Monday, July 8, 2013

Time per patient

This was a comment I received last week on one of my posts:

I am an Internal Medicine resident in the US, and considering a career in Primary Care. I have a question for those of you who are already practicing. I would like to limit the number of patients I see per day by having 30 minute encounters for follow ups, 15 minute for acute visits, and 1 hour for annual physical or new patient visits. I plan to request these time slots at interviews. How plausible would that request be?

I don't know if I have ever had a physician spend anywhere close to an hour with me, so I'm guessing not very. Any other wisdom?

23 comments:

  1. Primary care is very much in demand in many parts of the country, so I imagine the questioner could probably find a place that would accept her terms. However, she will have to bill the same as the providers who spend less time per patient, and thus limit her pay substantially compared to her collegues. (This might change some as Obamacare is rolled out, but I doubt there will be a dramatic change in the near future.)
    It is a noble goal, and probably doable if she really is dedicated to the idea, but I wonder more about her reasons for wanting this. While many providers are rushed, I think it is possible to give quality care even with shorter appointments than those listed.

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    1. It will change under Obamacare, less $ for providers, less time for patients. Healthcare is broke and it needs to be fixed, but Obamacare seems to be a template for how to take a noble idea and do it wrong

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  2. That can't be a serious question... Can it? Surely a resident already in the US knows that such a schedule is completely untenable and they'd be laughed out of the interview

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  3. Like Abby said. It's a noble goal, but I doubt it's going to lead to a job except in an area that REALLY needs someone. Realistically this person will be told within a few weeks that they need to see more patients to earn their salary.

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  4. In the practice where I work an an RN, yes we may have appointments that last one hour, but that is not one hour with the doctor. Typically these are for patients who are getting IMEs.

    The RN takes the patient back, gets vital signs and takes an H&P and does a brief physical exam. Then the RN gives a brief (1-2 minute) report to the doctor. Doctor then clarifies anything needed from the H&P and performs a more thorough exam. He may opt to get x-rays, fluoroscopy, or EMGs, which the RN does and then presents results. Then he has a conversation with the patient about what an IME is, what his findings and recommendations are, and what the practice will do next in terms of their care.

    IMEs are billed at $1200+ per visit at this practice. Fluoroscopy and EMGs may cost more depending on the contract and terms. The report (dictation that goes to whomever ordered the IME) is billed at $52-$475 depending on what they need.

    So it is plausible, with a very restricted patient population to have one hour visits.

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  5. I think the only time I've had more than a 1/2 hour visit was to establish care with my OB and my first prenatal appointment with her. (Two separate visits but each were at least 45 minutes long.)

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  6. As a patient, I don't want to spend that much time with ANY doctor (except maybe under anesthesia in the OR...when I won't know how much time it took). Ten minutes is all I can stand.

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  7. Also an IM resident, though in Canada where no one in IM practices primary care. Even so, I've never heard of follow-ups taking longer than "acute" visits, much less twice as long. Sometimes in clinic a complex patient might take an hour or more for the whole visit, but that's not exclusively time spent with the physician, and even then it applies more to teaching environments residents review with staff and slow everything down.

    In family med, some patients might take a while, but generally speaking 10 minutes is more than enough time for almost everyone. Exceptions come when there are any procedures to do. As a student I typically wasn't very fast (certainly not at first), but as a staff physician you should be several times more efficient. Otherwise, it's pretty crucial to realize that spending 30 minutes with a patient usually entails at least another 10 minutes of related paperwork or dictations or typing letters. With these kinds of numbers you might manage 10-15 patients per day, which is horribly inefficient for primary care, and arguably that's an overestimate.

    Otherwise, if I had allocated my time that way while on call last night, I wouldn't have slept for a second and I'd still be there taking an hour with each new (to me) patient.

