Time to change the 15 minute office visit

Who said that 15 minutes is enough time for a doctor to examine and take care of a patient? According to a Western Colorado radio station, KOOL 107.9 FM, this is roughly the same amount of time men spend on the toilet each day, which could increase depending on what you eat and how much toilet texting you do. Patient care is probably more complex than taking a dump (i.e., you don’t need as much training to poop). So how exactly did 15 minutes become the typical doctor’s visit length, and why isn’t this number being questioned more?

The reason is insurance reimbursement, which dictates a lot of what is done in medicine. Currently, insurance seems to pays hospitals, clinics and doctors only enough to justify 15-minute appointments. How, then, did insurance companies decide that 15 minutes is enough? As this piece by PBS explains, the answer is not completely clear but probably comes from a decision made by Medicare in the year 1992. Yes, 1992 was apparently when it all started. (Are you listening, Marty McFly and Doc Brown, in case you want to use your time machine?) Yes, the fateful decision that led to today’s visit length occurred several years before N*Sync and Google even got started. That year Medicare adopted the following “relative value unit”, or RVU, formula as a standard way to calculate doctors’ fees:

(Work RVU x Geographic Index + Practice Expenses RVU x Geographic Index + Liability Insurance RVU x Geographic Index) x Medicare Conversion Factor

The purpose of this now archaic formula was to reduce the variability in physician fees. Based on this formula, a typical primary care office visit should be 1.3 RVUs, which using the American Medical Association coding guidelines at the time translated to 15 minutes. Medicare then set its reimbursement rules based on this length of time, private insurance companies followed suit, managed care took over in the mid to late 1990′s, N*Sync emerged and then later broke up, Justin Timberlake became a star and medicine was no longer the same. Because of this series of events, nowadays, 15-minute doctor visits have become the norm with no apparent change on the horizon. Great Scott!

Why in Justin Timberlake’s name are we still sticking to a rule from 1992? It seems absurd to have to say this, but times have changed over the past 25 years since that Medicare decision. People actually use the Internet now. Miley Cyrus and Justin Bieber were born. Medicine is also very different. Many new and different treatments, tests, rules and regulations have emerged. Electronic health records began and grew. And the amount of paperwork involved has skyrocketed.

As a result, as indicated in a recently published study in the Annals of Internal Medicine, doctors aren’t even spending the entire 15 minutes talking to and examining patients. The study, led by Christine Sinsky, MD, at the American Medical Association, found that even when in the examination room with patients, doctors were spending only 52.9% of the time talking to or examining the patients and 37.0% doing paperwork. In other words, shrink that 15 minutes to under eight minutes (or the same amount of time women spend sitting on toilets a day, because apparently women are more efficient on the can).

Does eight minutes even make sense? Let’s examine a typical visit and see how you can squeeze everything needed into eight minutes. The visit begins with the doctor opening the door and saying hello. This can probably take under a minute as long as you, as the doctor, don’t shake hands too long and make any social greetings that require a long answer such as “enjoying the weather”, “have trouble finding parking” or “how’s the family”. Also, make sure that the patient understands and speaks English fluently, because any type of miscommunication or translation may require more than a minute. And patients, don’t talk to the doctor, which wastes time. Just say “hello” and smile.

This leaves seven minutes. Note that the patient should be already be fully undressed to save time and because patients just love sitting naked on a cold examining table waiting for the doctor. The next step is asking the patient why he or she is visiting. (As a doctor, make sure that you know the patient’s gender before the visit because figuring this out can take time. If you are a patient, then make sure you tell the doctor immediately that you are a man or a woman or something else. This removes any time-consuming mystery.) With seven minutes left, you as the patient should not take more than two minutes to tell your story, and you as the doctor should be able to understand the entire story within that time. After all, the typical television commercial is about 30 seconds long. Two minutes is like a typical commercial break from a television show. If four companies can get you to buy things in two minutes surely you can tell your whole story. Of course, you don’t have the benefit of paid accompanying actors, graphics and other visuals, and a nice soundtrack. But no one said you can’t utilize these for your doctor’s visit. Just make your story like a GEICO ad.

When telling your story to you doctor, stay concise and to the point. Avoid unnecessary time-consuming things such as saying that the symptoms are hard for you or describing your family or work situation or crying. There’s no crying in baseball or the doctor’s office. Doctors, don’t do anything to establish or strengthen your relationship with the patient. Again this takes valuable time. No small talk. No unnecessary comforting. No additional questions.

