Bending the cost curve: Whose responsibility?

Most observers would agree that the American health care system can’t sustain the continuing rise in costs. But figuring out how to “bend the cost curve,” as the phrase du jour describes it, is not going to be easy if we can’t agree on whose responsibility this is supposed to be.

Blogger/physician Kevin Pho is featuring an interesting poll on his site. He asks readers, “Who presents the biggest obstacle to cutting health care spending?” The poll allows you to pick one culprit: the government, physicians, or patients.

As of 11 a.m. today, 30.5 percent of the respondents blamed government and 54.2 percent blamed patients. Only 15.3 percent said doctors were the biggest obstacle to reducing health care spending.

I think Dr. Pho’s question is an important one. He writes:

Health economists estimate that 30 percent of annual health care spending is wasted money. That 30 percent translates to 700 billion dollars.

Why is cutting health care costs such a challenge?

Both Congress and the public are unwilling to admit that reducing health care is the only meaningful way to cut spending. Patients bristle at the suggestion of reduced access to an available test. This is partly due to the pervading belief that more care equals better care – when in fact, that’s not the case.

Dr. Pho points to the recent uproar over the benefit of mammograms for women in their 40s as an example of how difficult it has been to have this conversation. His observation: “This does not bode well for reformers who want to control costs by encouraging medical practices to adhere to the best available data.”

It should be noted that Dr. Pho’s poll is not scientific, nor does it indicate how many people responded. His blog also tends to have high readership and participation from physicians, so it’s possible the results are skewed. Nor did the poll include the health insurance system, which surely must be a significant contributing factor to the run-up in costs.

But before anyone feels unjustly singled out as the source of the problem, take a look at this article that appeared last week in the Minneapolis Star Tribune. The story describes an end-of-the-year rush at Twin Cities hospitals for elective procedures among people who have met their insurance deductible for the year. Here’s the money quote:

Doctors report that deductibles do affect patient behavior. Many patients now ask about price. If in the past they demanded a costly MRI, now they’ll question whether they need one. The [high-deductible] plans’ advocates say this sort of engagement is a first step to curbing the nation’s runaway health costs.

But once the deductible is met, “they go right back to their old behavior,” said Maureen Swan, a principal at health care consultancy MedTrend Inc. The incentive then is to use as many medical services as possible at little or no extra charge before the new year.

Some years ago I covered a series of health care forums being sponsored around the state by Blue Cross and Blue Shield of Minnesota. At one of these meetings, someone stood up and described his “Cadillac” health insurance, how much he was paying in premiums and how he wanted to get his money’s worth from his coverage. He had full coverage for emergency room visits but, if I recall correctly, a co-pay for visits to the doctor’s office. So when he developed a bad earache, guess where he decided to go? That’s right – the emergency room, which clearly was more expensive but at least didn’t come out of his own pocket.

This person may have been gaming the system, but when the incentives are so perversely aligned, what else should we expect? And it seems as if the escalating cost of health care is becoming a self-fulfilling prophecy: The more it costs, the less the average person can afford it without the help of insurance, so the more likely they are to take advantage of their insurance as much as possible, which drives up the costs further.

I’m not sure how constructive it is to look for someone to blame. The fact is, there seems to be plenty of blame to spread around. But we have to acknowledge this first, and this means taking a long, hard look in the mirror – regardless of whether you’re “the government,” “insurance,” doctors or the public. I’m just sayin’.

Getting rid of 2009: Bring on the catharsis!

The ancient Greeks had a word for it: catharsis, or the purging of the emotions to release tension and bring about spiritual renewal.

From a mental health standpoint, emotional cleansing can be a good thing sometimes, especially as we say farewell to 2009 and everything that made it a wonderful or an awful year.

That’s the idea, at least, behind New York City’s Good Riddance Day, which might possibly rank as the nation’s largest group-therapy session for seeking a fresh start to the new year. New Yorkers and tourists lined up yesterday to put their bad memories through an industrial-sized shredder, toss them into a Dumpster or flatten them with a sledgehammer.

