Tuesday, April 13, 2004

Quality time

Spring Break is over, has been over, and business in my new practice is sssssss s s l o w.

No patients scheduled for this week. Yet.

I worked half day shifts at Kaiser yesterday and today, and it never fails to remind me of why I chose to leave its relatively sheltered environment. I walked in the room yesterday and greeted the patient, man in his early 60s. He proceeded to unfold his story. He hates coming to the doctor, so the fact that he's here means something is really wrong. He's had "sciatica" for a month, so we go into that. Plus extensive psoriasis that he's never gotten treated before. During the exam, I find that his blood pressure is up, so there's a whole other discussion about how HTN is usually asymptomatic and why that needs to be followed ("Increased risk of heart attacks, strokes, and impotence" - the last one usually grabs their attention). Then he mentions that he's been tripping occasionally whenever he walks...

Another guy is here for a second opinion about the treatment he took for H. pylori, and it segues into a discussion about repeating an HIV test and how he should be immunized for Hep B, since he is gay and in a high risk group. He had tests showing that he was negative for Hep Bs Ab and Ag (twice). And yet no one ever advised him to get immunized for this highly contagious and common infection.

By the end of the half day, I was over an hour behind, and feeling like I had been through a wringer. I feel like I give a lot of myself, going the extra mile to give not just good but excellent service, and I pay for it in the end when I have a pile of charts that I didn't have time to write in because I was constantly playing catch up. OK, it's my own fault. But I wonder, am I an oddball for feeling like I need more time to spend with patients to give them good care? I've timed myself before over a 2 to 3 week period, counting the "face to face" time and the "charting time". I consistently came out to average 16 minutes of "face time" and 4 minutes of "charting time". Which is a problem because at Kaiser, I only get 15 minutes.

What is the norm for an office visit? It depends where you're at.

This study from the British Medical Journal looked at "consultation lengths" in 6 European countries and found that the average duration of an office visit was 10.7 minutes! In Germany and Spain, general practitioners see more than 200 visits a week. That's about 40 visits a day! Oy vey!

By comparison, American patients are living in the lap of medical luxury. This 2001 study looked at the average duration of office visits and concluded that U.S. doctors were actually spending MORE time in 1998 with the average visit lasting 18-22 minutes, compared to 16-20 minutes in 1989. The method of collecting the information however, lends itself to a lot of recall bias. Basically they sent a survey to all physicians asking them how much time per week they spent in various activities, including patient care. Then they asked how many patients, on average, they saw a week. They divided the hours of patient care by the number of patients to come up with the average length of visit.

I like this study better. This commentary from The Lancet sums it up:
They conclude that a doctor who consults more slowly is more likely to provide visits that include important aspects of care, and that longer appointment length can therefore be used as a marker for quality.

As my daughter might say, "Well, duh!" It goes on:
Despite the widespread perception among doctors and others that appointments are more rushed, the length of visits has remained stable or increased modestly over the past decade. This discordance, in part, reflects the fact that there is simply so much more clinicians can do, and are expected to do, during an office visit.

So not enough time in my old practice, and too much time in my new one. Time to try and figure out how to get more patients into my practice. Duh!