Turtles and Rabbits: Family Physicians Under Time Pressure
Are economic forces and time constraints threatening what's valuable in family practice?
Fam Pract Manag. 1999 Apr;6(4):21-24.
The financial stresses and time pressures imposed on American physicians by government and private-sector organizations in recent years have been widely discussed in Family Practice Management and elsewhere. One aspect of this issue that deserves more attention is the erosion of our ability to provide the competent, comprehensive and compassionate health care that is at the core of modern family practice. As dedicated professionals, we are increasingly confronted with a choice that we find repugnant: cram more patient visits into each hour, with the shortcuts that often follow, or face a serious erosion of income.
This dilemma was discussed at length during the annual meeting of the FPM Board of Editors last summer. The board, composed of family physicians with a wealth of practice, administrative and academic experience, meets in Kansas City, Mo., for two days each year with the AAFP staff members responsible for writing, editing and producing this publication. Members also review and write articles and serve other advisory roles for FPM. The focus of the board's discussion was set by this question: “Can you use all the interviewing skills you were taught in residency and do all the things you're supposed to do these days and still make a living?”
Family practice residents are typically instructed to take comprehensive medical histories with open-ended questions and attention to psychosocial factors. They are also expected to address health maintenance and health-related behaviors. Must these approaches be abandoned in today's “treat 'em and street 'em” atmosphere? Will doing so improve efficiency or just set the stage for otherwise preventable medical problems down the road? Does taking the time to build relationships with patients make subsequent medical visits more effective and productive, or is it just an expensive luxury that the system can no longer afford? People all around the table sat up and showed interest as the topic was introduced. It soon became apparent that this was an important issue for many of them, as indeed it is for all of American medicine.
Family physicians are feeling increasing economic and professional pressures to spend less time per patient.
Friction can develop between physicians with higher visit rates and those who spend more time with patients.
Some physicians see the pressure to “treat 'em and street 'em” as a threat to what makes family practice special.
Physicians need to understand how much their personal needs affect their practice style and visit rate.
Points and counterpoints
C. Carolyn Thiedke, MD: I started my practice 10 years ago with another woman. She stayed four years. When she left, I decided I didn't really want to be the sole owner of a small business, so I sold it to the hospital. They hired three other full-time family doctors, moved us into a larger space and opened an urgent-care clinic. We had a lab with a technician, and X-ray with a radiology tech.
The hospital-owned practice never operated in the black, but that never particularly troubled me for one reason: I wasn't the owner. Gradually, though, the hospital administrators became more and more concerned about the fact that the practice was continuing to lose money. Finally, they brought in a practice management consultant, and he made many recommendations. The one they chose to focus on was that our visit rates were below the median.
We tend to be perceived by patients as people who are willing to listen, people who are willing to take time, so I guess it's no surprise that our visit rates are below average. The practice manager sees this as a real black-and-white issue: You're not seeing enough patients; you need to see more. They can always point to people in town who have bigger practices and say, “These guys are seeing 50, 60 patients a day. Why can't you be like them?” For me, of course, it's not that simple. Over the years I've developed a style that I'm comfortable with and that my patients respond to. To be honest, it's also a style that suits me. I feel like I need time to gather data and make decisions. This whole idea that I need to see more patients in every hour has probably created more angst than almost anything else that's happened over my professional career.
Don B. Cauthen, MD: I see a parallel to our relations with internists. My docs [in family practice] get very frustrated with them because they're allowed to see fewer patients than we do. Of course, the internists always say, “Well, our patients are more complicated.” Our docs always reply, “Yes, but we have to work your patients in because you can't, so we have to see your patients all the time.” It's an issue that doesn't have an answer. Many internists define quality by thoroughness, whereas some family physicians define it by accessibility.
Sometimes we use the terms rabbits and turtles. The turtles prioritize. Their definition of quality is different from the rabbits'. Friction develops if you mix the two types because the slower-paced docs aren't as accessible, so some of their workload spills over onto their faster-paced colleagues. Do these slower-paced physicians attract more needy patients? How many patients can different doctors carry? Can you pay both sets the same? It's an emotional topic that truly doesn't have an answer, but it has to be dealt with because it has to do with remuneration: What's fair for both styles?
Susan Schooley, MD: There is this huge bell-shaped curve that goes from 2,000 to 6,000 annual visits per FTE. It's a dramatic curve, with the median sitting somewhere between 4,000 and 5,000. It's a problem if the 2,000-visit persons are getting paid the same amount of money as the ones at the 6,000-visit end of the curve. It's terrible, because the economics of reimbursement are such that they aren't seeing enough patients to earn their income, no matter how they're coding. There's also a tendency for the left side of the curve to be female physicians, and for their patients to be women coming for annual health maintenance exams and full Paps and pelvics and the whole bit. There's a trend for the doctors on the right side of the curve to be doing a great deal more episodic care, which is easier to do faster. But we still have to get the median visits up because the present situation isn't economically sustainable.