This is the third year the Times Square Alliance has organized the event. “It’s time to line up to say goodbye to everything from disappointing report cards to CDs with a song you never wanted to hear again to fattening foods you’ve sworn to renounce – anything with a bad memory from the previous year,” the Times Square Alliance folks explain.

What did people get rid of this year? The Associated Press reports:

Ben Winnick of Simsbury, Conn., shredded a newspaper story about the New York Giants’ 41-9 loss Sunday to the Carolina Panthers, which ended the Giants’ playoff hopes.

“Hopefully, next season will be better,” he said.

Roxanne Rodriguez of Manhatten shredded a piece of paper with “Writer’s block” written on it. She intends to buckle down and write a musical.

“This is going to be the year I’m going to be dedicated and focused, and I will get something down on the page every day,” she promised.”

One woman shredded her lease agreement. A TV correspondent shredded a list of all the women who’ve rejected him over the past year. Other people shredded bills, Tiger Woods headlines and photos of exes. The Times Square Alliance even handed out a $250 prize to the most creative entry. This year’s award went to 12-year-old Alissa Yankelevits of Los Angeles, who shredded the memory of a counselor on a school trip who later was featured on “America’s Most Wanted.” Last year’s winner of the $250 prize was Jay Ballestero, who said good riddance to all the unmatched socks in his drawer.

Is it therapeutic? Does it matter? Sometimes, the Times Square Alliance concludes, “you just need to let go.”

Associated Press photo by Mary Althaffer

2009: The health year in review

If the annual top-10 lists are any indication, health care reform and the emergence of the H1N1 novel influenza virus were among the biggest health happenings this past year.

As everyone compiles their traditional year-end reviews of the 2009 milestones in health care, these two are among virtually all the picks, including the Harvard Health LetterUSA Today, and the Wall Street Journal.

WebMD offers both a list and a slideshow of its choices for the top 10 stories. For a worldwide perspective, the World Health Organization has put together a photo essay of the top stories about global health in 2009. And at Kaiser Health News, there’s an entertaining retrospective of political cartoons about health care reform.

It’s intriguing to see some of the other choices among the lists of the top 10. For instance, Doctors Without Borders singled out malnutrition and neglected diseases as among the top humanitarian crises of 2009. One of the picks of the Harvard Health Letter editors was research suggesting there’s a social dimension to weight gain and other health-related behaviors – in other words, "Do your friends make you fat?"

This being the end of a decade, lists of the top health/medical advances of the past 10 years are being compiled as well. At his blog, Dr. Aidan Charles has put together a slate of the top 10 and is asking readers to vote on the three most significant (polling closes on New Year’s Eve). His ballot includes battlefield medicine, the human genome project, the public health benefits of smoking bans, and the growth of online health information.

MedPage Today also is running a series, "The Changing Face of Medicine, 1984-2009," that takes a look at developments over the past 25 years in medicine. The first couple of installments, which include video and expert commentary, assess our progress in treating peptic ulcers and HIV/AIDS.

Physician/blogger Richard Fogoros proposes his own list: the 10 most overblown health stories of the past decade. Among his picks: mad cow disease, an "epidemic of epidemics," and the persistence of the belief that vaccines and autism are linked.

If a local list of the biggest health care stories of the year were compiled, it would surely include health care reform and H1N1, both of which hit close to home this past year. We saw local medical providers work overtime as they prepared for pandemic influenza, gave out vaccinations and fielded questions and concerns from a worried public. The health care reform debate also went local when Willmar hosted a standing-room-only town hall meeting in August.

Other stories I’d put on the list are the hiring of a new chief executive at Rice Memorial Hospital, the grand opening of a new addition at Meeker Memorial Hospital in Litchfield, the opening of the Willmar Center for Diagnostic Imaging, the opening of the newly integrated Willmar Cancer Center (watch for an open house in another month or so), the establishment and adoption of a new strategic plan that will shape Rice Hospital’s future direction in the next few years, and physician recruitment efforts that have been stepped up and have begun to pay off with some successes this past year.

Are there other local stories you’d add to the top 10? Which one would you select as the most important? Leave your feedback in the comment section below.

