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20 Minutes of Questions Won’t Fit into a 7 Minute Doctor Visit

Greetings from Boston.  I’ve been attending and speaking at the Inaugural Summit on Behavioral Telehealth: Technology for Behavior Change & Disease Management.

The conference chair is Dr. Steve Locke, Prof. of Psychiatry at Harvard.  He opened the meeting yesterday with a thoughtful line of questioning to the audience.

Dr. Locke asked “How many of you audience members have participated in an ‘typical, average’ seven minute visit at one of the new retail doctor clinics?”  About 75% of the people in the room raised their hands.

He then asked “…and how many of you found the experience satisfying?”  Every single hand in the room went down.

Finally, he delivered the punchline: “…and how do you suppose you’ll feel if you had several chronic diseases — say diabetes or asthma — that you wanted to discuss with your doctor during that same time period?” 

The impact was clear: 20 minutes of patient discussion items won’t fit into a 7 minute visit.

I didn’t take his commentary as in any way a criticism of retail doctor clinics; rather it was intended to show the disconnect occurring between the ever shortening average doctor visit and the ever lengthening time needed by an aging baby boomer patient population.  People with chronic conditions will need and want more of their doctor’s time.  Our current health care system can’t deliver this today, and is actually going in the wrong direction from what patients will want tomorrow.

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1 Comment

  1. Gordon Norman, MD, MBA; Alere Medical, Inc. on June 1, 2007 at 7:15 pm

    Over the past 50 years, there have been recurring perceptions of a primary care physician shortage that have prompted new solutions for extending the capabilities of these harried providers to manage a larger practice panel while satisfying patient needs and preferences. While some observers claim these perceived shortages are simply due to regional maldistribution of a suitable aggregate number of PCPs, others have deemed the absolute number of primary care physicians insufficient for population health needs.

    Since WW II, we have seen the generalist-to-specialist ratio in this country reverse from >2:1 to 10,000 residents annually, and by 2000, the U.S had 71,105 family physicians which still comprised less than 10% of the total physician workforce.

    In the 70s, the movement for Physician Assistants and Nurse Practitioners as “physician extenders” took off to help address the shortage of primary care, with considerable success. With Family Medicine residencies still expanding, primary care became more fashionable for graduating medical students and the problem seemed temporarily resolved. (Some even began to worry about a looming physician surplus, but to the extent that has occurred since, it is limited to specialists only, not PCPs.)

    In the 80s, we saw the proliferation of medical office systems designed to expedite practice management, focused mainly on the front office scheduling function and back office billing needs. (Full electronic medical records, while emerging in prototype forms and a few commercial systems in the mid-late 1980s “ think MUMPS, COSTAR ” were not an appreciable factor until much later.) These systems were billed as enhancing office efficiency and provider throughput, but while reduced administrative overhead may have been achieved years after the initial capital investment, the degree to which the latter goal was realized in most practice settings is debatable.

    “Doc-in-the-box” and other forms of limited ambulatory and/or urgent care centers were also a passing phenomenon of the time (or so it seemed until their recent reemergence in the form of retail walk-in clinics, this time more often staffed by physician extenders than primary care physicians.)

    In the 90s, the rapid growth of managed care plans, particularly the unfortunately named “gatekeeper model”, which appeared to empower PCPs and raised their demand (and salaries) accordingly, attracted more graduating doctors to primary care specialties. Multispecialty practices grew up in some sections of the country, relying on a broad base of PCPs to attract patients and provide a steady supply of specialty referrals. In some cases, specialty physicians with an insufficient number of specialty referrals began doing primary care as well. There was also a rise in community hospitals purchasing local primary care practices to ensure an intact and thriving feeder system as increasing competition from neighboring markets threatened hospital market share.

    Throughout this time, the medical establishment has wrestled with the manpower issue, evaluated and reevaluated the adequacy of the primary care workforce, proposed various policy solutions, reimbursement reforms, and graduate training modifications, while the debate continued over what the optimal number of generalists and specialists should be. The federal government also played a significant role during this period through its National Health Service Corps and other support programs for underserved regions, particularly in rural America. But the fundamental forces shaping the U.S. physician workforce increasingly toward specialization and away from primary care have not been radically altered, so consequently the issue of primary care workforce adequacy remains.

