20 minutes isn’t long enough for an office visit

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As many of you know, if you’ve read my columns regularly, once a year the whole family escapes from the city, and we travel up to New Hampshire to stay at the lake house that’s been in my wife’s family for over 100 years.

A modest wooden house perched out over the water, situated just right for sunset viewing, for a few days of reading on the couch, hiking in the woods, splashing in the lake, returning to favorite ice cream and dinner spots, and general relaxation and recharging.

And, it often sparks in me the same sort of relaxing and recharging in my thoughts about the healthcare system.

Inspiration comes from the darndest places.

Take, for example, a recent afternoon, a busy practice session, patients crammed on the schedule.

One of the patients in the middle of my afternoon was a late-ish middle-aged gentleman with a couple of medical problems, who I was seeing for his annual physical examination and lab testing. I’ve got 20 minutes for him, and the clock is ticking.

He takes a couple of medications, has a few medical problems that are well controlled, has some mild arthritis in his knees and shoulders that occasionally bothers him.

Once we got through the first few minutes of social pleasantries, checking on his family, his recent vacation, how his work was going, I asked him how he was feeling, and if there were issues that he wanted to address today, as well as doing my own usual agenda-setting for the visit.

Nope, he replied, I feel great, the usual minor aches and pains but nothing really bothering me, just here for my regular checkup.

Once I was satisfied that there was nothing major going on, we proceeded to the physical examination, reviewed last year’s labs again, talked about the changes he needed to make, updated some vaccines and other healthcare maintenance items that needed addressing.

I told him to get dressed, stepped out, and went to enter the orders for his labs and re-ordered his prescriptions. When I returned from my office, I walked in and said, essentially, “Everything looks great, I think you are doing well, was great to see, we’ll talk after I get the blood tests back, why don’t you head on over to the lab now?”

That’s when he said, “Oh, do you have a few minutes? I have a few questions, and there are a few issues I want to address with you.”

At this point, we are already butting up against the next patient appointment time, but it felt wrong to shortchange him, even though I thought I had given him the opportunity to talk about these things earlier in the visit.

He took out a modest list of items written on a folded slip of paper, and we proceeded to talk through them, coming up with some ideas and a plan for each one.

Walking away, thinking back on our encounter, it struck me again, as it often does, that the idea of the 20-minute office visit, where we are expected to deal with the entire spectrum of health conditions and issues that our patients bring to us, to really get to the core of their health, to help them get through barriers to getting to a healthier state we all want — well, 20 minutes just isn’t enough.

So, sitting out here on the porch overlooking the lake, with beautiful blue skies and a breeze coming in and cooling us off, I can’t help but think how we need to find a way to rethink the encounters our patients have with us, to figure out a way to make each and every one of them function as we and our patients expect, this precious opportunity to advance the health of our patients.

We have to take money out of the equation, remove the crushing expectations of the fee-for-service system, and let us design a patient appointment to be what we really think it needs to be, the entire team of our patient-centered model taking care of our patients until everything — everything — is done.

I know this raises a lot of issues, and everyone from the insurance companies to the federal government will want to have a say in how we do this, but we need to bring the voices of the patients and the physicians and other providers back to the forefront.

It’s our practice of medicine, and it’s their time with their doctor, how did we let someone else decide what this should be?

That’s enough for now; I think I’m going to have a little lunch and then take a swim in the lake before we stroll up the road and do a little antiquing.

Wait, one more thing:

We need to dramatically increase access for patients to the care they need at the right time at the right place.

We need to get our phones answered.

We need an electronic medical record that serves us, as opposed to us serving it.

We need access to mental health resources to provide critical care that our patients and our community desperately need.

We need to create an environment where every member of the patient-centered team gets to practice up to their license.

We need the insurance companies and the government regulators out of the exam room.

We need to screen everybody for everything that we can do something about.

We need to destroy food deserts, and get our patients access to the nutritious foods they need to get and stay healthy.

We need to create environments where it’s safe for our patients to exercise and carry on their lives.

We need to work to remove implicit and explicit bias in our care, in our research, and in our teaching.

We need to open up the pipeline to train the next generation of providers, who are desperate to love the life of taking care of patients, so the field of medicine will more fully reflect our communities and all of our patients.

We need to refocus on meaningful research that answers the questions we all have.

We need to address burnout and all the other potential harms that plague our students, trainees, and physicians and other caregivers at all levels.

Wait, I’ve got a list.

Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com

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