West Central Tribune photo by Rand Middleton

A healthy dose of statistics

With a major winter storm on our doorstep that’s threatening to wreck people’s Christmas travel plans, some of us might be wondering: Why on earth do we live in Minnesota?

Why, it’s for the quality of life, of course. The state has long had a good reputation when it comes to health. Life expectancies in Minnesota tend to be longer, there’s a lower incidence of tobacco use, fewer Minnesotans are uninsured, and the state generally scores well when it comes to the quality of its health care services.

A view of Minnesota by the numbers can now be found on the Web site of the National Center for Health Statistics, a division of the U.S. Centers for Disease Control and Prevention. This newly developed feature, dubbed "Stats of the States," offers a wealth of state-by-state data on measures ranging from teen births to diabetes and cancer mortality. You can click on any state to see the latest figures available. Statistics buffs could probably spend hours poring through the data.

Some figures gleaned from Minnesota’s collection of statistics: The state is among the top 10 at reducing the number of preterm and low-birthweight infants, both of which are risk factors for an infant’s future health status. Minnesota’s infant mortality rate in 2005, the most recent year for which figures are available, was 4.78 per 1,000 births, while the national average was 6.83. From 2004 to 2006, Minnesota also had one of the lowest percentages in the U.S. of individuals who were without health insurance.

Some of the most fascinating statistics on this new Web page have to do with causes of death. Heart disease is among the most prevalent conditions in the United States, and for decades it was the single biggest cause of death in Minnesota. But mortality from heart disease is slowly dropping (a similar trend has been occurring nationally for several years), and cancer is now the state’s leading cause of death. In fact Minnesota currently has the nation’s lowest death rate from heart disease.

There are probably several reasons for the decline in heart disease mortality – better early identification of risk factors, for one thing, and better prevention strategies, such as effective medication for lowering cholesterol, for another.

How might all of this translate to the local level? Let’s consider the significant effort that has been invested here in Kandiyohi County to evaluate and treat heart attacks as rapidly as possible.

Because heart muscle soon dies if it’s starved of oxygen, time is critical when it comes to treating a heart attack. Thanks to teamwork and training, local emergency medical services have managed to shave their response time down to an average of 90 minutes or less, from the time the patient arrives in the Rice Memorial Hospital emergency room until he or she gets into a cardiac catheterization lab – no small feat, considering the nearest cardiac cath lab is in St. Cloud, 60 miles away, and requires a helicopter flight. Local physicians say this aggressive protocol has been reducing deaths from heart attacks and reducing the likelihood that survivors will develop congestive heart failure.

Thanks to the work of a Kandiyohi County coalition, it’s becoming increasingly common to find automated external defibrillators in public places such as churches, malls and grocery stores. The Willmar Ambulance Service also is heading a countywide initiative to speed up the process for evaluating potential heart attacks while the patient is still in the ambulance.

Statistics have a reputation for being rather dry and dull but when you put them together with the stories behind the numbers, what emerges is a picture that can be very meaningful to individual consumers. Check back at the NCHS Web site in upcoming months for more new reports on birth and death vital statistics, health behavior surveys, health insurance coverage and hospital data.

Bad Santa

Santa Claus has been bad, bad, bad.

It’s all those cookies that children leave for him on Christmas Eve. And the milk. And the calories and their effect on Santa’s waistline.

The Pennsylvania Medical Society is calling on families to skip the cookies and leave carrots and celery sticks for Santa instead. They’ve done the math: 96 percent of the people polled by the Institute for Good Medicine at the Pennsylvania Medical Society said they plan to leave treats for Santa on Christmas Eve. If you figure one medium-sized chocolate chip cookie (made with butter) contains 75 calories and one cup of 1 percent milk contains 100 calories and Pennsylvania has 4.7 million households, this amounts to more than 780 million potential calories in Pennsylvania alone for Santa Claus to consume.

Santa apparently has his own team of Pennsylvania doctors who have developed what they call the “Santa Snack Plan”:

According to Peter Lund, MD, lead physician on the Santa health team and founder of the Institute of Good Medicine, “The premise behind the Santa Snack Plan is simple and very easy to follow”:

– Choose lighter, healthier foods over the tempting goodies. Santa enjoys carrots, apple slices, and celery sticks. He’s truly grateful for the roughly 4 percent of those surveyed who do leave healthy snacks instead of cookies.

