While in training, we were told that we were not efficient if we couldn’t see 20 or more patients and complete our notes for billing. We were told that primary care offices were asking our residency program for our efficacy data before consideration of hire. This was the line drawn in the sand by our new health care system. We would either rise to the occasion or be harassed by the administration and coding department because we were not producing. These efforts were done in the name of efficiency for us to be “better doctors.” Unfortunately, this blind faith in productivity was squeezing every ounce of humanity out of what primary care is supposed to be about.
Years later, I had case demonstrating why time is so important in primary care. My team and I were seeing a patient for an initial visit. This person had an elevated blood pressure and was not very fond of medications. She didn’t know what high blood pressure was and what it could do. After providing some education, I stopped the doctor talk. I said we would like to get to know you better as a person, not as a patient, tell us about yourself. For 40 minutes, she spilled a life story of female independence, raising two children by her self, one with epilepsy, the other who struggles with alcoholism. I just listened, honoring her with the time to be heard. The context of stress was important not just for understanding the person in front of me, but what the real contributor to her high blood pressure likely was. There is therapy in listening; there are changes in delivery when the context is understood.
This would have never come to be without having the time, an hour-long visit, to develop trust and understand the context of the person in front of our team. The only way this was possible was by the organization that I work for having a capitated contract with an insurance company. The capitated contract eviscerated the fee for service stranglehold that creates the hallucination that efficiency is the real answer. Efficiency demonstrated by seeing more than 20 patients a day is nothing more than systematic negligence to the cornerstone of relationship formation in primary care. To develop meaningful, trusting relationships takes time and the ability to listen. A recent study showed that physicians spend only 27% of their day performing direct clinical care with patients. How do you fit relationship formation in when you only spend that much time interacting with patients? You can’t.
Health care reform needs more payment models that are fully capitated for primary care if we are to change the experience of the patient and health care team interface. Primary care is the frontline of health care. It has been shown that it reduces costs and improves outcomes over time. Capitated payment models for primary care would allow for us to break the fee for service delusion of efficiency as a solution. It is where the rubber meets the road, where people can be heard. What we need is time in primary care.
Cole Zanetti family physician.
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