When Mr. D interjected, I could tell that everyone in the room was starting to get antsy. He was talking about his girlfriend again, a toxic relationship that was a major contributor to his anxiety and depression. I was sitting in on a patient visit with the attending physician and a senior medical student, and I could tell that both of them were trying to guide him back on track as gently as possible. Although they were concerned about his mental health, they had already discussed with him a plan to manage it and still had his four other chronic conditions to address. With the clock ticking tellingly behind them, they knew that they didn’t have any more time to hear the details.
This is far from the first time I have observed this uncomfortable dilemma as a medical student. That fact is unsurprising, considering that, on average, a physician in the United States is able to spend only about 15 minutes with a patient to discuss an average of six medical concerns. Patients, on the other hand, typically spend a little over two hours on a visit to the doctor, including time spent on travel and in the waiting room. Yet despite all that effort, they are given only 15 minutes to build a relationship with their physician, share their concerns and get their questions answered. And it’s not enough.
This time constraint can significantly compromise both patient satisfaction and quality of care. Studies show that during short appointments, physicians are less likely to adhere to published guidelines on medical management and more likely to prescribe additional medications, some of which may not be necessary. There are often other effective interventions prior to starting a medication that the patient may have to take for the rest of their life, yet those solutions inevitably require time to explore. Shared decision-making between doctors and patients is also less likely to occur during shorter visits, which reinforces the knowledge and power disparity between the doctor and patient.
In my own clinical experiences, I have witnessed firsthand the dissatisfaction that patients express with the amount of time the physician spent with them and how effectively their concerns were addressed. “Doctors are always too busy to answer my questions,” one frustrated patient told me as I was taking her medical history in the hospital. By the time her doctors asked her if she had questions about her care, they were usually already backing out the door, one eye on their beeping pagers.
Medical schools are working hard to diminish these deficits through careful training of future providers. “Patient-centered medicine” is the current catchphrase in medical education; in the past decade, there has been an increased focus on developing communication skills, minimizing implicit bias and creating trust between physicians and patients. These initiatives are without doubt a major step in the right direction in terms of improving the patient experience; however, how effective will they really be when implemented in such a limited window of time?
When examining a patient with a 15-minute time limit on the clock, it can be tempting for the brain to fall back on stereotypes. Fifty pack-year smoking history? Doesn’t care enough to change. Chronic pain? Probably a drug-seeker. Not taking her medication? Non-compliant patient. These may seem like extremes, yet I have heard such assumptions made too many times by well-meaning but time-crunched physicians.
On the other hand, I, the student volunteer, had time to learn that the man with the smoking habit had tried to quit, but started back up again after his father had passed away from cancer. Another man’s chronic pain was so severe he had barely left his house in months. The woman not taking her medicine had not been able to afford to refill the prescription. This kind of stereotyping is exactly what we are trained in medical school to avoid. Yet when there is no time to elicit the full story, unconscious bias may inadvertently fill in the blanks and any semblance of trust between patient and provider can be broken in an instant.
The burden of this, naturally, falls on patients who are underserved, minority or uninsured. The same can be said for the deficits in care that arise from the imbalance of time spent by patients in order to visit the doctor and the time they receive in return. Prior to starting medical school, I volunteered at a community clinic that served uninsured patients. It was during one of these shifts that I met Ms. M, a Hispanic woman who was there to follow up on her poorly-controlled diabetes and high blood pressure. She had walked thirty minutes in the pouring rain to make it to her appointment on time because she had no other available mode of transportation that day. She had missed her last appointment for the same reason, but was determined not to do so again. Upon arriving at the clinic, she was directed to the waiting room. When my shift ended three hours later, she was still there.
This type of situation is unfortunately not uncommon. Research shows that African-American and Hispanic patients spend almost 25% more time at medical appointments due to increased travel and wait times. Because of the additional inconvenience this creates, these patients are even less likely to seek health care as often as their white counterparts. They then in turn have more pressing medical concerns to discuss at any given visit and less time to spend discussing each problem or other aspects of preventive care.
Severe time constraints take their toll on the physical and mental well-being of doctors as well. Physicians are overworked and overextended, and often feel unable to properly care for their patients in the time they are given. As a medical student, I have not yet been personally faced with this dilemma. During my clinical experiences, I am given one patient to see in the four hours I am there. Some of that time is spent reviewing the chart, going over material with the physician and writing the note, yet I am still left with ample time to talk to the patient and really hear their story. After the visit, I leave armed with a reservoir of information about their home life, access to resources and emotional well-being to supplement the usual medical history. Beyond that, I leave feeling like I have built a relationship with them and hopefully made a difference in the care they will receive.
But what happens when, 10 years from now, I have 16 patients to see in four hours, instead of just one? Will I still feel just as fulfilled? According to a recent survey, 80% of physicians felt they lacked enough time to provide the best quality care, and nearly 50% reported consistently experiencing burnout. Even now, when I learn a new skill or patient interviewing technique, I’m often told by older trainees, “Oh, you’ll never really use that in practice, there’s just not enough time.” It’s undoubtedly discouraging to spend years of training being taught the importance of the broader picture in both understanding and diagnosing the patient, and then to later be pressured to restrict visits to 15 minutes, no matter what aspects of patient care must be shortchanged as a result.
There’s no easy solution to this problem. The fee-for-service reimbursement model in medicine still incentivizes short clinic visits and expensive diagnostic testing rather than teasing out detailed medical histories and patient stories. There is still a shortage of physicians and an abundance of patients who need health care in this country. Yet overworking physicians to maximize output at the expense of patient care is definitely not the answer. In fact, it is actually undermining many of the measures that have been so carefully put into place to improve the doctor-patient relationship and the quality of care that patients receive.
Medicine needs a reimbursement model that emphasizes the highest level of care over the quantity of patients seen in a day. Beyond that, we need a system that allows for flexibility in the length of clinic visits and places more value on the time of both physicians and patients. Not every appointment is complicated, and not every visit needs to be long. But if there was more to Mr. D’s story, I’d like to have had the chance to hear it without the ticking of the clock drowning it out.