– Occasionally, Santa can’t resist and he doesn’t want to disappoint the children by not trying their snacks. So, he’s learned to take a taste, not a plateful. Sometimes Santa breaks off a little piece, eats it, and then sticks the rest in his Elf Treat Bag to take back to the North Pole where droves of busy elves await the rewards of his travels.

– Be active. Besides eating less, Santa does burn calories. Santa works off thousands of calories on Christmas Eve lugging around enormous bags of gifts and climbing up chimneys. During his off-season, he also stays active – brisk strolls through the North Pole to check on the elves’ progress and exercise with the reindeer-in-training.

As such, Santa says that by helping him, all Pennsylvania children will also be helping themselves.

Well, all I can say is: For the love of Rudolph, is nothing sacred anymore? Have we become so obsessed with weight and calorie-counting that we have to attack the sweet, benign tradition of leaving treats for Santa Claus?

This is apparently not the first time Santa has been the target of advice about his health. A couple of years ago the Pennsylvania Medical Society issued a similar statement about Santa’s annual flu shot, his exercise program and, yet again, his weight.

OK, so talking about Santa’s health might have some application to the rest of us - a teachable moment and all that. If only it didn’t seem so, well, Grinch-like, so antithetical to the magic and mystery of what the Christmas season is supposed to be about.

For one thing, why are these experts discussing Santa’s health and his weight and his mental state in front of the whole world? Have they never heard of HIPAA? For another, what makes them think Santa is in need of their help?

Wrap up a mystery in silver paper and tie it with a red bow and a sprig of holly, and you have Santa Claus. We don’t even really know how old he is, although tradition suggests that early in his life, he was known as St. Nicholas, a third-century bishop in what is now Turkey.

We don’t know for sure what he looks like and we certainly don’t know his body mass index. Historians have attempted to reconstruct his appearance, but it’s mostly guesswork. The enduring image of Santa Claus as fat and jolly seems to have been the poetic creation of a single person, Clement C. Moore, who described Santa this way in his famous poem, “A Visit From St. Nicholas.” In various public appearances at malls and Christmas parties, Santa seems to be a shape-shifter – sometimes tall, sometimes short, sometimes fat, sometimes relatively slender.

What little we know about his lifestyle is speculation about snow, chimney-climbing, elves and flying reindeer, none of which have ever been scientifically observed or confirmed. As for his alleged girth, the experts seem to have succumbed to the belief that if you’re fat, it’s because you eat too many cookies, even though there’s no direct evidence of what Santa actually eats or how much he eats.

Santa doesn’t need our well-meaning advice. As near as anyone can tell, he has survived for nearly 1,700 years and he is sure to outlive us all. If there’s a secret to his health and longevity, maybe it isn’t ours to know. So save the carrot sticks for the reindeer, and let Santa Claus (and the rest of us) keep the cookies and milk he loves so much.

H1N1: Much ado about nothing?

It has been eight months since the news broke of a new influenza virus sickening hundreds of people in Mexico. For several weeks this past spring, Americans were mesmerized, and a little fearful. The news media went into overdrive with its coverage of the virus we’ve come to know as the novel H1N1 flu virus or, more familiarly, swine flu.

Where are we today? Well, after lingering through the summer and peaking in October, H1N1 appears to be waning. Worries that the virus would become widespread and that it would swamp the health care system never really materialized. We now have a vaccine available to protect against it.

So was it all a big deal about nothing?

Fearmongers have overblown H1N1 into a crisis – a label it doesn’t really warrant, asserts Jeffrey Hall Dobken, a physician and bioethicist. Dobken’s thought-provoking column, which appeared last week in MedNews Today, is titled "About Crying Wolf":

What is the impact on children and families when every 15 minutes there is an "update" on the latest H1N1 news? The Health Department serves up statistics and guidelines to professionals with incredible frequency these days: hospitalization plus morbidity/mortality rates, availability of medication, utilization of medication, changes in vaccine availability and guidelines for use and/or delivery plus demographics as to who is to be vaccinated and who isn’t.