Also, patients, don’t mention any weight issues (unless that is the specific reason for your visit) because they take time to address. Pain or opioid medication issues? You can always see multiple different doctors to get enough collective time. Remember we’ve already taken out 7 minutes for the doctor to review the patient’s medical record, ask any questions about items in the record and correct any errors.

This leaves five minutes. Now the doctor has to wash his or her hands. Proper handwashing should take at least 30 seconds of lathering and hand rubbing with soap. Pushing the soap dispenser, turning on and off the faucet, getting a paper towel and drying then takes another 30 seconds. There may be time for you to throw the paper towel away as long there isn’t more than one different trash receptacle (such as trash vs. recycling vs. hazardous materials…darn conservationists). When in doubt, just throw the paper towel on the floor to save time. Patients, you can help the doctor wash his or her hands by pushing on the soap dispenser or maybe bringing your own soap packet.

This leaves four minutes. Time for the doctor to examine the patient. Taking medical equipment out consumes valuable time. One option is to have the patient hold all of the equipment before the doctor walks in the examination room. This will not only save time but strengthen the patient’s muscles and make the patient look like a Christmas tree, which can be very festive during certain times of the year. Of course, this may be a problem for frail patients, but who ever heard of frail patients going to see the doctor? The other option is to not use medical equipment. As a doctor, your finger can serve a tongue depressor, and you can put your eyeball against the patient’s ear.

One problem is the rectal exam. (I know, you’ve never said those words about a rectal exam.) Rectal exams require additional time and are only useful to detect prostate and colon problems such as cancer. Putting on gloves, applying lubrication and checking carefully. If you want the doctor to skip any of these steps to save time, the choice is yours.

This leaves one minute, if the doctor can complete all of the exam in three minutes. In the final minute, the doctor needs to tell you what to do. If the doctor found nothing wrong, great. The doctor can then tell you when your next appointment is within one minute. If the doctor found something wrong, he or she can simply say “that sucks” and quickly tell you what you need to do. If the doctor is unclear about what’s going on then he or she can just say “who knows” and leave the room.

Remember, as the patient, don’t ask questions. Questions take time. The doctor has to listen to you and actually answer. Thus, avoid questions like “what causes this problem” and “what are other options?” Remember, 15 minutes is what you have. And doctors, don’t listen to or answer patient questions. Other patients are waiting.

Time is up, so not much time for goodbyes. Maybe a quick “hasta la vista, baby” will work. Doctors, make sure that you are on your way out while saying goodbye, because the 15 minutes does not account for travel time between patient rooms. Clinics often book doctors back-to-back-to-back-to-back because reimbursement does not account for doctors having to catch their breath, take breaks, make phone calls and, of course, go to the bathroom.

Of course, specific visits may vary from the above-mentioned scenario. An unexpected emergency could make things longer. Also, the length of visit may vary by specialty. In fact, some specialty visits have even less time, such as orthopedic and dermatology visits. The bottom line is there is little time to actually listen or talk to patients and maybe not enough time to carefully examine them. Who, then, is really happy with the 15-minute visit? Wouldn’t doctors want more time to do their work well and get to know the patient? Wouldn’t patients want more time to air their issues and communicate with the doctor? Surveys by the Physicians Foundation and Commonwealth Fund have shown that many doctors are suffering from burnout. As Peter Pronovost, professor and director of the Armstrong Institute for Patient Safety and Quality at the Johns Hopkins School of Medicine, explains in the Wall Street Journal, running on a 15-minutes-per-patient treadmill can contribute to such burnout. Studies such as this one have found that shorter visits can lead to less patient satisfaction. Wouldn’t hospitals and clinics prefer patients and doctors to be more satisfied as long as their bottom line is not affected? Wouldn’t pharmaceutical and medical device companies want more time for patients and doctors to discuss treatment options?

This brings us to insurance companies. Perhaps the thought is that shorter visits will reduce healthcare costs. But is this actually the case? If shorter visit times are hurting the quality of care then maybe ultimately healthcare costs increase. A study published in 2003 in the American Journal of Public Health showed that physicians do not have enough time to provide all the preventive services recommended by the U.S. Preventive Services Task Force (USPSTF). And less preventive care means more disease and higher healthcare costs. Short visit times could also lead to overlooking medical problems and medical errors, leading to later treatment of problems and even more healthcare costs. So, who exactly is benefiting from 15-minute doctor visits?

There is a lack of science supporting the 15-minute limit for a doctor’s visit. Where are the studies? Where is the justification…from today, and not from 1992? The situation is a bit ludicrous (meaning absurd and not the rapper Ludacris, who incidentally wasn’t yet famous back in 1992.) Is everyone in society being hurt by a rule that was arbitrarily set over two decades ago?

 

 

Advertisements