). I'm curious how others feel about the 15-minute model and the emergent obligations to screen for suicide risk and, in some states, assess and manage that risk? Can it even been done with time constraints?
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Does anyone feel that Telemedicine has any potential to help here? It changes the value proposition for the patient significantly. Instead of losing 2 hours or more to go to the doctor's office, the patient can use their smart phone. There is no question that not all patients will qualify or that all encounters could be done over the phone, but some encounters could be done this way. Any thoughts?
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