All this interspersed with items reporting U.S. vaccine production shortfalls, then vaccine distribution plans through commercial, big-chain pharmacies and supermarkets but not physician offices, or to special groups on Wall Street or at Guantanamo.

It is all bewildering enough to the professional. What must this be like for the patient, for the child told they are at greatest risk, or the pregnant woman, or the elderly who are advised that they "don’t need it"?

Dr. Dobken concludes with the suggestion: "Perhaps we can tone down the sky-is-falling just a little bit?"

Admittedly, the media hype about H1N1 has bordered at times on frenzy. Many of us in the media are aware of this, and we’ve struggled to balance the need to provide up-to-date information with the tendency toward overkill. It’s hard to know where to draw this line. If you stick to the basics, is it enough? Or should you be giving your audience more? It hasn’t helped that the situation has been extremely fluid, often changing from one day to the next. Even health providers have had a hard time keeping up.

The bigger question, though, is whether H1N1 itself has been exaggerated out of all proportion. From the start, there were doubters and critics of the U.S. reaction to the novel virus. Plenty of people wondered why this was any different from seasonal influenza.

I’m not convinced the critics are right. Even though H1N1 has turned out to be a relatively mild illness, there are still thousands of Americans who have become very sick. Young and otherwise healthy adults have ended up in intensive care, in some cases requiring a ventilator. In Minnesota, 50 people have died from H1N1 since May.

Nationally, it’s estimated more than 50 million Americans have had H1N1, with children and young adults hit the hardest. There have been more than 200,000 hospitalizations – "about the same number that there is in a usual flu season for the entire year," the U.S. Centers for Disease Control and Prevention pointed out in a recent media briefing. And there have been nearly 10,000 deaths – again, mainly among children and younger adults.

Perhaps because we’re accustomed to dealing with influenza every year, we tend to let down our guard and forget that flu can sometimes be fatal. It can be easy to overlook the cost of flu-related medical care and hospitalizations, and the toll that absenteeism takes in schools and in the workplace.

Public health officials can’t always win. If they urge everyone to be prepared and the threat subsequently fizzles out, they’ll be criticized for crying wolf. But if they downplay or brush aside a potential threat that turns out to be serious, watch the blamestorming erupt. The messages about hand washing, vaccinations, staying home when you’re sick, etc., are messages we should be heeding anyway, regardless of H1N1. There’s nothing wrong with reinforcing them, or with pushing the need to plan and be prepared. It’s simply the prudent thing to do.

Photo: Negative stain electron microscope image of the 2009 H1N1 virus. C.S. Goldsmith and A. Balish, Centers for Disease Control and Prevention.

The fallout zone

The headlines earlier this week were rather startling: Radiation from medical imaging, particularly from CT scans, might be exposing people to unnecessary risk and contributing to an increased likelihood of getting cancer.

The news appeared in the latest edition of the Archives of Internal Medicine. In an accompanying editorial, the question was raised: Although computed tomographic scans have aided greatly in visualizing the interior of the body, have we become so carried away with the benefits that we’re minimizing the risks? From the editorial:

Every day, more than 19,500 CT scans are performed in the United States, subjecting each patient to the equivalent of 30 to 442 chest radiographs per scan. Whether these scans will lead to demonstrable benefits through improvements in longevity or quality of life is hotly debated. What is becoming clear, however, is that the large doses of radiation from such scans will translate, statistically, into additional cancers. With CT scan use increasing annually, it is imperative that clinicians take into account the radiation risks when assessing the benefits to their patients.

Two new studies published in this week’s Archives of Internal Medicine underscore the point. One of these studies attempts to quantify the future risk of cancer from CT scan exposure, using 2007 as a baseline and analyzing the risk based on age, gender and type of scan. The conclusion: As many as 29,000 future cancers might be related to the use of CT scans. The risk appeared to be higher for CT scans of the chest and abdomen, and for patients who were younger.

