The 8 Minute Visit
This blog post in the NY Times is a few months old but it is still relevant. It talks about relationships between the doctor and patients and the importance of those interactions in the healing process and…..how those days are gone. The blog describes a new study that “doctors-in-training are spending less time with patients than ever before.” Pauline Chen MD, author of the blog, details how the history of how residents got their hours cut from the 1980s until now and how they may have got it wrong:
- The Journal of General Internal Medicine reveals that while the initiatives of the last two decades were implemented with the best of intentions, the result has been a perfect storm of unintended consequences.
- As in earlier studies, the researchers found that current interns spend the majority of their time in activities only indirectly related to patient care, like reading patient charts, writing notes, entering orders, speaking with other team members and transporting patients.But when they calculated the amount of time spent face to face with patients, the researchers found that interns were devoting about eight minutes each day to each patient, only about 12 percent of their time.
- “Medicine is such an experiential learning experience. It’s really astonishing that so little time is spent at the patient’s bedside.”
- The dramatic decrease in time spent with patients compared with previous generations appears to be linked to new constraints young doctors now face, most notably duty hour limits and electronic medical record-keeping. The study found, for example, that interns now spend almost half their days in front of a computer screen, more than they do with patients, since most documentation must be done electronically.As a result, efficiency has become an overriding concern. Compared with previous generations of young doctors who spent a significant percentage of time eating or trying to sleep, the interns in the current study spent only about 10 percent of their time doing so.
- Young doctors required to see the same number of patients in less time try to speed up their work by culling from computer records all available information about patients, their symptoms and even their physical exam before seeing them in person. When finally in a room with patients, they try to speed up their work again, but by limiting or eliminating altogether gestures like sitting down to talk, posing open-ended questions, encouraging family discussions or even fully introducing themselves.
Sound familiar? Sure it does because the same experience is happening to almost all of us doctors in practice today. We are rushed, we spend less time with the patient and more with the computer, we always try to speed up our visit and we try to pre-fill our computer records even before we walk into a room. This training has created INDUSTRIALIZED MEDICINE to the detriment of what I call AUTHENTIC MEDICINE. What we have now is a travesty to our heroes and mentors who practiced medicine before us. Yes, this is not your father’s healthcare system but in many ways that is a really bad thing.
In the past (1990’s) the patient shows up at the time on the schedule. They arrived before that time and there was time for nurse and the doctor to finish the visit.
Than they had to come 15 min early for the nurse to get their work done before they see the doctor.
What next?
I was thinking about this the other day. Traditionally in a visit there are things that you want to talk about and things the patient wants to talk about. We’ve all been in the position of a patient coming for a recheck of the diabetes who also wants to talk about their back or skin lesion or whatever. I think most of use do a decent job getting everything addressed to the patient’s satisfaction while still taking care of the main reason for the appointment.
Now there is a third entity in the room. I’m not sure what to call it but it’s the EMR/CMS/PQRS/Meaningful Use entity, and it has things that it insists be addressed as well. It is often more insistent than you and the patient. You and the patient probably don’t think it’s that important to check a little box saying you recommended smoking cessation again for the tenth time, or that the BP that has been in good control for years is still in good control, or your A-fib patient is still taking their coumadin, or did a get-up-and-go test on your patient that told you about their half-marathon, but for the third entity that little box is supremely important. If you don’t check that box the entity will threaten not to pay you or pay you less. And the entity doesn’t make it easy to do what it wants, it often makes it difficult.
The result is usually that the entity wins and it’s wants are taken care of first. Since there is only a finite amount of time, the time spent on things you and the patient wanted to talk about is lessened. On a national scale the entity will say it just has everyone’s best interests at heart, but when it comes down to you and the patient in the exam room it really doesn’t care much. Since it is only interested in measurables and sometimes doesn’t keep up very well with current recommendations, it may ask you to do things that don’t make sense or are even harmful. Since it is the most powerful in the room though it usually wins.
Great points. Agreed. DPC removes this.
Those “heroes and mentors” were greatly responsible for and practiced through the truly greatest period of diagnostics and therapeutic innovation ever seen in medicine.
But even as they were teaching us to listen and learn from the patient, they spoke in easy terms about “everyone deserving care” and “effective stewardship of resources”, rolling over for the AMA and CMS and every self-serving, ill-founded study from academia that would lead to more MOC, more EHR’s, and more phony medical homes, mainlining government cash until now the humanity has been regulated out of this work. Yeah it’s hindsight, but the heroes and mentors were they only ones who could have stopped the industrialization of medicine and the commodification of patients and doctors – and they took a pass.
(Along these lines, can we start referring to hospitals as “health factories”?)