Thursday, November 29, 2012

The 80-20 Rule

I am currently in San Mateo, CA in anticipation of watching my UCLA Bruins take on the Stanford Cardinal for the Pac-12 Football Championship tomorrow. Winner gets to go to the Rose Bowl!

I mention this to remind people that despite having a solo micropractice, I am able to take time off for vacations and other frivolities thanks to the kindness of my fellow family doctors back home. And I am happy to reciprocate for them whenever they need time off.

On the long drive here, I was discussing (what else) the current state of medicine with my friend who is a physician working at Kaiser, where I also worked before going solo.

While we both admire Kaiser's organization, efficiencies and high healthcare quality scores, we both lamented its rigid "one size fits all" 15 minute per patient structure, and how this leads to a unnecessarily high physician burnout rate.

I observed that part of the problem was how every doctor has a few patients that are very time-intensive, and have a problem list a mile long. These patients always take longer than 15 minutes to manage, and there are usually a lot of psychosocial issues that go along with their complex cases. After a visit with these patients, the result is usually dissatisfaction from both the patient who didn't get all his/her problems addressed, and from the doctor who didn't have time to take care of everything and is now running late.

There is a concept called the Pareto Principle that states that 80 percent of the effects come from 20 percent of the causes. Put another way, 20 percent of patients account for 80 percent of the work. Based on this idea, I suggested to my friend that Kaiser should have two tracks for patient care.

For the "slow track", Kaiser could identify that subset of patients who are more complicated to care for and pair them with physicians who are interested in caring for them. These doctors are then given longer visit times (e.g. 30, 45, 60 minutes) in order to do an adequate job addressing all their relevant concerns, and providing counseling to make lifestyle changes or help with coping skills.

For the "normal track", this is the way patients are seen now: 15 minutes per visit to address 1-2 straightforward problems. I think most physicians would welcome a schedule change like this.

To compensate for the longer visits, the doctors on the "slow track" would see fewer patients per day. One might argue that if these doctors are seeing fewer patients, then they should be paid less than someone seeing more patients. But the amount of work may actually be equivalent depending on the complexity of the patients. I will bet you that every doctor has a patient on their schedule whose visit takes as much work as 3-4 others. Nevertheless, I bet there are plenty of doctors who would accept a lower pay in exchange for seeing fewer patients per day. I know I would.

The results of this 2 track system would be:
  • happier "slow track" patients because they get more time with their doctor and get all their problems addressed
  • happier "normal track" patients because their doctor is running on time
  • happier "slow track" doctors because they get more time taking care of their needier patients and because they don't have a crushing workload
  • happier "normal track" doctors because they are running on time and don't have to try to wedge complicated patients into 15 minute time slots
It's a win-win for everyone.

However, it makes so much sense that I doubt that Kaiser or any large healthcare organization will ever implement it. Then again, improbable things sometimes happen. I mean, who ever thought the US government could pass healthcare reform?

If UCLA beats the odds tomorrow, and somehow beats Stanford, then maybe, just maybe, there's a chance that something improbable like this could happen, too.

Go Bruins!