Some interesting figures from this study: Approximately one-third, or 35 percent, of the projected cancers from CT exposure were among the 35-to-54-year-0ld age group. Since there’s a long latency – as much as 20 to 30 years – between radiation exposure and the potential development of cancer, it stands to reason that exposure from CT scans would pose a higher risk to younger people whose life expectancy is comparatively longer. Lung cancer was the most common projected cancer, followed by colon cancer and leukemia. Women also appeared to be at higher risk, possibly because they have a higher frequency of CT scans than do men.

There’s also dose, scan type and technology to take into account. The second study published in the Archives of Internal Medicine examined CT scans done at four institutions in California last year and found that, depending on the scan and the equipment, the amount of radiation varied by anywhere from 6-fold to 13-fold. Whole-body scans, for instance, subject the patient to more radiation than more limited scans. The researchers also found that in many cases, the radiation amount was substantially higher than previously thought. "It is important to understand how much radiation medical imaging delivers, so this potential for harm can be balanced against the potential for benefit," the study’s authors wrote.

Do consumers need to worry? I admit to cringing over some of the alarmist headlines that have appeared this past week: "CT scans blamed for surge in cancers." "CT scans more dangerous than previously assumed." "Thousands of new cancer diagnoses predicted, due to soaring use of CT."

It’s true that CT scans deliver considerably more radiation than the average X-ray. It’s also true that this form of medical imaging is widely used and is to some extent overused.

But concern over radiation exposure from medical imaging is by no means a new issue. Multiple studies have documented that there has always been some level of risk. This study, for instance, addresses the safety of doing CT scans of the head among children. Here’s another study that takes a look at the use of CT scans for detecting coronary artery calcification among asymptomatic adults.

Some caution also is warranted in interpreting the statistics contained in the Archives of Internal Medicine study. First of all, the projections are the result of computer modeling, not actual cases. Secondly, even if the projections are accurate, they still represent only 1.5 to 2 percent of new cancers diagnosed annually in the United States.

None of this should be taken to mean that CT scans are dangerous or that people should stop having them. The American College of Radiology weighed in this week with its own statement, pointing out that medical imaging has greatly improved the ability to diagnose disease and injury and is far cheaper and less invasive than surgery.

What it seems to come down to is whether the technology is being used appropriately. From the ACR’s statement:

The American College of Radiology advises that no imaging exam should be performed unless there is a clear medical benefit that outweighs any associated risk. The ACR supports the "as low as reasonably achievable" concept which urges providers to use the minimum level of radiation needed in imaging exams to achieve the necessary results.

This message of moderation is one we’ve been hearing rather often lately, first with mammography and cancer screening, and now with CT imaging. While it might be confusing and possibly alarming to people, overall it’s not a bad thing to insert these issues into the public discussion. Medical intervention often involves a balance between benefit to the patient and potential risks. The more we understand that it’s not entirely risk-free, the better we’ll be able to make good decisions.

Name games

Like or dislike:

– You’re in the waiting room at the doctor’s office and a nurse/medical assistant summons you by calling out your first name.

– The doctor introduces himself/herself as “Dr. Lastname” and proceeds to address you by your first name.

– The doctor always calls you “Mr./Ms. Lastname.”

– You call the doctor by his/her first name.

There are many shoals and reefs on which the doctor-patient relationship can founder, and what to call each other is one of them.

Is it disrespectful to call patients by their first name while insisting that the doctor be called by his or her last name and title? Would patients rather be addressed with their first name or with a more formal title? What about calling the doctor by his or her first name – is this appropriate? Do the patient’s and the doctor’s age and gender make a difference?

Whenever the subject comes up, it seems to generate many opinions – some of them quite vehement – and not a great deal of consensus. The question was tackled a couple of days ago in a New York Times article that asks: What’s in a name? Dr. Anne Marie Valinoti writes:

Regardless of whether I am “Anne Marie” or “Dr. Valinoti” to a patient, I rarely call a patient by his or her first name. As a rule, patients who are my senior are always “Mr./Ms./Dr.” Patients I meet for the first time are always addressed by their title, even teenagers (it seems silly, I know). Although many patients introduce themselves by their first name, I would never presume to address them as such without their specific permission. And even then, frankly, I find it hard to call a man old enough to be my father “Frank” or “Jim.” It is akin to my habit of still addressing old friends of my parents by their formal titles.