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  8. Unless you are seeing some very very complicated patients, or doing your own psych counseling, that seems way too long. What would you do for a full HOUR with a patient, unless it was someone rambling on that you'd be better off redirecting anyways? I've had transfers come to me with 10 inch thick binders of records (and 18 serious conditions) that may take an hour, but that is not the typical new patient.
    Having longer slots would give you time to finish all your documentation in between patients, room to breathe and to deal with emergencies without getting behind for the day. It sounds lovely in theory. if you are willing to take a part-time salary (because you'd be seeing part-time patient volume) for the luxury of being unhurried, it may be feasible to work out with an employer. If you wanted, however, to be paid the same as everyone else, I'm pretty sure they'd want you to see exactly as many patients as everyone else.

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  9. I established care with a new doctor in a top 20 academic hospital. My appointment was for 40 minutes but I spent close to an hour because he did a physical as well.

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  10. This person is living in a dream world. So if he happens to get all new patients in a day he'd only sees 8-10? That is not sustainable, and he'd quickly go out of business/be driven out of the practice.

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  11. That's actually my schedule- 1 hour for new and 30 minutes for follow-ups, but I do pediatric neurology in an academic hospital. It's a nice schedule and my patients love that I can listen to them talk (and talk and talk about their children's many and myriad issues), but we were just informed that we're going to have mandatory overbooking because our no-show rate is so appalling. Well, it was nice while it lasted...

    In any case, this is probably part of the reason why academic salaries are lower compared to private practice.

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  12. Neurology and Medical Genetics both have the 1 hr for new and 30min for return schedule in my academic hospital. Of course the pay is a bit lower than private practice and everyone's expected to do a bit of research on the side.

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  13. work at the VA, that is how much time they have with their patients.

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  14. I actually get one hour long visits with new patients but I am a specialist, I doubt this happens as often in primary care. One very important thing I have realized however is that I have become MUCH more efficient in my first 3 years of practice as an attending. So new patients occasionally TOOK me a whole hour when I was starting out and agonizing over every little decision. Now I give the same (or better) quality of care and can do it in 30 minutes (then have 30 minutes to document, catch up on other stuff).

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  15. When you initially start in Primary Care, there are some sites that start you with 1 hour slots but progressively cut down on the time as you become acquainted with the system.

    There ARE very complex patients who do require an hour+ of primary care time. However, as a patient, how much can you remember if you've had all the med changes, lab results and future plans to see various specialists done at a single visit?

    Typically at my residency, patients have 20 minute acute/follow-up slots and 40 minute physicals. Then again, this realistically turns into more like 15 and 30 min slots, since it factors in (for the patients) face-to-face time with our medical assistants and nurses who give vaccines, do counseling on colon and breast cancer screening, request records from other practices and help them book appts.

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  16. I've seen doctors before that have had appointments that are this long. They tend to be well-established doctors who don't bill to insurance. They also tend to either practice integrative medicine or take patients with very complicated issues.

    I have a rare disease and a complicated chronic condition. Even among the doctors I've had that have spent a lot of time with me going over complicated issues and medical options, I've only ever had one doctor spend more than 45 minutes of face time with me. That was a specialist in the rare disease that I have (and she didn't even think I had it.) I was in the office for three hours and had about two hours of face time with her and/or one of her staff members. I thought I was going to die once we hit the 1.5 hour mark. It was just too much time in the office and I kind of checked out mentally. All I could think about was "get me out of here" and I had waited for months for that appointment.

    On the other hand, the primary care physicians that I have liked sometimes spend 30-45 minutes with me going over a new symptom and looking at lab work, paging through other doctors' notes, and trying to come up with a new strategy. Sometimes the extra time gave us the opportunity to discuss hidden fears and complex issues. Other times, it was because one of us was distracted (doctor being paged, etc) or because the nurse forgot something.

    Having some flexibility in scheduling can be useful. These primary care doctors just accepted the reality that they were going to behind schedule or knew that someone had cancelled and they could use that time to catch up. But time isn't everything. You can waste a lot of time in a patient-doctor encounter. (Like the doctors who go off on a tangent about how you should quit grad school or something.) Patients have a limited attention span. We get worried and bored and paranoid staying inside tiny exam rooms, especially if we don't feel that anything useful is being accomplished. I can see your ratings actually go down if the amount you accomplish per time spent becomes less than optimal. And you can't always fix a problem even if you have 15-30 extra minutes. My rare disease is still going to be just as rare.

