86 minutes.
That’s what I found when I added up how late patients were through a single practice session earlier in the week.
Some patients arrived on time, and some a few minutes early, but the average was about 8 minutes late, ranging up to one patient who showed up an hour and 12 minutes after their scheduled appointment time.
The reason I went back and did the math was because of how harried I felt at the end of that particular practice session — somehow those inroads into the time allotted to spend with patients had been eroded by those late arrivals.
When one person was late and then needed a lot of attention, this invariably led to another patient not being able to be brought into the room until much later, and then that appointment would feel rushed, and I would begin to think about the patient after that, and the one after that, and the one after that.
Looking back on my schedule, because of overbooked urgent visits and a few patients whose scheduled appointments didn’t cross over from one scheduling program to another, I ended up having six patients scheduled during one hour of my practice session that day.
Even without the late arrivals (and in fact, there were a few patients who got there early), it feels like there’s no way that I can do justice to the care I want to provide for my patients when the expectation is that six patients will be seen and cared for in one hour. That means the total amount of time a patient gets my attention is limited not by their health needs, but by some bookkeeping function that expects me to produce a certain volume of visits every day.
During that practice session, I worked through my “lunch hour” (who has time for lunch?) and began to bump up against the afternoon practice session. I noticed a few of the medical technicians were going off shift and others were covering for them, so it took some time for them to catch up and get back into the swing of things (is anyone around who can help with an EKG?).
True, there were some patients with some fairly simple issues, routine annual physical examinations, but even these almost always had a couple of extra little surprises added on. “Oh, Dr. Pelzman, one more thing …”
Fortunately, at the end of the day, as the last patient left the exam room and headed off for their vaccines and labs, I felt that I had been able to pretty much keep up with making sure that I did all of the really important things we needed to do. Those who were there for their annual visits had their labs, vaccines, and cancer screenings updated. The person who had recurrent syncope, and the one with palpitations, and the one with progressive dementia, all had appropriate workups teed up and a plan put in motion.
But I wonder, am I doing justice to each of my patients when I only get to spend 7, 8, 12, or even 15 minutes with them?
Now, I have friends who are in concierge private practices, who offer hour-long appointments for their patients’ annual physicals. Of course, they often charge several thousand dollars for these visits, but for the life of me I can’t figure out why any one patient would want to spend that long talking to me about almost anything relating to their health. Sure, we can talk politics, global warming, sports, kids, and work, but I think for the most part, after an hour, we would both be bored from looking at each other, and run out of things to talk about.
Sometimes, try as I might, when I sit down with the patient who’s there for their annual physical, they tell me nope, nothing’s going on, I feel great, I just wanted to do the old checkup, check under the hood, kick the tires, can’t think of a single thing wrong, nothing to complain about. I can do that even if you are 14 minutes late for your 20-minute appointment.
But then suddenly, as I collapsed exhausted into my office desk chair, I thought to myself, “Who among the dozen patients I just saw did I have an end-of-life discussion with, did we identify their health care proxy, did we really get to fully explore their own health care model and what they want to pursue or ignore or defer?”
Did I have a truly shared decision-making discussion with all of those patients on all of those issues that we addressed today? How can we possibly do this in under 10 minutes?
My only hope is that as we continue to evolve the team that’s helping us take care of patients in a patient-centered model, that enough of the mundane tasks that need to be clicked in the electronic health record will be taken away from us, so we can get to pause, sit back, take a deep breath, and really have an opportunity to take care of our patients.
I know that each and every time we find something new for our medical technicians and our nurses and our social workers to do that truly engages them in the care of our patients, rather than just more forms they need to fill out, they feel more a part of this team, and they, and the patients, really appreciate it.
We can only hope that in the future there will be a time when we get to a health care system that doesn’t demand that we crush patients into a schedule on top of each other, and expect the doctors to get it all done in a tiny sliver of time. That’s not really fair to our patients, and definitely not fair to those trying to take care of them.
Whether they are late, on time, or early.
Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.
Image credit: Shutterstock.com
