The efficiency factor: One visit or five?

It’s game show time: Behind Door No. 1 is a 30-minute visit with the doctor during which you’ll be allowed to address multiple issues. Behind the other door is a series of three 10-minute visits addressing one issue apiece.

You chose the 30-minute visit? Bzzzt! Wrong answer.

It’s an unfortunate reality that most doctor visits are short, and patients who want to bring up more than one concern will likely be asked to make another appointment.

The issue came up awhile back in a guest column by Dr. Danielle Ofri which appeared in the New York Times health section, lamenting an encounter with a patient who arrived with a long laundry list of problems. How do you sort through them all without becoming overwhelmed – or, as in this patient’s case, possibly missing something critical? Dr. Ofri says she learned a lesson:

When a patient presents with so many complaints that it’s not possible to cover them all in depth, I openly acknowledge the limits and say, “Today, we are going to review three of your concerns: you pick two and I pick one.” This allows the patient to select the two most concerning issues, and allows me to home in on the one I think might conceal a serious illness.

If there are other issues that haven’t been addressed or resolved, the patient presumably would be told to make another appointment.

On many levels this is a reasonable course of action. After all, doctors have other patients who need to see them too. And patient volume, rather than time spent with individual patients, essentially is what supports the practice’s overhead costs.

Is this really better, though, for overall patient care? Dr. Ofri’s column was picked up this week at Kevin, MD, where the online discussion quickly grew interesting. The comment that most caught my attention came from a medical office practice manager who wrote, “Patients… resist numerous shorter appointments as they feel they are getting less for their co-pay, and want the most bang for their buck.”

Whoa… what?

Money certainly enters into the equation. There’s no getting around the fact that two office visits and two co-pays are more expensive for patients, especially if they’re uninsured or underinsured or have a large deductible. Sometimes this is the main reason patients show up with a long, and frustrating, list of issues that need addressing: They save up all their concerns and bring them to one visit because they can’t afford to come in more often.

But I can think of many other reasons why patients wouldn’t be thrilled with a system that requires them to make multiple appointments to get all their issues addressed. For working-age adults, it means taking more time off work. For adults who are caregivers or who have small children, it means making arrangements each time to reorganize their personal responsibilities. What about older people who no longer drive and must find transportation for each of those additional doctor visits? What about people who are frail or not very mobile, for whom a trip to the doctor can be an exhausting logistical challenge?

There are many times when a face-to-face visit is necessary, regardless of the hassles it might entail. Nor is it reasonable for patients to expect unlimited time with their doctor. But from the patient’s point of view, being asked to restrict their visit to one or two issues and make additional appointments to deal with the rest is a fragmented and inefficient way of doing business – and providers should not be surprised that patients sometimes “resist.”

It would be interesting to speculate on how this practice might be contributing to the escalating cost of health care in the United States and the increasing burden on the health care system. Ten-minute visits can help churn patients through the process more quickly, but if many of those patients have to keep coming back, what has been gained? How does it save money or help the system operate more efficiently?

Much of this goes back to how doctors, particularly in primary care, are paid. They’re rewarded for volume and procedures, not for diagnosing, problem-solving, coordinating and managing. There’ll be little progress until this changes.

In the meantime, how about a little more mutual understanding? Patients aren’t villains for resisting multiple short appointments when a single longer appointment would do, any more than doctors are villains for asking patients to keep it short and come back another day.

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