Maybe It's Time to Slow Down the Pace of Medical Treatment
Tuesday, September 15, 2009
"This felt more like a tea party than a doctor's appointment," a patient observed as we wrapped up our first clinic visit.
I had served him tea and even poured a cup for myself. But what really impressed him was that we sipped our brews at leisure and even got a refill.
My patient had just been the recipient of a rare and highly valued medical commodity, a treatment that is as quantifiable in its effects as the milligrams of a medication or the number of stitches in a wound: Time.
Ten years ago, as I contemplated opening my own family medical practice, "more time" was my mantra. I had spent several years working in both private and public clinics and desperately wanted to escape the 15-minute office visit. Realizing that this amount of time is simply what most doctors consider feasible once the costs of running a practice are subtracted from revenue, I decided to shift the balance: I designed a practice with very low overhead, principally by eschewing private insurance contracts, which devour not only time but about 45 percent of the overhead in many practices.
The Society for Innovative Medical Practices recently reported that more than 5,000 primary care physicians have made similar choices, adopting a range of models from concierge care (where patients pay a set fee each month) to fee-for-service. My practice, which does contract with Medicare, uses a sliding-scale, fee-for-service model, and patients pay according to their income.
In all honesty, my impetus for change was selfish. I could no longer stand my regular voyage into the realm of exhaustion and fear: exhaustion from days spent running from room to room and nights spent finishing incomplete medical charts; and fear that the patient may have revealed the most critical health complaint -- the chest pain, the blood in the stool -- just as I was scuttling out the exam room door.
But a desperate measure to improve the quality of my life has proved to have an even greater impact on the quality of care I deliver to my patients. Sometimes this extra time leads to the subtle clues that finally clinch an elusive medical diagnosis. For example, earlier this year, nearing minute 30 of our appointment, a new patient mentioned her broken heater. This seemingly random piece of data helped us figure out that carbon monoxide poisoning was the cause of her headache and fatigue, two debilitating symptoms that had already prompted several 15-minute medical visits as well as a slew of expensive but inconclusive tests.
More time also allows patients with complicated health issues to express their desires and for their doctors to develop an individualized treatment plan.
Recently, I saw a woman with autoimmune hyperthyroidism who, despite the warnings from her endocrinologist, wanted to forestall any treatments that would lower her thyroid levels. What she had discovered was that her overactive thyroid was helping her melt away the extra 60 pounds that she had been struggling, for more than 20 years, to lose. After taking time with her (and conferring with her cardiologist and endocrinologist), we agreed that the extra weight was probably the source of her pre-diabetes, hypertension and severe sleep apnea and that, although this approach was unorthodox, we would monitor her for ill effects and let her thyroid disease help treat her other health problems. In my previous incarnation as a 15-minute doctor, I would simply have viewed her as a noncompliant patient and insisted that she take her thyroid medication.
One of the most fascinating outcomes of manipulating the time variable is that I have garnered a reputation as an "integrative physician." When I opened my practice, I had no formal training in complementary or alternative medicine, no particular knowledge of nutrition or mind-body techniques and only a slim familiarity with herbalism, ayurveda and homeopathy. But because I listened to patients and explained the pros and cons of various treatments, they viewed me as "holistic."
Meanwhile I found that every minute spent with my patients translated into fewer prescriptions and less testing -- and, as a result, fewer side effects and unnecessary procedures.
My observations about the value of time in primary care visits are supported by studies. Thomas Bodenheimer, a professor of medicine at the University of California at San Francisco and a national expert on primary-health-care policy, has long railed against the "tyranny" of the 15-minute visit: "The shorter the time, the worse the quality of care, the worse the patient satisfaction, the worse the physician satisfaction."
He cites a recent study, not yet published, where a medical practice in Washington state took a cadre of physicians and reduced their patient load from 2,300 to 1,800 while increasing their visit length from 15 minutes to 30. At the end of a year, the researchers documented impressive spikes in physician and patient satisfaction, objective measures of quality of care and, most important to the bean counters, a drop in emergency room visits.
Given that the average ER visit costs at least 10 times more than the average primary care visit, I ask Bodenheimer why clinic visit length is not a central focus in health reform. Bodenheimer's answer: "Even if the reimbursement were to change, there are simply not enough primary care health providers to go around."
The universal coverage experiment in Massachusetts offers us a depressing illustration of this reality. Once the barrier of health insurance coverage was lifted, wait times to see an internist skyrocketed to 30 to 50 days -- and one can only imagine what would happen if they extended their office visits to 30 minutes! According to Bodenheimer's projections, we would come up short even if every future graduate of medical school (including nurse practitioners and physician assistants) were to pursue a career in primary care.
So what is the solution? Bodenheimer and many of his colleagues feel that the best option is for physicians to limit themselves to doing things "that only physicians can do." He gives the example of clinics in Sweden where physicians see only about 20 percent of patients -- the really complicated cases and very sick people -- and leave the others to a team of nurse practitioners, physician assistants, nutritionists, pharmacists, physical therapists, etc. In short, the primary care doctors become specialists.
The Swedish model deserves a closer look. Meanwhile, who knows what kind of radical changes might occur in our health system simply by extending face time? It would almost certainly result in cost savings in ER visits. It is also possible that some physicians, who refuse to work in family medicine because of the 15-minute visit, would come back once their schedules became more humane. And mightn't each patient have needed fewer visits if the ones they did have were actually substantive?
As the debate rages on about public vs. private insurance and what that insurance should and should not cover, I am waiting for a plan that pays me directly, eliminates red tape and values the time I spend with my patients.
As Bodenheimer says: "All you have [as a family doctor] is your skills and knowledge -- and time. What you can offer a patient is basically time."
For now, at least, the best thing I can do is throw my tea parties.
Daphne Miller is the author of "The Jungle Effect: The Healthiest Diets From Around the World -- Why They Work and How to Make Them Work for You." Comments: firstname.lastname@example.org.