Saturday, December 08, 2012

"This Work Just Isn't Sustainable"

Last week I went with my wife to the Kaiser Annual Holiday party where they honor retiring physicians and recognize longevity milestones for those who have stuck around. If I had continued at my previous position, this would've been my 22nd year. It was nice to see some old familiar faces.

During the course of the evening, they announced the winners of the Walter Lusk Distinguished Physician Award with touching videos profiling each physician and the excellent job they do caring for their patients. One award winner repeated a quote that Dr. Lusk was fond of saying: "Patients don't care how much you know until they know how much you care."

A week later, someone pointed me to this article by Dr. Lydia Dugdale about the crisis in primary care:
But primary care is broken across the board. The work is unsustainable. I'll tell you why. 
For a start, the pace is manic. In our clinic, we see established patients roughly every 15 minutes. This flows well when the patient is a young healthy woman on no medications coming in for the common cold. But what about the 70-year-old man with diabetes, high cholesterol, high blood pressure, and prostate trouble? He sees four specialists and takes 17 medications, is retired and enjoys chatting. Even though he keeps in his wallet a list of his pills, he forgets to update it. We spend six minutes fixing his medication list, eight minutes reviewing the recommendations of his sub-specialists, and he hasn't yet mentioned the reason for the visit. You don't need to be a mathematician to calculate why your doctor is always in a rush.
This is why I left Kaiser. On top of seeing a patient every 15 minutes, there is "the work no one sees":
If the primary care doctor's only task each day were to see patients within a very limited time frame, it might be doable, but unbeknownst to many outside of medicine, the doc does so much more. How much? A recent study in the Archives of Internal Medicine looked at clinics just like mine -- academic general internal medicine practices -- and for the first time ever attempted to quantify "the work no one sees." The researchers found that in a typical clinic day, the general internist completes electronic orders for 70 laboratory tests, images, and consultations; writes and signs 31 prescriptions; responds to seven patient care-oriented messages; and reviews, edits, and signs 19 electronic medical documents. Most of this occurs outside of face time with patients, and -- they postulate -- this estimate is conservative.
Dr. Dugdale proposes 2 suggestions to fix this:
1. Provide greater incentives so more people choose primary care.
2. Provide greater resources to primary care physicians to handle the workload.

I think she didn't go far enough in her suggestions, as neither one addresses the underlying problem which is the workpace. Primary care's most important tool is the doctor-patient relationship, and for that to develop, one needs time. Without enough time, the relationship is stunted or broken. Without a strong doctor-patient relationship, patients are less compliant with taking medication or making lifestyle changes. Consequently, they don't get better and they continue to need lots of time taking care of their health problems. But they don't get enough time, and it becomes a vicious cycle.

My suggestions to fix primary care:
1. Pay primary doctors a higher reimbursement rate. This will attract more medical students into the field, and allow primary care doctors to spend more time with patients without taking a financial hit.
2. Increase the amount of time allotted per patient to 30 minutes. This will result in fewer patients seen per day, but the most time consuming visits are from those with chronic healthcare conditions who make frequent visits. If you take more time with them, they might actually get better and not have to come back so often.

Alternatively, there's my previous suggestion to separate high-needs patients from regular needs patients.

As I have said before, this isn't specific to Kaiser's model. Allotting 15 minutes per patient is standard throughout the healthcare industry. In fact, some places are even worse, allowing only 10 or even 5 minutes per patient. But Kaiser is such a leader in the medical field that if they were to institute a change, others would follow.

Patients don't care how much you know until they know how much you care. And they know how much you care by how much time you spend with them. 15 minutes just isn't enough time.