A Doctors lament, imagine how his patients feel.
When medical care is delivered in 15-minute doses, there’s not much time for caring
By Michael Stein
The Washington Post
Michael Stein is professor of medicine, health services, policy and practice at Brown University. He is the author of six novels and two non-fiction books and is working on a collection of essays about kindness.
I have 15 minutes. I’m generally not happy that, as an internist who works for a large medical group (most of us do now), I’m instructed to conform to this assigned length for visits with my patients. Being told to arrive at 2:45 p.m. makes it clear to patients that every doctor-hour is broken into quarters. But the pressure to keep to the time limit is felt primarily by the doctor, who must stick to the schedule or expect the 3 p.m. patient to come in unhappy about the wait.
A patient in any medical practice rightly wants the visit to take as long as is reasonably required. A healthy 25-year-old with a sore throat is thrilled to be out of my office in less than 10 minutes, after a focused exam and a culture. Most patients, though, don’t present a single problem that can be addressed with a targeted answer. The 15-minute visit shortchanges those patients while frustrating the doctors who want to help make them well.
Marvin is thin, 6-foot-4, a 36-year-old commercial mortgage broker with a lineless, hard-to-read face. I’ve seen him once before, 11 months earlier, so this is considered a follow-up visit, half the length of a 30-minute first encounter.
There’s a typical sequence to a 15-minute visit. In the opening phase, researchers who have studied primary-care interactions expect that I would “establish a cordial atmosphere” and “convey interest,” and in fact I talk to Marvin about the Yankees’ pitching problems. In the history section, I gather data with yes/no questions and tell-me-more-about-that follow-ups. “My back’s acting up,” Marvin says. Back pain is one of the 10 most common patient complaints in primary care and is almost never life-threatening. This shouldn’t take very long if I’m clinically efficient and a clear communicator. Still, I try not to show that I am in a hurry. I do not wear a watch. Did your back pain begin after an injury? I ask. Have there been pain-free days? Are there certain positions or medications that have afforded relief? “It’s been bad the past couple of months,” Marvin says.
The origin of the 15-minute visit is capitalistic, money tied to a clock. Unlike the psychotherapeutic “hour,” which has shrunk to 45 minutes, the length of the average primary-care visit has held steady. It remains driven by arbitrary 20th-century insurance service codes, based on diagnostic complexity, that dictate physician payment.
Visits involving minor problems or their follow-up care are rightly brief. I hurry through patients with bloodshot eyes and fading rashes, banking the extra minutes for needier patients in the hours ahead. I’ll need that time, because the 15-minute standard doesn’t take into account that the average patient in 2015 is older, with more complex problems and more treatment options, than a patient 25 years ago. One in five people now take three or more medications for their chronic diseases, according to the Centers for Disease Control and Prevention. Doctors can schedule longer visits for complicated cases, but that requires documenting the need to insurance companies — which means time spent in front of a computer rather than a patient.
And contrary to what insurance companies would like us to think, visit length doesn’t neatly correspond with medical complexity. Studies reviewing video and audio of hundreds of primary-care interactions show that the longest visits involve more intricate patient storytelling and emotional content. In the shortest visits, patients initiate few topics, ask few questions and answer curtly — as a result, their doctors may underestimate the severity of their diseases or injuries.
There are two kinds of talk in the office. There is the sharing of facts, or symptom reports, as when Marvin says, “It hurts when I reach down.” And there are revelations of the speaker’s state of mind, as when Marvin says, “I’m unhappy that I can’t sit in my chair for long at work, which means I’m not getting much accomplished.” But even in a symptom-directed 15-minute visit, office talk is complicated. There are questions, opinions, goals, encouragements, jokes, statements of understanding or lack of it. During the history section, information flows from patient to doctor; during the diagnosis and treatment section, the flow reverses. After finishing a physical exam, I educate Marvin about the muscle spasm I’ve found and reassure him that he has no nerve damage. Threads of conversational topics braid through the encounter.
We know that patients who ask questions are more engaged when they leave the office, and they are less likely to leave with an unnecessary prescription. Of course, allowing patients to speak at length does not necessarily lead to constructive answers from doctors, nor to a shared understanding of the problems being discussed. One part of quality care is providing, when possible, simple, competent answers to fixable problems.
Depending on how far off-schedule a doctor already is that day, he may think, guiltily: I hope this patient isn’t too wordy, doesn’t have a long, scattered list of complaints and understands what I say. He feels the conflict of the need for speed vs. the need to stop and listen. He wants to take care of more than the job at hand — this is what his patients will experience as kindness — and he wants to allow time for that.
Marvin thinks that his back pain is a result of his gym routine (a CrossFit workout, also scheduled for 15 minutes) or from sleeping in an odd position. I’m inclined to believe that his pain is muscular and can be simply managed. Only when I ask him again, before I recommend a course of action, if there are any new major stresses in his life since I saw him nearly a year ago does he tell me that his divorce negotiations are moving slowly, that he’s moved out, that child-custody issues are paramount. He announces the end of his marriage during our 13th minute together; he sounds angry and hurt.
This visit could run long, I now understand, depending on what I say next. The least I can do is offer a medication and send Marvin for physical therapy. Maybe his pain is exercise-induced, and maybe that’s all he needs. More likely, it’s stress-related. But if I draw the connection between the onset of his pain and the dissolution of his marriage, I risk turning my examining table into a couch. Without time constraints, I’d be glad to expand the conversation and try to get at the source of the problem. Here, though, I have to choose: Do I try to stay within the 15-minute hemline, or do I open a new thread of discussion and fall behind schedule for the rest of the day? What is my duty to Marvin, who is not looking at any clock?
I tell myself that what a patient needs is concentrated attention. Time is not necessarily proportional to attention. A lot can get done in 15 minutes or, in this case, the last two of those 15. Studies show that the most satisfied patients are the ones who spend more time with their doctors than they expected, regardless of the visit’s actual duration. Patient-centered care — benevolence — is about how a doctor attends to a patient’s concerns and vulnerability. I know that empathy and reassurance constitute only 2 percent of the average patient visit across the many visits studied. The average number of empathic utterances per visit is one. “I’m sorry to hear about your divorce,” I say.
I mention physical therapy and psychotherapy. Marvin says he doesn’t have time. I show him some back exercises and propose a return visit in a week to hear how he’s doing. Sometimes the very fact of meeting someone, a neutral presence, for a few 15-minute appointments is a lifeline. If Marvin keeps the next appointment with me — and I sense, despite his acceptance, there’s good chance he won’t — I suspect that his back pain will require a series of visits to put his symptoms in context. Primary-care doctors don’t schedule enough of such series: Their calendars are full, or they are more comfortable triaging such counseling.
The one-size-fits-all time limit is hard to resist. A string of visits that go beyond the 15-minute mark makes for a longer day, with all my other activities — calling specialists, reviewing lab reports, speaking to visiting nurses — pushed to the night hours or eating into my lunch break. And scheduling longer visits means seeing fewer patients, which frustrates people who need appointments.
Yet the 15-minute visit runs the risk of turning every symptom into a problem and a solution. My job, in its barest 15-minute form, is to separate the serious possibilities from the less serious, offer a diagnosis and an explanation, recommend any additional testing and list the possible courses of action. But a hurried, task-oriented approach doesn’t accommodate the meandering, overlapping, widening issues of patients. It undermines kindness. And it prevents doctors from being what our patients hope we will be when they walk in: unrushed explorers on the lookout for the next discovery.