When readers weighed in, the discussion got lively. To many people, the use of names and titles is a big deal. Someone with a Ph.D. wrote,”The issue is about reciprocity. I don’t mind if a doctor uses my first name, if I can use his. But a doctor who says, “Hi, Liz, I’m Dr. Smith” is just being rude. He’s trying to assert himself as an authority figure who should be obeyed, not as my collaborator in health.”

Someone else wondered, “Why should I call a doctor or dentist Dr. So-and-so when no one else is addressed this way?”

There was a strong current, however, of preferring some formality. Author/blogger Kairol Rosenthal commented:

The reason I like to call my doc Dr. is because it lends a sense of formality and distance to the relationship. What? Yep – distance. I’m a huge proponent of good doc-patient communication and my docs and I are very personable with each other. But I’ve got cancer, and some of the news we have to discuss is really serious stuff. I want my doctors to have objectivity when it comes to my case. I want them to treat me with the clarity of a formal relationship, not one that is blurred by personal friendship.

Several doctors also shared their point of view. “When people become ill, they want to have a doctor take care of them; not Johnny, Susie or Betty-Lou,” one physician commented. Another doctor wrote, “I don’t mind if they use my first name, but I do like to be asked, and I do expect the informality to be reciprocal in that case.”

So who’s right? There doesn’t seem to have been much formal study of this issue. In a survey conducted in Scotland several years ago, most patients either liked or didn’t mind being called by their first names. Those who didn’t like it were generally over the age of 65, which suggests that preferences might be partially determined by age or by the generation to which the patient belongs. This same study also found that most patients did not want to call the doctor by his or her first name. It’s not clear if these same findings would apply in the United States, or if attitudes have changed in the two decades since the survey was conducted. We are becoming an increasingly informal society, after all.

When I consulted my copy of “Miss Manners’ Guide to Excruciatingly Correct Behavior,” the recommendation was to use titles – Dr. Lastname, Mr. or Ms. Lastname -unless otherwise requested.

Many of the commenters at the New York Times complained (and I noticed virtually all of these were health care professionals) that it’s too hard to keep track of how patients wish to be called, and anyway, gosh darn it, patients are just so easily offended nowadays. I’d agree we need to lighten up. As long as the doctor is skilled and respectful, I don’t have any personal preference for how I want to be addressed (although 20 years from now, it’s possible I might feel a teeny bit resentful at being called by my first name by some whippersnapper in a white coat). And I wouldn’t call a doctor by his or her first name unless specifically asked to do so.

But I don’t know what’s so hard about asking patients how they want to be addressed, and noting it on their chart. And there seems to be no reason why health care professionals can’t introduce themselves to patients by using their own preferred form for how they want to be addressed – “Hi, I’m Dr. Smith but everyone calls me Dr. Joe.” In this, as in all other aspects of the doctor-patient relationship, a little communication and respect can go a long way.

The 10-minute office visit

The last time you saw a doctor, how much face time did you get? If it was 10 minutes, the length of the encounter was probably right around the national average.

The amount of time spent with the doctor seems to be shrinking at an alarming rate. Patients used to be able to count on 15 or 20 minutes – sometimes even longer – but no more. The rising cost of doing business, along with the increasing workload of nonreimbursable tasks, is forcing many physicians to crank their patients through the assembly line in order to just keep up.

It’s a situation that is not exactly ideal. How are patients supposed to communicate their concerns when the clock is ticking? People with a new diagnosis might have numerous questions and worries. Ditto if they’re being given a new prescription, or if they have a chronic condition they’re struggling to manage. Maybe they have a list of five or six things they want to ask the doctor about – but there’s not enough time to address them all. Perhaps the real reason they’re in the doctor’s office is something they don’t immediately want to bring up. Or maybe they feel rushed and they forget to ask an important question.

It’s not surprising, then, that people often leave the doctor’s office feeling a) shortchanged; and b) unsure whether their concerns have truly been addressed.

