How many patients can a doctor safely see a day?

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.

Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.

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  • BudgetDoc.com

    This is a tricky question, and one that I think is easy to try to answer in hindsight, based on results. It’s easy to say that a patient would have benefitted from more attention, or had time wasted on them, depending on the results of their care.

    • Luis Collar, M.D.

      That is true; hindsight can tell us a great deal about outcomes. But there are certain things that need to be done to fully evaluate a complex patient regardless of outcome (e.g. we are trained to perform them because they are useful and effective, but it doesn’t mean they will yield a measurable result in every case). Policies that reward “skipping” any of those, or that punish physicians for actually taking the time do them, are ill-advised in my opinion.

  • SC Doc

    The real question will be how many patients will we be pressured to see in a day when the millions have insurance and seek care from a static primary care workforce. Also considering so many of the new policies pay so little it will be a new class of medicaid. It will be an interesting year for sure…

    • Luis Collar, M.D.

      Very true… I agree that we won’t know the real impact for some time yet. But I do think there is an observable trend (not just as a result of the ACA, but rather one that has been developing for the last couple of decades). Medical care as cheap commodity, etc… Thanks for contributing.

  • buzzkillerjsmith

    Back in the day at Kaiser we saw 28 pts per day, one every 15 minutes for 7 hours. We also had “work-ins” when we got busy, so we could actually see up to 32/day. Was it unsafe? Hard to say, but I can tell you it was an exceedingly nasty job.

    I especially enjoyed the 15-minute heart attacks, when pts would walk in with an acute MI. Of course stabilizing them took more than 15 minutes (more like an hour) so then you had the rest of the afternoon seeing pts who were pissed off at having to wait.

    God am I glad I got out of there.

    • Luis Collar, M.D.

      I could be wrong, but I think that type of “efficiency” is where the system is headed. High volume, algorithm-driven, medicine-as-commodity care delivered independently by more and more “providers” etc… And I don’t believe that is a good thing for physicians or patients.

  • doc99

    If physicians were paid (yes, paid – not “reimbursed”) for their time, not cpt codes, this problem would soon disappear.

    • JPedersenB

      Using the word “reimbursement” instead of “fee” is simply bad English. I believe the reason this usage became popular is (1) because it has 4 syllables and (2) because in the old days, a patient would pay the doctor directly and then submit a claim to their insurance company to be “reimbursed.”

      • Luis Collar, M.D.

        Great observations. “Reimbursement” is the term currently used, but I agree it doesn’t make sense (e.g. you reimburse things like expenses, not professional services).

      • Sunjay R Devarajan

        Definitely true! We like to use the word because its a health-care policy wonk word but we also are uncomfortable with society seeing as greedy. Being “reimbursed” for your healing sounds better than being “paid” for doctoring.

        • Luis Collar, M.D.

          Great point on the image angle of the vocabulary used. Makes me wonder if owners of supermarkets or restaurants should be “reimbursed” for their food rather than paid for it. After all, food is even more a basic human need than medical care.

          • Sunjay R Devarajan

            Haha touche!. There is something about the vulnerability of sick people that differentiates it from everything else.

    • Luis Collar, M.D.

      Agree payment models need to be looked at to ensure that physicians’ goals are in line with patients’ goals. (Those two are usually already aligned, but third party payment, as it is currently modeled, doesn’t help keep them aligned — e.g. insurance companies / govt are the payors making decisions on resource allocation, but their interests can never be fully aligned with patients’ interests. Doctors, then, are effectively caught in the middle between the competing interests of their patients and their employers / govt / insurance companies, etc… Those entities lack the training and fiduciary responsibility to patients that physicians have, not to mention the profit / cost control motive the must make a priority.) Independent physicians have a responsibility to patients; other entities have a responsibility to taxpayers / shareholders. Reducing our reliance on those parties would help realign objectives.

  • Steven Reznick

    If you are in a student health service at a university you are certainly going to be able to see a larger patient load of mostly non life threatening illnesses that are self limited than if you have primarily an adult over 45 years of age population. Yes in my former traditional internal medicine practice I saw 20- 30 patients a day plus hospital and nursing home visits. As these patients aged and stayed in the practice the complexity of their problems necessitated switching practice models and offering them more time not less. Patients need your undivided attention and time. That time increases as they age. This is not to say there are not very complex younger patients fighting horrible diseases but for the most part older patients need more time and the author is correct in his assumptions and comments

    • Luis Collar, M.D.

