Abstract
Keywords: Participatory medicine, physician-patient communication, quality of care, shared decision making, patient portal, EMR, electronic medical record.
Citation: Smith CW. Never enough time for patient care — what can we do? J Participat Med. 2012 Mar 7; 4:e5.
Published: March 7, 2012.
Competing Interests: The author has declared that no competing interests exist.
My fellow Editor-in-Chief Joe Graedon reminded me recently that doctors and patients spend an average of about seven minutes together during an office visit. The pressure is relentless, and patients must queue up for just a few minutes with their doctor. They often leave with more questions than answers, and the result is just bad care. Too few patients receive appropriate, evidence-based care for conditions like diabetes, hypertension, and hypercholesterolemia. Healthy patients who simply need good preventive counseling and screening seldom get ideal care, either. To a great extent, this is because of time constraints.
What is the answer? First, we should maximize the time we have together. Both the patient and the physician can prioritize their tasks for the visit. Patients can help by jotting down two or three key questions that they need answered. They can also help by limiting their issues and questions during the visit to the top priorities. The physician can review the medical record prior to the visit, suggest to the nurse those tests or procedures that need to be done today, and quickly review the most recent office visit, thinking about what issues need to be revisited today.
After the visit is when participatory medicine really begins to kick in and change things. Since there is not enough time to give and receive good care in the approximately seven minutes we have at the office, we agree that one or more of the following will happen between visits:
- A care plan will be followed, a copy of which is shared with the patient as she leaves the room;
- Her test results will be available on the “patient portal” within three days, together with a letter from me, outlining any actions needed as a result of the test results;
- She agrees to email me with any questions or concerns that arise between visits.
It turns out that the patient has a question about her lab results. We exchange emails which address the question. As a result, we decide she needs to begin a medication. I open the electronic medical record and send the prescription electronically to the pharmacy.
She experiences side effects from the medication (which she realizes as a result of a Google search and review of a health information website) and decides she needs to come in earlier than scheduled to discuss this. She logs onto the portal and makes an appointment — I see her in the office the next day. The cycle continues.
This is the “tip of the iceberg” of participatory medicine. The patient is actively engaged, communicating through methods that don’t require office visits unless they are absolutely necessary. We are saving money, communicating efficiently, tweaking issues as the need arises. The result is more satisfying, more effective, lower-cost care that has the potential to change the game of health care in America!
Copyright: © 2012 Charles W. Smith. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.
There is little “participation” here. This is simply directive medicine adding a list of “orders”. It is still pedantic, dogmatic and condescending in that it does not indicate (although this may be done in the golden seven minutes)whether the patient understands the options for treatment, the meaning of the test results and clearly doesn’t allow the patient to be the final decision maker in their treatment. They are expected to just “follow orders” and then when they don’t they are contemptously designated “non compliant” patients.
Participation requires a discussion/negotiation/agreement with the patient as to which treatment options they are willing to accept (not comply or follow). While it is preferable that the patient lead this discussion and leave with “ownership” of the treatment plan, it is the doctor that “owns” the 7 minutes. Unless the doctor enfranchises the patient to lead the discussion there is not much “participation” taking place.
The patient should be the leader of their medical “team”.
Dr. Smith’s reply:
I can understand the frustration of patients who want to be more participatory and don’t see doctors and the system facilitating this. This editorial is primarily intended to address the physician’s perspective on how to deal with the lack of time to provide good patient care, and how encouraging active engagement, dialogue, and use of technology can help the problem caused by having to provide the majority of health care in the context of office visits (that average 7 minutes each). The “participatory” part has to do with the patient preparing for his/her visit, negotatiating and agreeing to a plan of care, participating in online research to identify drug side effects, pointing them out to the physician, and subsequent e mail correspondence with the physician. Clearly this is the “tip of the iceberg” of participatory medicine and is simply intended to be a brief example.
Recognizing the need for the patient’s perspective, our fellow Co Editors Joe and Terry Graedon, will provide a follow up editorial next month on this subject, so stay tuned.
–Charlie Smith
I love this discussion – part of me wishes it was on the blog, but hey, as journal editor you get to put it where you want! 🙂
A couple of thoughts:
– I keep hearing from practices who say their office managers explicitly don’t WANT things to be done outside of billable office visits. I’m starting to think that Fee For Service (the cause of this situation) is The Great Satan, to use a famous dictator’s term. I’ll be glad to see it go, as the reform bill rolls out – perhaps that’s giving us an unprecedented opportunity to stop doing unproductive things and think constructively?
– Another big obstacle seems to be not medicine but workflow management – which hardly any practices get trained to understand (in my experience anyway). Specifically, lots of practices seem to find it hard to imagine having idle capacity so someone can just “log in to the portal and I see her the next day.” Do you think practices are getting better at resolving this?
In my speaking I’m heartened that so many people seem inspired by the whole “let patients help” idea but so many of them seem suffocated by work environments that aren’t agile at change. Here’s hopin’ that’s changing!
Dave,
Thanks for your comments. Dependence on office visit fees clearly is a major obstacle and we hope that health reform will provide the means to help us change the model!
I think, though, that most of us can, and will, juggle schedules to get a patient in same or next day, particularly if we have been in touch and both agree that a follow up visit is needed.
Charlie
I agree with most of what you are saying here although yesterday during the s4pm tweet chat several MD participants pointed out that patient portals are not affordable for most practices and therefore do not solve the communication issue for most physicians. So the question becomes how do we get more portals out there so communication via a secure web space can take place and ease stress for both patients and providers inherent in the seven minute office visit? Perhaps through regional health exchanges or with funding provided to community hospitals to create and maintain portals. No easy answers.
Nancy,
Portals are a part of the patient centered medical home criteria and are supported by meaningful use incentive dollars so, hopefully, this will help. Most of the portals nowadays are tied to instititions that provide them to physicians.