This was the end-of-the-hallway conversation with an elderly patient after wrapping up a recent office visit, as we walked away from the exam room toward the front desk to schedule her follow-up appointment, and she realized that we were “celebrating” 20 years together.
I met her when she was admitted as an inpatient when I was on service as a junior attending just starting out, and after going home she came to see me in the office to establish care.
She’s been through a lot, and has had a number of health challenges, as well as overcoming numerous life stressors and tragedies in her personal life.
I feel like I know her, and I know many of her family members who’ve come to her appointments with her, as well as numerous home health aides who accompanied her to her visits through the years.
But after she left for the day, and I’d finished seeing all the rest of my patients, it made me start to wonder how much do I really know her, how much time have I actually spent with her, and is that enough time for her to really say she loves me?
Making the calculation
Let’s do the math.
Even with not counting overbooking, let’s say 20 minutes for each office appointment.
She is one of my patients who likes to leave her appointment today with a follow-up appointment scheduled, so instead of using open access she already knows when she’s coming to see me for the next visit, for 3 months in the future.
So that’s four visits a year.
Each office visit of 20 minutes is 1.3889% of the day, and with four visit per year that works out to 0.015221% of each year that we spent together.
That means that over the course of a year, she spends 99.9848% of her year not with her doctor, which if you think about it is probably a good thing.
But over the course of our past two decades together, with 20-minute visits, four per year, that works out to 26.66 hours that we spent in my office exam room as the sum total of our time together in our roles as patient and provider.
Not a lot of time.
The usual forms
Several days after her most recent appointment, I got the home health form from the agency that’s been sending her aides to the house all these years.
It’s 17 pages long, and includes the usual list of all of her care team members, her medical conditions, her medications, her allergies, her prescribed diet.
Tucked in around page 5, after some incomprehensible section on claims data listing a bunch of claims ID numbers, dates of service, providers, CPT codes and diagnosis codes, were a couple of sections that seemed like they were designed to help improve her care, and move her towards a healthier state of being.
These included a section called “prevention”, one called “guiding opportunities”, one called “improvement goals”, one called “interdisciplinary team approvals”.
These at least look sort of like the kind of health things that I think she should be getting, but they were presented in such a strange fashion that it felt like there was really nothing there that was actually moving the patient forward.
Under the guiding opportunities, there were list of HEDIS measures that included:
- Consider scheduling an appointment with PCP for medication review.
- Consider scheduling an appointment with PCP for pain assessment in older adults.
- Consider scheduling an appointment with PCP for functional status assessment.
- Consider scheduling an appointment with PCP for advance care planning.
- Consider scheduling an appointment with PCP for use of high-risk medication.
- Consider educating member/caregiver regarding cardiovascular and respiratory symptoms.
And my favorite one: “If not already seeking care, consider scheduling appointment with a primary care provider for assessing the member.”
Aren’t they getting these orders and sending them to me as the PCP? Don’t they know that she has a PCP? How does this question persist on the form if someone was thoughtful and actually looked at this form? How could someone say this really is an important question to put on the form and ask for an answer to?
There are then a whole bunch of other items, some of which were relevant to her, some of which were not, including questions about certain bodily functions, nutrition education, breast cancer screening, flu vaccination, medication management.
Going beyond lip service
When I think about how little time we actually get with each patient, as documented above from all those calculations, it makes me frustrated when we see these forms that seem to imply that care is happening in the community, but we’re not sure if anything is really going on out there.
In a truly patient-centered care model, we depend on other members of the team outside of the office to help the patient stay healthy and get healthier, because we only have them in our grips, under our “control”, for such a tiny fraction of their lives.
If care in the community is really going to make a difference, it can’t just be lip service, a bunch of boxes to get checked off on a form.
The people who are doing this work are clearly vested in trying to help our patients, but if all they’re doing is seeing the patient and then sending me back a form that says the patient should consider seeing me, then maybe they’re just giving me more work to do and not really helping our patients.
I know it’s challenging in our resource-strapped health care environment to try and expect that a single community health worker out in the field with a huge panel of patients they need to visit and take care of will be able to affect change, really educate a patient, really make a difference in their lives, when they are just as overworked, overwhelmed, and stressed as we are.
But we need to recognize that that’s where the patient lives, that’s where their health challenges and opportunities live, that’s where all of the rest of their life issues, from stress, to food security, to safe housing, to adequate nutrition, come to bear and impact their health.
We’ve ignored this for far too long, and tried to convince ourselves that these homecare workers and community health workers have the resources, training, and tools to really make a difference for our patients.
As we move forward, and go about designing a better health care system, we need to recognize that we as the providers in the exam room really only get these patients for a tiny sliver of their lives.
We have an opportunity to make an enormous impact, but the rest of the team out there in the real world with our patients may be just what the doctor ordered.
Let’s demand that our society provide us with an army of people to help take care of our patients, and give them the resources to truly educate our patients, truly get them the nutritious food they need, educate them in a culturally appropriate way, guide them to appointments so they can get their preventive care done, get their vaccines done, make it to their appointments.
It’s about time.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.
Image credit: Shutterstock.com