    Just some thoughts from a chronic patient,
    Abigail

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  17. I'm kind of surprised none of the doctors who posted here mentioned boutique medicine. For the med student, "boutique medicine" refers to a cash practice (or, for medicare patients, medicare + cash as well) in which the attending limits the total number of patients seen by the practice to some arbitrary number (ex: 150). The patients who are willing to pay extra now get a doctor who is not pressed to see 15 patients a day, and they each get an hour (or more) for their appointments. Usually this doctor also has a private direct line that they make available to their patients so that the patients aren't constantly chasing the doctor down. A lot of times, the doctor is willing to see them at home, in hospital, anywhere required.

    Obviously this is a very appealing idea to a lot of doctors, but one major downside is that virtually every other medical doctor you meet will hate your guts for taking all of the rich patients and leaving them with all of the medicaid patients. Also, some patients can be really annoying and dealing with constant calls from them is not a good idea if you don't like being on call 24/7/365 for stupid complaints like bleeding secondary to a shaving cut. It's also really hard to get your name out there as a physician doing this, and get started with your practice.

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  18. Right, well, here on earth, the typical primary care doctor will see a patient for 8 minutes or so and then spend the next 10 minutes catching up.

    When my sister entered practice, she entered into a suburban partnership that had a progressively retracting re-imbursement schedule to pay her salary. What that means is that she wasn't fast enough at first to pay her own salary, but for the first couple of years the partners paid into a fund to guarantee her a minimum salary. After that time it went away.

    Six years later, she sees a patient for an average of 6 minutes and catches up for about 6. She eats on the fly and works 10 hour days, seeing an average of 38-41 patients/day. There are a few longer slots for new patients or longer counseling (telling someone they have a terminal illness, for instance). She says for stuff like medication refills with no complications she doesn't even enter the room all the way.

    They have a monthly meeting where everyone's production is displayed on power point, and the lowest ones get grilled. Since there's a partner's cut first then a collective bonus, it can get pretty testy.

    From what I've heard, this is typical. And this is why I didn't go into Family.

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  19. Seems like 15 minutes for regular visit and 30 for physicals and new patients. I am not a doctor, I used to work in Finance at a sliding fee clinic. I am pretty sure most of our clinicians saw new patients in 15 minute time slots. It was a family planning clinic so it was easier than primary care. One thing that you can negotiate or ask for is downtime on your schedule, i dont know what is typical in the field.
    ~Kristen

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  20. After working in finance, I got my masters in social work and became a licenced counselor. Typically we booked our visits for an hour. We actually only saw them for 45 minutes (long visit). But did all of our documentation in the 15 minutes. As we were in a licensed clinic, we had an unbelievable amount of paperwork (our assessments were 12 pages long). The agnecy I worked for was considered "nice" as they allowed us three hours of paperwork a week. The only way you could complete all the freakin paperwork was if you had no-shows. And us clinicians were paid crap. The worst part of the job was that we had to play nurse for our doctors (calling in freakin scripts all day too). And they were idiots....remember there is a shortage of psychiatrists. Now if I worked at a non-licensed or private facility my documentation would be cake
    ~Kristen

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  21. Make sure you meet the staff: Not just the NP and PAs.... the nurses and the medical assistances...even the front desk people can make or break you

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  22. Seconding the concierge practice idea, which may need to be something you start on your own, rather than something you join up with (though who knows, maybe some docs are looking for a partner in this sort of model). As a medical student, I did an outpatient IM rotation in a concierge practice, and we saw patients for a minimum of thirty minutes. Annual H&P's were scheduled for 90 minutes, but lasted upwards of two and a half hours on more than one occasion while I was there. Time was spent talking, doing an incredibly thorough review of systems, summarizing the status of the patient's chronic conditions, discussing encounters with other specialists, etc. Saw anywhere between two and six patients a day, and actually did manage to bill insurance in many cases.

    If the original emailer sees this, they may find this site helpful for establishing this sort of practice.

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