When doctors become mercenary about their time

The other day I received my copy of the periodic newsletter of our neighboring Canadian medical society. It made me realize that both countries’ primary care doctors, in spite of our entirely different health care systems, are facing some of the same issues.

The bulletin warned Canadian doctors not to enforce a one-problem-per-visit policy, but to offer more comprehensive care to their patients.

The way doctors and clinics are paid in most settings here, two short visits are reimbursed at a much higher rate than one long and complex visit that takes up as much or more time. When patients feel the pinch of co-pays, travel costs and lost time at work for doctors’ appointments, tensions between the agendas of health care consumers and providers are inevitable.

It can be challenging enough to provide a healing atmosphere in a busy clinic. When doctors feel so much pressure that they become mercenary about their time, any hope of healing is lost.

I never understood the logic behind the one-problem-per-visit way of rationing health care. I do accept that the time we have to spend with our patients is finite, but there is usually some wiggle room. I tend to be upfront with patients about how much time they were scheduled for. Some patients require extra time for even the seemingly most straightforward problem, but I have many patients who can bring up several problems and allow me to address them in a fifteen minute visit.

A patient with abdominal pain and joint stiffness may have an inflammatory bowel disease that explains the two seemingly unrelated symptoms.

A patient with pneumonia and a raging grief reaction needs both issues addressed in that visit, most likely with early follow-up for both problems.

A person with uncontrolled diabetes never has just high blood sugars; there is always a multifaceted story behind the numbers. That story often touches deep seated issues like self worth and depression.

Doctors in today’s health care machines, not just in our country, seem to think of themselves too often as widget makers, and not as healers. If we deliver only cookie-cutter health care, perhaps every aspect of our work is measurable and more of a commodity than a unique, personalized service. But, by reducing ourselves to generic providers of mass market care, we breed discontent among our patients and burnout within ourselves.

My wife often points out that when I hurry to do things around the house, I become less efficient and actually get less done than if I just plod along and do what needs to be done without fretting about it. In my work, I have just that ability. I am blessed to most of the time be able to enter the exam room with a mind free from the clutter of busyness and engage with my patients in an unhurried manner. Sometimes, when I am running late, I will enter the room and literally sigh before sitting down with an apology about running late because of a tight schedule. Patients invite me to relax, and I show them that all my attention is on them at that moment. Not being scattered allows me to accomplish more in a short time.

We need to always think of ourselves as “selling” our expertise and experience, not just our time. An appointment of any length can be effective or ineffective. A brief but well planned visit, where we enter the room prepared and where our documentation in the medical record doesn’t detract from the patient interaction, is more satisfying to the patient and the doctor, and gives some room for connecting with the person behind the symptom.

If we don’t fully master our EMR technology, we will be distracted and ineffective during the visit, and we could fail to document our clinical thinking well enough to be effective in follow-up visits.

I also think we as physicians need to always value the personal aspect of the work we do in order to be of any real help to our patients. If everything about our care is ever so correct, but bland and uninspired, we invite demands for more, as patients feel unsatisfied. If we spend our allotted fifteen minutes delivering exceptional care, our professional satisfaction will carry us further. Our patients will not feel cheated the way many do when we are too stressed to even recognize their needs, let alone begin to address them with skill and compassion.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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  • Dr. Drake Ramoray

    “*Administrators* in today’s health care machines, not just in our country, seem to think of *physicians* too often as widget makers, and not as healers.”

    Fixed that for you.

  • ninguem

    “Mercenary” about our time?

    That leaves me with the impression that Country Doctor has an infinite amount of it.

    What’s your secret?

    In the 19th century workers fought for the 8-hour workday. They fought for overtime pay. Were they mercenary about their time?

    • Acountrydoctorwrites

      See my reply above


    “If we spend our allotted fifteen minutes delivering exceptional care, our professional satisfaction will carry us further.”

    1 minute for greetings/good-byes, 2 minutes to review the patient’s prior history and chart, 2 minutes for history taking, 2 minutes for examination, 3 minutes for orders/refills/referrals, 3 minutes to go through the differential, recommended treatment, and negotiate treatment based on the patient’s perspective and preference. 2 Minutes to address anticipatory guidance, health screening, and the various “preventative health” objectives, and 3 minutes for documentation.

    That’s 18 minutes for a 15 minute appointment. Those 3 extra minutes per patient, x 22 patients per day, would mean that Country Doctor would be running behind by 1 hour each day just from routine appointments, longer if there was anything remotely complex.

    Also notice that there is no time in that schedule for THINKING about the case or problem. The assumption is that the doctor already knows the diagnosis by the time he’s finished examining you, which is often not the case. I’d also love to know how Country Doctor does it.

    What’s “mercenary”, IMO, is the schedule that assumes everything will be simple and uncomplicated, no patient will have any special needs, and the doctor will always know exactly what to do by the time he’s put the stethoscope down. When these are the underlying assumptions that dictate payment, staffing and scheduling, how can we not expect delay and frustration at both ends?

    • Acountrydoctorwrites

      This post was retitled when it was reblogged.

      I agree that today’s schedule is challenging, to say the least. But if you get too stressed and frustrated it will show, and the patient will be less likely to feel helped by such a doctor. If you feel and act like a widget maker, you will continue to be treated like one.

      In most visits, I sit down next to the patient with my laptop and work the EMR with the patient, showing labs, vitals etc. I revise medlists, do refills with the patient. That way there is no mystery of what goes into the record. I type while we talk in such situations,but have several templates that speed up data entry. When we get up from our chairs, the note is done, orders entered, scripts done etc. Those visits are often under fifteen minutes.

      For hospital follow ups, psychiatric issues, frustrated or in any way dissatisfied patients or of I sense there is a diagnostic challenge, I put the laptop aside and “lock on” to the patient with active listening and eye contact. I find that with diagnostic challenges, I just need to leave the documentation aside until I start to move ahead with differential diagnosis and formulating a plan.

      You really do have to think fast in today’s primary care. That means I sometimes have to “chunk down” a problem into manageable steps. Some visits, I solve several problems, and some problems span over several visits. For example, ruling out heart pain comes before the GI work up; ordering the endoscopy would be unsafe as a first step, so don’t belabor visit one with that. I might say “after we’ve checked your heart out, we’ll need to think about…”

      I have been a Family Physician since 1984, so I’ve had some time to practice thinking on my feet.

      One thing I do try to do is keep the fluff agendas, like shingles shots and the like, out of visits for new or challenging problems. I address diabetes in quarterly visits, and ignore computer warnings about missing microalbumens if diabetics come in for conjunctivitis or gout in between. I also have a simple rule that has avoided a lot of confusion: Avoid starting several new medications at the same time. So one strategy I use for managing disease as well as managing time is to do things step by step.

      I see 22-28 patients per day, and while there was a time when I literally ran on time, I decided to loosen up and be more human. I occasionally now will run up to 40 minutes behind. That is my pain threshold.

  • http://cognovant.com/ W Joseph Ketcherside, MD

    I’m sorry, I guess I missed when the US congress passed the law that said doctor visits have to be 15 minutes long. When exactly did that happen? Or did we calculate how much money we want to make, divide that by what we get paid per visit, and fit those into the day, and then decide that only leaves 15 minutes for each visit? Here’s a novel idea, maybe spend the amount of time a patient needs to handle their problems when you see them.

    I constantly hear about how difficult it is to fit everything into 15 minutes. Well, I got news for you. It’s not a 15 minute job.

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