Today’s question is a simple one. How many patients can a physician see in one day and still be thorough? Don’t get me wrong; I’m all for efficiency. But we need to recognize when efforts at efficiency become “medical sloppiness” or, frankly, malpractice.
With health care policy and insurance reimbursement what they are today, it’s not uncommon to encounter physicians seeing forty, fifty, and even sixty or more patients a day in the outpatient setting. The truth is, though, no matter how experienced the doctor, no matter how technologically streamlined the practice, one physician can’t maintain medical accuracy at that frenetic a pace. Many physicians like to think they can because they manage to see every patient on their schedule and do their thing. But, in most instances, good medicine simply can’t be practiced in five to seven minutes.
Sure, there are cases where that is all that’s required. A young, healthy patient, a simple physical, or a stable patient that just needs a medication refill can usually be handled that quickly. But I often see physicians trying to care for medically complex, older patients on multiple medications in the same fashion. The rationalization is usually that, with enough experience, one can take care of these patients just as quickly. But the issue, then, becomes precisely what constitutes “handling” a patient.
A patient with a complex medical history always requires more time. Trying to argue otherwise is simply intellectually dishonest. You can’t take a history, no matter how focused, reconcile all current medications looking for undesired interactions or required modifications, review labs, monitor patient progress, look for better therapeutic approaches, address new issues, encourage communication, conduct a thorough physical exam, and spend time on health counseling / preventive care in five to seven minutes. It just can’t be done that quickly with these patients.
I’ve worked in offices where this level of “efficiency” is touted as the future, the result of effectively leveraging new technology. But the truth is, as much as it pains me to say it, it’s just bad medicine. And the argument that a particular practice doesn’t have that many complicated patients is, in most cases, yet another fallacy.
Complicated patients are not to be confused with medically interesting patients. Many of the most common chronic illnesses that find their way into physicians’ offices are, in fact, not interesting or exciting for seasoned medical professionals. After all, diabetes isn’t exactly extraskeletal myxoid chondrosarcoma or any of the “sexy” hemorrhagic fevers, but that doesn’t mean it isn’t an exquisitely complex illness requiring a thorough clinical approach.
So the average primary care physician may not have many “medically interesting” patients, but they probably do have many complex patients. I would argue that if any practice has a significant amount of patients over the age of fifty, then seeing more than about twenty-five to thirty patients a day is irresponsible. Seeing three to four patients an hour yields a number somewhere in that range. And while some patients can be “handled” more quickly than others, once you go above that number in one day you’re entering dangerous territory.
If you look at the available data and the current incidence of obesity, heart disease, hypertension, diabetes, and depression to name a few, then any practice serving patients over the age of fifty must, by definition, have a good number of complex patients. Although common, none of these illnesses are “simple.” Quick refills, not listening, not asking probing questions, shoddy physical exams, not looking for all possible signs and symptoms of disease progression, poor or no counseling, and not actively staying ahead of a disease are all poor practice. More importantly, those practices lead to poorer patient outcomes and increased health care costs in the long run. That is particularly true with this patient population.
The challenge, of course, is that our current system still rewards speed and procedures much more richly than patient interaction and thorough analysis. Although not a new concept, as reimbursement continues to decrease necessarily (Medicare’s pockets aren’t as deep as they used to be) and more patients gain access to the system, addressing the question of “medical speed” will become increasingly important.
Admittedly, the thoughts presented here are only based on anectdotal evidence collected over several years of working with numerous physicians, in multiple settings, and at several different hospitals. However, I do believe there is a trend here. The more “evolved” our health care system becomes, the more pressure is placed on physicians to leverage technology and see more patients, the more bad professional habits are being developed. Technology can help increase efficiency, but it can’t yet replace ample time with an interested, compassionate, well-trained physician. Not every patient requires thirty or forty minutes, but if we’re going to be honest, forty or more patients a day is simply ridiculous.
I would challenge all physicians to honestly evaluate how long they spend with complicated patients. More importantly, I’d be interested in knowing how they define a complex patient. And I would question any definition that doesn’t include even the most common chronic illnesses. No matter how “boring” these may be, their intrinsic complexity and impact on public health certainly justify more than a few minutes of diagnostic effort, even with routine follow-up visits.
I would also encourage all patients to expect more from their doctors than a couple of questions and some quick advice in five to seven minutes. If you’re there for a simple cold, then maybe that approach is appropriate. But if you have a chronic illness and are concerned by some new symptoms or recent changes in your overall health, you should expect much more from an office visit.
And finally, I would encourage all policy makers to recognize the valuable role physicians play in our society. We need policies that encourage them to do their jobs properly instead of punishing them for it. Ultimately, though, it’s up to physicians to choose. I hope they are true to their training and show humility in the face of complex, albeit common, diseases. It’s a shame to simply toss all that “medical school stuff” out the window simply because the system is currently what it is.