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Wednesday, February 16, 2011

Fast medicine, slow medicine and the trend towards shared decision making

It is very common for patients to complain that they don't get to spend enough time with their physician, or that their questions don't get answered.  This is more true now than it was 20 years ago, and is a direct result of the fact that physicians are paid, not for taking care of patients, but for seeing patients, not for solving their problems but for spending time, even a very small amount of time, physically in an office with them. Physicians are not paid for talking on the phone with patients, for e-mailing them, for discussing their case with learned colleagues, for evaluating their complex medications with pharmacies or for coordinating care with specialists, caregivers or family members. What we do get paid for, and often well paid for, is office calls.

The other day I read an article published in a trade journal called the American College of Physicians Internist reviewing suggestions made by Dr. Neil Baum, a urologist in New Orleans, in a session of the Medical Group Management Association about cutting office costs.  He recommended, among other things, having a scribe take the entire history from the patient, presenting it briefly to the physician who could then pop in for less than five minutes to do a (very) brief exam and tell the patient what he or she should do.  Anything educational that would take extra time could be turned into a video that the patient could watch while the doctor was seeing other patients. He stated that using such techniques allowed him to reduce the time he spent with patients from over 20 minutes to less than 5 minutes.

I'm surprised that anyone comes back. Perhaps he really packs some value into that 4.5 minutes, with amazing clinical exam skills and empathy, but it is pretty hard to imagine.

Still, this is not an uncommon trend, this squeezing of more patients into a day of work as a method of making more money.

As I have practiced medicine I have become more and more sure that the key to doing a good job is spending enough time with each patient.  This is even more important as we aim increasingly at involving patients in decisions that affect their health.  The present buzz word for that is "shared decision-making" and apparently those who write about such things believe it is an important and positive trend. Far from the paternal doctor who hears the problem and delivers the advice and prescription, shared decision making involves understanding a patient's values and preferences, presenting options and coming to a consensus about immediate and contingency plans.  Plans that come of such meetings of minds are more likely to be appropriate and to be adhered to by patients, since they not only understand, but have participated in crafting these plans. One such appointment may obviate the need for many more appointments, efficiently using both the provider and the patient's time and energy.

Shared decision making rarely fits into 4.5 minute appointments.

Fast medicine, like fast food, has a place, but lacks substance and quality.  Some problems can be treated well, quickly, such as lacerations and warts, but even the common cold needs some explanation and has different implications for each individual.  There are situations in which many patients need attention in a small amount of time, and expediting treatment and cutting corners can be necessary. I often see patients who have been unable to get in to see me (possibly because I don't see patients every 4.5 minutes) who have been at urgent care centers. They have all appreciated that such options were available, but often many of their questions were left unanswered, and treatment and evaluation were suboptimal.

I think we need, some way, to figure out how to support slow medicine as generously as we do the fast variety.  The fee for service system does not do that at this point, and salaried physicians are often forced to see large numbers of patients by the corporations that pay them, with a similar set of incentives going on.

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