What doctors want: more time with patients
“You answer someone's question, and they have three more," says Jordan Shlain, M.D., an internist in San Francisco. Meanwhile, more patients await, “and you may not be getting paid for your work."
In a 2017 survey of more than 1,000 physicians on the athenahealth network, six out of ten agreed with statement, “My visits with patients are often too short for me to answer their questions and treat them effectively." Along similar lines, earlier research by athenahealth and others shows that primary care doctors are doing more work during each patient encounter, even as appointments have shrunk to 15 minutes or less.
Visits are becoming more difficult and complex — in part because some easier cases are going to walk-in clinics — yet schedules have grown increasingly tighter as practices have struggled with the realities of reimbursement.
“The fundamental problem is that the fee schedule that Medicare uses, and most private payers emulate, underpays for time and overpays for tests and procedures," says Robert Berenson, M.D., a senior fellow at the Urban Institute in Washington. Recent studies suggest that physicians now spend around half of their time on uncompensated tasks, he notes. As they've turned their attention to documentation and desk work, doctors have been forced to squeeze as many patients as possible into the brief time they have left.
The good news, Berenson says, is this may change with payment reform. CMS “innovation models" like the Comprehensive Primary Care Plus (CPC+) program are quietly gaining ground, and “if they're successful — we'll have to wait and see — they could make a difference for a lot of practices." The programs offer providers lump-sum payments “you can allocate wherever you want," he says. “That way, when you have a patient who needs more time, you're in a position to give it."
Many healthcare organizations have already taken steps to lengthen patient visits — or to maximize the time, within a short visit, that doctors are able to spend on patient care. Interviews with top performers on the athenahealth network yielded four specific strategies. High-performing practices focus on chart prep long before appointments, and empower medical assistants and other non-physician staff to handle lab work, vaccines, and quality documentation before the doctor enters the exam room.
They also encourage ongoing communication with patients through portals. And they treat wellness visits, which may be scheduled for as long as 45 minutes, as prime opportunities for counseling as well as clinical care.
In addition, many providers leverage technologies like telehealth and texting to boost patient contact outside of office visits. Messaging applications such as OhMD or Hale permit easy (and HIPAA-compliant) communication between patient and physician via video or text, while software start-ups like Shlain's own HealthLoop help providers track and monitor their patients in real time.
“For patients, it's about encouraging engagement through dialogue and connectivity," says Shlain, who founded HealthLoop in 2009. “And for physicians, it's an automated and proactive tool for checking in, and for minimizing office visits that aren't necessary."
The moment of care
Making the most of every minute of an appointment is partly a matter of giving clinical and non-clinical staff the tools, resources, and latitude they need. But even modest changes in physicians' actions and demeanor can also help immensely, says Helen Riess, M.D., director of the Empathy and Relational Science Program at Massachusetts General Hospital and an associate professor of psychiatry at Harvard Medical School.
“It begins with creating a space where your patients feel like they're being listened to," Riess says. Toward that end, she recommends that doctors sit down and make eye contact when they talk with their patients.
“If you're standing up as your patient is seated, and you're talking down to them during your discussion, you're going to find it hard to build rapport or to develop any sense of trust," she says.
Similarly, Riess says, doctors shouldn't try to type data into an EHR at the same time they're talking with a patient.
“Instead, focus on the patient conversation, and then explicitly say, 'I'm going to turn to the computer now and look up your labs,' or whatever it may be," she explains. Give each patient your full attention, “and it won't feel like a waste of time for them — and you'll make the best of your time as well."