Our organization is undergoing primary-care redesign like many other health systems and practices across the country. As part of this process, we are looking at what are the key problems in the current delivery of primary care. One issue we’ve identified is that patients are more complex overall. Primary-care clinicians are not seeing the patients with strep throat, ring worm, UTI, or uncomplicated hypertension as much as we once did.
When I was a high school student, I worked for our local general practitioner. He would double and triple book 15- minute appointment slots. Today, this seems ludicrous to me as I can do almost no single visit in just 15 minutes.
While I’m not advocating for a system designed around two to three minutes for the patient-physician interaction, the reason he could keep up this pace is because the majority of issues were self-limited concerns. Those with chronic disease had far fewer treatment options. Payment was less complicated as well. There absolutely were complex social situations that required a lot of time and attention but these were few and far between, and the relatively low quantity could be absorbed during the course of the day.
Three decades later, even when I think I’m entering a patient room to address a simple strep throat, I never am. The patient may call for sore throat, but the rest of the story is that the patient has already been to urgent care twice and received a z-pack. He is no better two weeks later and I need to find out why. Due to both the economics of health care (naturally patients want as much as the $30 co-pay can buy) and the economics of time (just like us, patients are busy and do not have time for repeated visits), patients are asking us to do more and more in a single office visit.
During a recent clinic session, I had three separate patients whose lives were completely falling apart. While they sought care for physical symptoms of abdominal pain or headache or back pain, the root issue was untreated mental health conditions, severe social stressors, and financial, relationship, and legal challenges. Not only am I ill-equipped to handle a large range of social issues, but I usually do not have adequate time to do so, even if I was prepared.
What we see is that the traditional office visit can no longer meet the needs of 21st century primary care. The quantity of medical issues a primary-care physician needs to cover, per current evidence-based recommendations, well exceeds the time we have with our patients (even excluding phone calls and electronic health record documentation). Adding on to this a cacophony of psycho-social challenges that we cannot possibly address places the primary care clinician in an untenable role.
Like any complex problem, this one requires many different solutions and approaches. However, the first step is recognition — by clinicians, administrative leadership, payers, and patients — that the modern office visit is an entirely different experience in 2016 than it was in 1986. Expecting a single clinician to meet the healthcare and other needs of a patient in a fifteen or 20-minute appointment is unrealistic.