      Thank you for contributing. We are in agreement. The approach to any given patient should be determined by a physician. Policies that seek to drive efficiency by forcing physicians to “move faster” without regard to individual patient needs are ill-advised.

      For accounting and tax purposes, there is a difference between an “employee” and an “independent contractor.” An employee is provided with the tools to perform his or her job and is also told how to perform the work. Technically speaking, an employee can be terminated not only for achieving poor results but also for not following company rules regarding how to perform their work, regardless of outcome. An independent contractor may use some of the tools provided or accept guidance, but they perform their jobs independently based on their own training and judgement. They can only be fired (or not paid) based on failure to achieve results or do what they said, but not solely based on how they choose to do the work. I think health care policy should reinforce the latter approach to patient care whenever possible.

    • Vikas Desai

      The problem is all the advanced level thinking involved in treating complicated patients is wholly unrecognized as a medical service and thus goes unreimbursed. no one is disagreeing with you but when every aspect the cost of your business goes up with absolutely no other way to increase revenue , , you end up seeing more patients, or closing up shop because you can’t cover costs.

  • Ron Smith

    Hi, Luis. Good article.

    Office policy and practice direction really nowadays dictate the quality of patient care. We balance the continued shrinking professional payments against the time required to give the best of our skills.

    Those Pediatric practices around me, so I’ve heard from many patients who are transferring to us, are seeing a high percentage and absolute numbers of Medicaid patients.

    Why is that?

    There is a pervasive idea that practice income increases as the number of patients seen per day increases. This thinking leads to the purely walk-in clinics. Medicaid patients, of which there are a many, for whatever reason flock to this type of access for whatever reason. Its what they have come to expect it seems.

    In Pediatrics, I found over the years, that many of the children that I saw whose parents brought them to us when we were (long ago) a walk-in clinic, had minor and sometimes obscure complaints. Their parent’s reasoning for coming was as grating as simply wanting a prescription for over-the-counter acetaminophen, and their attitude made me think that they felt compelled to abuse the system trying to provide them with descent care. It left me with a metallic taste in my mouth.

    Why did these parents see me no differently than a fast-food restaurant?

    I’ve observed in Pediatrics around me, that volume-centered practices provide grocer-like efficiencies that lead to poor patient care, dirtier facilities, unfriendly staff, and very long wait times.

    In these scenarios, increased ‘efficiency’ is, I think, the only way these practices can see themselves surviving. Seeing forty-five patients a day is not due to seasonal variabilities, but is routine.

    And this then is why we have become fast-food medical restaurants.

    My colleagues are being squeezed from all sides to cut costs and do more in less time. The only end I can see is that this bubble is going to pop like a pimple. Physicians as well as patients, I’m afraid, have bought this picture of low-end medical care as the norm.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • Luis Collar, M.D.

      Thanks for the comments. Unfortunately, I think medical care is increasingly viewed as a cheap commodity, a quick service that can be obtained from many different “providers.” While doctors struggle to keep up with decreasing reimbursement, increasing overhead and greater administrative burden, each new policy (from both private insurance and the government) is effectively reducing the profession to a series of algorithm-driven tasks that can be performed independently by others to (supposedly) drive efficiency and lower costs. I’m not a conspiracy theorist by any means, but it seems to be about much more than “reimbursement pressure” and leveraging technology. While the profession will not be obsolete any time soon, I do believe that what it means to be a physician in just ten years will be quite different than what it means right now (which is already quite different than what it was thirty years ago).

      • Ron Smith

        Hi, Luis.

        I think you are quite correct in the changing nature of future physicians.

        It is worth mentioning that when I refer to office policy, I didn’t expound on that. It is probably a worthwhile elaboration.

        Patients present to the front desk with generally one of two attitudes. Either they are controllers or non-controllers. By that I mean that they either want it their way and when and where they want it, or they are truly seeking care with the thinking that the provider and the office staff are their to serve them.

        Providers office staff also carry a banner that champions their desire to serve patients well, or their incredulous annoyance at having to deal with another bothersome patient. There is room for some in-between here of course, But I believe the attitude of the office as a whole is simply the same attitude of the controlling provider(s) or the corporate management.

        This carries the possibility of four combinations. There are good offices (i.e. those with an obvious caring attitude) interacting with good (i.e. non-controlling) patients, good offices interacting with controlling patients, bad offices interacting with good patients, and bad offices interacting with controlling patients.

