MANAGED CARE April 2001. ©MediMedia USA
Recent studies have measured the length of time doctors and patients spend together in the exam room. Contrary to urban legend, the duration of primary care office visits has not shortened over the last decade. It has slightly lengthened, with HMO patients having longer visits than patients with other kinds of coverage. (In addition, there is evidence that the content of HMO visits tends to be more substantive.)
Nevertheless, the myth of increasingly diminutive office visits persists. Sometimes this comes up as simple HMO-bashing, where it can be dismissed as propaganda. Occasionally a thoughtful question arises, "OK, but doesn't the visit seem shorter — even if it's not?"
To grapple with this perception, we've got to move the discussion beyond time in the exam room, and analyze what is going on in there. I argue that, relative to its agenda, the office visit — longer than ever — is still too short.
Einstein was among many who've noticed that time passes at different rates, depending on the speed of one's train. In today's primary care, the train is pulling a lot more cars than it used to. I believe the primary care agenda now packs more into the traditional office visit than it can accommodate, mainly because patients are receiving better care.
The laws of physics limit what the best doctor and patient can achieve in a given visit, and contemporary practice has crashed into this barrier — physicians just haven't acknowledged it yet.
First, let's dispel a bit of nonsense, that managed care busywork fills the office visit with needless tasks. This is a red herring. Granted, managed care adds some clerical and organizational burdens to the clinical encounter which, in the abstract, don't directly bear on healing the sick. In most offices these are negligible.
"What about referrals and formularies and precertification and all that?" you gasp.
Sorry. Clerical nuisances aren't the problem. First, much of the clerical load in primary care is borne by staff, not physicians. It doesn't have a measurable effect on exam room time.
Informed consent
Second, the management tasks that do necessitate time in the exam room mostly fall under the rubrics of informed consent and case management — vital duties shamefully neglected in many care settings (managed or not). These are ethical responsibilities physicians owe patients via advice and assistance in navigating the health care system.
No ethical physician can say, "Devising a screening strategy for colon cancer to suit your risk and psychology, enlisting a specialist to collaborate, and arranging it within your financial means is not practicing medicine." Of course it is!
The perception that management is extraneous to patient care is a rampant delusion in medical training and practice — that health care is provided by physicians hermetically sequestered in private little booths, oblivious to the grand systems outside.
The record keeping, referrals, prescriptions, and communications that do occupy an increasing part of the clinical encounter are inescapable, because the delivery of health care involves so many interdependent systems.
This being said, none of these issues is the real problem. What makes the office visit perplexing today is enormous pressure from improved standards of care. We now expect screening, discussion, investigation, education, and intervention for conditions unknown in previous generations.
90-minute minimum?
Every day, the number of diseases and risk factors into which we are able to usefully intervene grows. Every season, a new screening criterion emerges, a new set of guidelines is adopted, a treatment is released for a previously untreatable condition, a subtle therapeutic distinction is recognized. All are absolutely beneficial to patients, and all are taking more time in the exam room. Even the healthiest patients require a visit that's hard to complete in under 90 minutes.
We might move briskly through the family/genetic pedigree, touch lightly on depression and substance abuse, and skim over domestic violence and handgun safety so that we can dwell a bit on sexual history, preferences, and orientation.
Without delving too much into exercise and nutrition, cardiovascular status, and attention deficit disorder, we must hasten along to occupational, travel, and environmental exposures — so there will be time to touch on medication history and adverse reactions, current medications and interactions (prescribed and non), as well as to quickly survey alternative therapies, vices, and habits.
Of course, we still need to update the problem list, procedure log, and immunization history before climaxing with the piece de resistance: laboratory tests. The visit at some point includes a ceremonial auscultation with stethoscope and the illumination by various light sources of places where sunshine is rare, but these only occupy a trivial portion of the exam.
All this might conceivably be possible before all air in the room is exhausted, if the clinician can avoid the fatal trap of asking, "Now, do you have any questions for me?"
It isn't "inconsequential care" that crowds doctor's time — it's care, period. Standards are more rigorous, options wider, treatments more numerous, and patients far more discerning.
Be careful what you wish for — especially if it's an informed patient with a DSL modem. Even the well population needs more intervention than ever before — especially with the advent of genetic screening. I believe we have exceeded the practical limits of what can reasonably be accomplished in the old-format, 15-minute visit.
Fewer conditions every year can be managed with a shot of penicillin and a slap on the back. (Besides which, it's inadvisable to slap people these days, never mind where.)
There is a lot of talk, some of it insightful, about the relationship between the pace of practice and professional satisfaction. Clearly a percentage of physicians are unhappy because of time pressure, totally apart from finances, liability, technological imperatives, and other stresses.
Many doctors who feel inordinately fatigued at day's end have not accurately identified the true source of their misery. In my analysis, the blame should be placed on two sources: obsolete expectations about the content of a typical encounter and obsolete information systems that are grossly inadequate for today's demands.
We still need to re-engineer the patient encounter, and more systematic thought needs to be devoted to this. Remember that, the next time you are falling behind schedule because someone wants you to explain fibromyalgia one more time.