    Once again, we are facing a growing shortage of health professionals, most acutely in the nursing profession today, but also a growing shortfall for primary care. Residency matching rates for family medicine, general internal medicine, and pediatrics residencies have been dropping steadily for two decades. And despite several rounds of Medicare payment reform, public and private sector reimbursement for ambulatory care has not kept up with that for their specialist brethren, and in some cases, not even general inflation. For those PCPs who rely predominantly on state Medicaid reimbursement rates, the situation has grown even more dire.

    What to do? Since this is the U.S. where we have no systemic manner for controlling the voluntary selection of specialties by doctors, it seems that the resupply of our dwindling primary care workforce is and will remain under the control of complex market forces. For a variety of reasons too extensive to enumerate here, those forces have favored the choice of specialty medicine over primary care. If we cannot directly remedy that fundamental supply problem, what alternatives remain? Go back to past solutions like more doc-in-the-boxes, more physician extenders? Rely on rapid widespread adoption of EMRs and PHRs to alleviate the unmet demand for primary care? Or simply grin and bear it when the 7 minute MD visit allows only a fraction of the dialog that patients wish to have (and deserve to have) with their providers?

    I respectfully submit that one major component of the remedy lies in Disease Management team models that surround the MD-patient dyad with an extensive set of additional, complementary resources that can be used by both to improve the efficiency and effectiveness of care. This includes periodic risk assessments, patient-specific health education, lifestyle behavioral support, remote patient monitoring, claims review for gaps in care, monitoring for medication adherence, telephonic coaching, web-enabled interactive tools for self-care, reminder systems for overdue tests/visits, etc. Especially, for the growing population of patients with multiple chronic conditions, this seems to offer a winning proposition for all stakeholders. Importantly, it’s a viable solution that exists today, in the form of current DM programs that are producing better clinical, functional, and financial outcomes with highly satisfied patients and supportive PCPs.

    While perhaps hard to argue in concept, there is still ongoing debate over what forms these types of programs should take. Inevitably, who has what accountabilities and what gets reimbursed by whom are important issues that must be resolved to mutual satisfaction of all parties. Whether implemented by provider organizations using the Chronic Care Model or “advanced medical home” concept, or developed by health plans with an assortment of insourced/outsourced capabilities, this expanded health team approach offers the opportunity to leverage the precious time of our primary care physicians to focus predominantly on those patient issues that require their advanced expertise and judgment, while other professionals on the expanded care team look after more routine issues that often require considerable patient contact time.

    In a 2001 paper titled, What Does Family Practice Need to Do Next?, Dr. John Geyman, Professor of Family Medicine at the University of Washington, outlined new paradigms for patient care that included evidence-based medicine, population-based care, and chronic disease management supported by group practices, electronic medical records, improved patient access/scheduling, seamless systems of personal care, team practice, and public health collaboration. How far have we come toward those goals in the intervening six years? Not far enough, in my estimation.

    If we continue to rely exclusively on our beleaguered primary care doctors to do all the needed caregiving for us, most especially our aging Baby Boomer population as their chronic maladies and insatiable appetite for health services consumption increasingly swamp their capabilities, demoralize the surviving stalwarts, and disincentivize new entrants into primary care, then we deserve the result. It won’t be pretty!

    PCPs are only human, they do not thrive on “revolving door” patient encounters, and cranky doctors who are not professionally fulfilled do not provide the best care possible. It’s time to allow our generalists to “specialize” in doing essential tasks that require their skills, and deploying the tools and know-how of an expanded care team “including assorted ancillary professionals, the DM industry, the e-Health/Health 2.0/Healthcare Unbound worlds“ and some good ol’ American ingenuity to the “20 minute peg into the 7 minute hole” dilemma of today’s primary care. This problem can be solved, and the means for doing so are at hand, if only we can see beyond traditional boundaries and roles to embrace the exciting possibilities of this collaboration.