Many physicians aren’t thrilled either with this state of affairs. It’s hard for doctors to get to know their patients when they might only see them for 10 minutes once a year (or even less often than this). It puts considerable pressure on the doctor to stay on schedule, stay focused and to steer the conversation in the right direction. There’s the ever-present worry that in the need for speed, something will be missed or overlooked with dire consequences for the patient. The time crunch for physicians is a significant factor in occupational stress and dissatisfaction, and has also been linked to a higher risk of burnout.

So how much time is optimal for the doctor-patient appointment? As it turns out, the answer is harder to nail down than you’d think. In a survey conducted among Israeli patients, the optimal length of the visit was placed at 15.4 minutes.  Other patient satisfaction surveys suggest a length of 10 to 20 minutes. A study published a few years ago in the Archives of Internal Medicine found that perception also is important: The patients in this study were most likely to be satisfied when they perceived they’d spent adequate time with the doctor.

In reality, patients don’t always need 15 or 20 minutes with the doctor. Some trips to the doctor’s office can be accomplished in less than 10 minutes.  Health issues that are more complex or that call for more extensive discussion and decision-making might require half an hour. The key, it seems, is in how the encounter is conducted and what gets accomplished, regardless of the length of the visit.

In other words, it’s about quality, as this article on “Time and the Patient-Physician Relationship” concludes:

…With an increasing emphasis on value and efficiency in health care delivery, quality time between physician and patient is an increasingly valuable resource. Physicians spend time in face-to-face contact with patients, gathering information, and developing a relationship, doing administrative work related to visits, and maintaining their knowledge base. Importantly, time is always finite: no matter what demands a physician faces, there are only 24 hours in a day.

How can quality be increased? By improving the communication, listening to patients, and inviting them to participate in the decision-making, the authors wrote. They also suggest that visit lengths of 15 to 20 minutes are best for most patients:

It appears that, in the United States at least, visit rates above 3 to 4 per hour may lead to suboptimal visit content, decreased patient satisfaction, increased patient turnover, or inappropriate prescribing. To make the most of whatever visit time is available, we recommend that medical training contain improved instruction in doctor-patient relationships. Furthermore, this training should be extended to all levels of practitioners including students, residents, and practicing physicians.

This isn’t a one-way street. Patients can help facilitate the visit too by being better prepared. The Joint Commission, the main accrediting body for U.S. Hospitals, has newly beefed up its patient educational campaign on how to make the most out of a visit to the doctor.  Among its advice: Speak up if you have questions or don’t understand what you’re being told. Know what medication you’re taking. Participate in decisions about your care. If you can’t advocate for yourself, have another family member or trusted friend who can.

I’d add a few more. Show up for appointments on time; just one latecomer can throw off the doctor’s entire schedule and affect everyone else who has an appointment after yours. Write down a list of your concerns so you can prioritize what’s most important. Ditto for questions to which you really need answers. Don’t wait until the doctor’s hand is on the doorknob before bringing up the real reason you’re there. (Yes, they actually are called “doorknob questions” and they can be quite frustrating for doctors to deal with.)

It’s interesting to note that the Minute Clinic phenomenon is all about getting in and out of the doctor’s office quickly. In this particular context, short visits apparently are not only convenient but desirable. The same goes for online consultations, many of which are offered in 10-minute blocks of time.

Perhaps it’s all about what we expect, and the extent to which our expectations square with reality.

How much shorter are patient visits likely to get? There have been some signs recently that the dwindling face time may in fact have bottomed out. One of the most recent studies, published last month in the Annals of Internal Medicine, found that the duration of a primary care visit increased from 18 minutes to almost 21 minutes between 1997 and 2005. It’s not clear whether these are isolated findings or a widespread trend. Some of it might simply be attributed to the fact that many patients have complex and/or multiple health conditions that require more time for the doctor to manage. What’s notable, however, is that the face time in this particular study registered an increase at the same time as the overall number of patient visits also went up. So perhaps health care is starting to get the message that when office visits get shorter and shorter, the results often are less than ideal for everyone involved.

Photo by Anne Polta