        Office policy is the written expression of provider and staff attitudes. We carefully write office policy and post it on our web site so that patients can see it.

        My goal is to take good care of my children and their parents, but to make sure that the parents know that we can’t allow them to be controlling. That is one reason we don’t do walk-ins. Controlling patients inevitably encroach on someone else’s care and that is just not fair.

        We also provide exceptional access. I have a full-time position for nurse phone triage. I have a nurse facilitator who does nothing the direct and maintain good patient flow through the office. We all have email addresses and the parents of children today who are device aware, want and appreciate the modern and traditional access we offer.

        They may have come to our office with a necessarily controlling attitude from another practice, but they soon learn, that they don’t need to be controlling since we are meeting their needs in the first place.

        In contrast, offices with bad attitudes tend to attract controlling patients and repel the good patients. They tend to be volume centered as well. This is probably why ERs and Urgent Cares tend to have a poor patient reputation when I talk to my patients about their experiences. They may even be considered a ‘necessary evil.’

        The point I’m making here is that the establishment of good, written, posted office policy from providers is key. Just going through the process of thinking about and writing the policy is enlightening and will cause a provider to self-examine. He or she may well then see things they don’t like and begin to change. Once that happens, then they will begin to see results even at the check-in desk.

        Warmest regards,

        Ron Smith, MD
        www (adot) ronsmithmd (adot) com

        • Luis Collar, M.D.

          Great observations / advice. Before becoming a physician, I had the opportunity to write polices and procedures in the fields of finance and technology. The documentation process often does, in fact, elucidate opportunities for improvement and allow one to change the “culture” of a given environment.

          The process you describe is a good one that, in my experience, yields results. I would only note that, in many cases, that process does not occur or occurs under the leadership of non-physicians. For example, I have worked with / for offices that are owned by hospitals or health systems, or practices that are part of other non-physician-run business models. In those instances, it appears that there is a disconnect between those developing policies and those that are tasked with carrying them out. In short, when physicians are not in charge (or at least consulted for real input), the policies / procedures often aren’t successful at aligning attempts at efficiency with patient needs. Efficiency that leads to good outcomes is great, but efficiency for the sake of efficiency (corporate model) is often burdensome to the physicians operating in that model and ineffective at truly helping the patients being seen there.

          • Ron Smith

            Hi, Luis.

            You are so right there. I didn’t want to elaborate on that per se, but I’ve been there and seen that too.

            I’m a solo Pediatrician with two wonderful nurse practitioners and a great staff all who I value highly both professionally and as friends. I never have to wonder about them when I’m not at the office.

            I think folks who have glance at, and quickly moved on past, solo practice like I have, maybe should consider it again if they are unhappy. There is a way to be viable and enjoy caring for patients who also value us.

            Warmest regards,

            Ron Smith, MD
            www (adot) ronsmithmd (adot) com

  • Luis Collar, M.D.

    Agree on the “herd mentality” you are alluding to. In fairness, though, it would help if policymakers (private and public) didn’t so often effectively force independent physicians to choose between their training and profitability (or sometimes survival) in a system increasingly turning toward high volume, algorithm-driven, one-size-fits-all medicine. I don’t think there is anything wrong with seeing some patients quickly, and I am a big supporter of efficiency and driving down costs, but the decisions need to be in the hands of patients and physicians, not bureaucracies.

  • Bob

    Like it or not Doc, your now on the clock with your handy dandy EMR laptops, todays version of the old time and motion testers.
    This will cover the most important government records of service and price. The quality will be taken care of as you have to see the same sick patients with the same illnesses several different times, and get many different tests, before being able to diagnose them; and possibly need to send many of these to specialists, if you can find any who take their insurance.

    • Luis Collar, M.D.

      Thanks for the comments. We agree that the direction in which we are headed may not be best for anyone involved.

  • Bob

    I am glad I don’t share your view about doctors, nurses, pharmacists and elementary teachers who are the most respected professionals in our country, and didn’t get there by happenstance.
    They fully know who they serve and individually decide how they will treat their patients, friends, neighbors and society and will not bastardize their professions, I pray.

  • Dave Mittman, PA, DFAAPA

    Luis:
    Also depends on what “see” means. I have seen physicians either because of insurance company changes or because they have forgotten what “practicing” means that we just referring people out. Truly referral services. We all could see 50 people a day without really seeing any of them; just let someone else worry about it and cover my backside. Or we could do the exact opposite, as I have always done; take 20-25 minutes for most visits and take some time to know your patients, ask questions about their life and let them now you. So the number does not tell the story-the experience of the encounter does.

