Time as a Quality Metric
It’s a funny thing but I could not find anyone using “time with patients” as a quality metric. Isn’t that weird? It is my belief that the more time you spend with the patient, the better job you will do. I say this is my belief because I couldn’t find a study to back me up. And who is going to do this study? The money train via insurers and hospitals do not want doctors even in the equation. They want us gone. Why would they study this? Also, time with patients, which I will abbreviate (TWP) goes against the industrialized medicine model. I know because I was there in my former life. I would churn them through, borrow time from the healthy 25 year old to give to the Medicare chronic, and so on. The truth is you cannot bend reality and pretend rushing through the patients is still giving great care. It wasn’t for me. Now that I live in a different model/world, TWP is important. People bring things up that are relevant to their health. I understand the family dynamic. I know their jobs. I know what they eat and if they exercise. I can teach them things and vice versa. I can send them references via email and vice versa. I give them time. And I am a better doctor than I was. That metric, TWP, cannot and will not be ever measured by the insurers or the government because it would be shatter the myth of how they define quality.
So tell me if you find an advertisement or website where the “system” brags TWP or time the doctors spend with patients? Oh, yeah, do not count concierge or direct primary care practices. We all do that. It’s a given.
It has always seemed obvious to me that the reason we are not paid by the minute is because some payor thinks we will waste them, or come up with too much to do. Just look at the complete nonsense that they came up with to delineate five levels of visits without defining them the obvious way, by time involved. And have you noticed that things that really take your time, like patients who can’t give succinct and accurate answers, or a health system that makes you hunt for information, don’t count in the scoring for these levels? And you can’t get paid for phone care, or more than one service a day because the patient must have some inconvenience in obtaining care or demand will be limitless. Not only do they not pay us for our time, they (the nebulous they, the many powers that be that includes us) judge as as efficient, good, smart, savvy, productive, when we cut corners and do things in less time, while “slow” is somehow a negative, associated with inefficiency and lesser competence.
Excellent point. This is especially true in psychiatry, where the doctor is TRAINED to keep the visit short, and does not even listen to what is troubling the patient, only listens for key words with which he develops a diagnosis along his choice of scientifically unproven or scientifically disproven grounds, then looks up a formulary which tells him which drug or drugs to prescribe. This is not patient care.
There are plenty of articles showing the ill effects of short time with patients. But business in America today is concerned only with short term profit, for the most part. Health insurance companies that consider doctors’ offices as “cost centers” do what they can (high co-pays, restricted access, etc) to prevent visits to them.
I like the idea of concierge practice for those who can afford it. The problem is that ~15% of Americans today are below the poverty line and can’t afford it. Part-time $10/hr jobs aren’t the answer.
I had my semi-annual chekup with my primary care doc last week (fasting bloodwork, all that stuff). It was our first meeting since his organization imposed electronic record keeping. He sat on the stool and typed (as I do with two fingers of each hand) as he asked me the standard questions and typed in my answers. He listened to my heart and breathing. Fortunately, I am a relatively healthy 74-year-old. I asked him about how he experienced the change from ball point pen- writing in the chart to ERK. “There’s less eye contact with the patient,” he said. Great. But he said he apologizes to the patients because of his Velcroed relationship with the computer during the appointment. He prefers not to use a scribe. The appointment was slotted for 20 minutes. It was over in 20 minutes. There was nothing that required extended conversation, but he gives no time for “warm, fuzzy” conversation except to comment as he typed, “I hear it’s getting more humid outside.”
Led, this is indeed a shame. Part of the benefit of the doctor-patient relationship is a little of getting to know each other, finding common ground and trust. All the cultural competency and sensitivity training and “patient engagement” garbage cannot make up for limited face time with the patient.
I spent 10″ extra with what should have been a quickie DOT physical because the gentleman had some serious questions about a totally unrelated medical topic. I don’t get any extra pay for that, but that’s fine, if he felt comfortable enough to talk to me, hopefully I helped allay his fears.
I have spent many extra minutes talking to patients about sick spouses, unruly children, lovable pets, fun vacation spots, etc. To me, this is the essence of medical practice. And I don’t even do Primary Care, I do Occupational Medicine.
While we do use computers in my practice, I use old-fashioned dictation and paper charts. I am able to look patients squarely in the eyes during the exam and pay attention to facial expressions or postures that help clue me in on physical findings.
The continued corporatization of medicine is going to kill whatever little is left of physician-patient relationships, and with it good medical care.