We spent 10 years attracting physicians with pamphlets with sailboats on them. “Come here and we will schedule 32 hours of patient contact and you can shut your beeper off because we're a group practice and somebody's taking care of your patients after 5.” Then the economic world changed and we said, “We're changing the rules. You keep your beeper on 24 hours a day, and you do whatever it takes to get your visit rate to the median if you want that paycheck. You want to have 2,000 visits? We'll pay you two-thirds of a paycheck. You want to have 6,000? We'll pay you $160,000.”
I have a number of doctors who are experiencing the same discomfort, and I'm in dialogue with them, saying, “I value the intimacy you have with your patients, and your patients also value it, but it is not economically supportable with your current paycheck. You can continue to do what you're doing, and it will affect your compensation. Or you can do what you're doing but do it more hours every week to maintain your current pay. Or you can change your style. It's not efficient for you to do counseling, for you to sit there with a pack of oral contraceptives and say, ‘Here's how you take it and here's what you watch for’ and so on. You've got to turn that over to your nurse, because your time's too valuable.” And they're grieving. (See “Is efficiency the answer?”)
William D. Soper, MD, MBA: I think that's one of the cruxes of the issue. There is this grieving process for doctors and patients alike: This is why I went into medicine. People just don't want to give up hanging on and having the opportunity to talk.
Gillette: You always need to ask yourself, whose needs are being met? When you spend extra time, are you meeting the patient's need for more understanding, more care, or are you meeting your own need for a tranquil practice style? These are questions that lack objective answers, but you have to be honest in dealing with them as best you can. Physicians need to be aware of their personal needs. Some of us like to go home at the end of a hard day and look in the mirror and say, “Somebody needed me today and that makes me feel good.” That's OK, but you need to understand it in yourself and not get carried away by it.
Thiedke: Sometimes I say to myself, “Get over it. You can do it. It's not that big a deal.” I'm willing to acknowledge that there are efficiencies to be gained, that patient flow through our practice is not what it could be. We could see more patients if we had nurses who were well trained. But when it comes down to altering my style of practice, I feel threatened. The idea that I need to get in and out of a room in a timely fashion makes me feel as if I'm not providing good patient care.
Is efficiency the answer?
Participants in the discussion had no shortage of thoughts on how to improve practice efficiency. Here are some of the best (for more ideas, see “13 Ways to Be More Efficient” ):
William D. Soper, MD, MBA: Charting is a huge time waster. You need to dictate charts, and do it immediately. Some even do it in front of the patient. They say, “I'm going to dictate your record right now. If there's something I don't get straight or you don't agree with, stop me and let's get it right.” Actually, that's kind of a patient satisfier.
Don B. Cauthen, MD: When you have a work-in, always stand, don't sit. Deal with the immediate problem and save the rest for a scheduled visit.
Robert D. Gillette, MD: Mechanical things are important. The dictating equipment must be ready to go. I'm not sure there's an advantage to either pocket-sized, hand-held units or central dictating systems. Use what you like best. You've got to have referral forms, patient-information sheets and other papers physically at hand. Be there on time to see the first patient, and stay on time, because being behind schedule is a self-perpetuating problem.
Susan Schooley, MD: Our most productive physicians are our most satisfying ones, because when someone calls with a pressing problem, they find a way to squeeze that patient in. Probably the chief efficiency is to know your patients. If you do, you can get them in and out in five minutes and they're happy. And if you have a five-minute visit, you can afford to spend 25 minutes with the next patient if you need to.
Soper: What about patients who come with a list of problems as long as your arm? I'm not sure that we're doing these people a lot of good by going through everything on their lists. What you're really doing is teaching them to ramble on without reaching closure. My observation has been that the next time they come in they still want to talk about what was No. 4 on the list, because they don't remember what we said before. In many cases, it's better to concentrate on one or two things.
Cauthen: If people can get in when they think they need to, they're less likely to have lists.
So what is the answer?
Clearly, the discussion did not come to a resolution. But how could we expect it to be resolved simply? Whether you see the issue as compassion vs. haste, self-indulgence vs. efficiency, or thoroughness vs. superficiality, it's an issue no family physician can escape today. The world beneath our feet is changing profoundly, in medicine as elsewhere. Health care spending now accounts for one dollar of every seven spent in the United States, more than our outlay for education and national defense combined. Cost pressures can only get worse as our population ages, as previously ignored health care needs are met, and as new and more costly medical technologies come on the scene. Those who pay the bills (primarily governments and businesses, the latter working through third-party organizations) will inevitably intensify their control over the system, changing it in ways that we can only partly anticipate.
Our power to modify these changes for the benefit of patients and our own legitimate self-interest are crucially dependent on our ability to “see the big picture” and react to the world as it really is. I believe we can meet the challenge successfully both as individuals and as a specialty, and I have some thoughts about how we might do it.
I would like to hold those thoughts for now, though, in order to give you a chance to express yourself on the subject. If you have something to add to the discussion, and particularly if you have found a way to deal with this challenge effectively, please let me and the editors of FPM know. FPM will publish a selection of reader comments in an upcoming issue.
Dr. Gillette is a semiretired family physician and family practice educator and a member of the Family Practice Management Board of Editors.
Copyright © 1999 by the American Academy of Family Physicians.
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