    Dave

    • Luis Collar, M.D.

      Definitely depends on the individual patient being seen. However, I would argue that “referral services” do not really fall into the realm of practicing medicine. Specifically, if all someone does is take a quick look at the patient and then move them through the system, that is not in line with what the role of a physician has traditionally been. That is why I’ve replied in other comments that this sort of “practice” isn’t medicine at all; it’s prevalence is gradually changing not only the role of primary care physicians but also the very nature of what it means to be a physician. Referrals have a place and are a useful tool. But gradually losing the analytical / diagnostic aspect of the job will have wide-reaching repercussions for both patients and the profession.

      • Dave Mittman, PA, DFAAPA

        I could not agree with you more. Could not do what they were doing. I was really taught diagnosis and treatment and delighted in it!
        Dave

  • querywoman

    Thank you. A very good insight into Kaiser.
    Doctor’s notes for jobs can get ridiculous!

  • l84wrk

    One issue that affects both time with pts and fee structure is the fact that each pt presents as an individual. Someone has already mentioned the “one-size-fits-all” mentality. If there were ever an “industry” where this is a mismatch, medicine is it.

    The same disease can present very differently in two similar (demographically) people. Each pt’s perception of his dx is different – what causes excruciating pain in you is a mild discomfort to me. And let’s not forget that “the disease doesn’t read the book.” That is, while most of the time, symptoms of any one condition will be similar, if not the same, in most folks, that it doesn’t *always* is what makes medicine an art more than a science.

    And, there’s just not a good way to figure out how to “data-ize” the art of dx and care for any individual patient, or to specify that a certain amount of time is sufficient per patient (or even to try to say that a cold gets you 5 minutes and a non-specific gut pain gets you 15, if the bean-counters are trying to quantify illness-minutes).

    When you can’t “data-ize” care, in terms or either time or judgment/experience-value, bureaucrats get nervous.

    • Luis Collar, M.D.

      Great points… I agree it shouldn’t be done, yet in many ways that is exactly what is happening. Attempting to boil medicine down to a series of steps that must be followed for all or most patients, standardizing documentation, mandating what tests / procedures / medications will be reimbursed, the emphasis on EMRs / practice support, and many other trends – all things that could be good except for the fact that these “rules,” “technologies,” or “best practices” are often based on expediency rather than real, impartial evidence – are setting the stage to transfer more and more responsibilities from physicians to others. In many ways, what was once a profession that offered a unique service is rapidly becoming a low-skill position offering a commodity.

  • Luis Collar, M.D.

    That is a great question. First, let me be clear that I am not familiar with that data, if it even exists. But my opinion is that, above some critical number, “burnout” would increase. I believe this for two reasons.

    The first is the most obvious. Namely, seeing more and more patients is physically taxing and often accompanied by longer hours (not only in terms of additional hours in the office or hospital, but also with regard to time spent on administrative work or fielding calls on your cell and at home, etc…)

    The second is that the increasing struggle to see more patients in less time may provide less “career satisfaction.” Of course, precisely what constitutes “career satisfaction” is highly variable. But if you became a family physician to build relationships with your patients while still addressing some complex medical issues fully, then becoming more of a referral center that progressively dedicates less time to both of those activities may contribute to career dissatisfaction and “burnout” as well.

  • Thomas Luedeke

    I really love reading your articles, Dr. Collar. You somehow always manage to eloquently nail the issue, and provoke much thought…

    • Luis Collar, M.D.

      Thank you very much. I really appreciate the feedback.

  • Sneezerdoc

    This frenetic system is a money making scheme set up by CEOs of the healthcare industry. Every doctor knows that history and physical are the most important part of the visit. By limiting the amount of time a doc has with the patient, they are forced to order unnecessary tests/ referrals to make up for an incomplete history. This generates money for the hospital and the CEO can make 5 Million +. PAs and NPs are even better because they get paid a lower salary and order even more tests and unnecessary referrals. Until doctors realize they are nothing more than the cog in a wheel and refuse to participate in this fabricated system this will continue. The argument that there are too many patients is simply not true. If you spend 30 min with a patient and solve their problem you wont need to see them 2-3 more times the same month because they have been misdiagnosed. Unfortunately, most physicians wont stand up for whats right because they dont want to rock the boat – they have a loan to pay off and they cant jeopardize everything to do the right thing.