Doctors Manage Several Patient Problems in Short Office Visits

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A new study of conversations between physicians and patients reveals that primary care doctors often juggle many patient concerns during routine office visits.

“We documented that on average there are six topics that were discussed, and there is not a lot of time allocated to these topics,” said lead study author Ming Tai-Seale, Ph.D.

During the doctor-patient interactions, the topic that received the most talk time was typically discussed for about five minutes. The remaining issues typically received about a minute of discussion each, found the study in the latest online issue of the journal Health Services Research.

“Some of those ‘remaining’ issues may have deserved more time,” said Tai-Seale, an associate professor at Texas A&M Health Science Center. “Those topics can be about mental health, personal habits — maybe smoking, diet or social network or end-of-life care - things that are very important.”

With so many issues competing for a physician’s attention, it is difficult to know if the quality of care for the visit as a whole or the individual issues is good or bad, she said.

To increase the chances of a satisfying medical appointment, Tai-Seale suggests that patients bring a written list of their concerns to the doctor’s office. Patients should share the list at the beginning of the appointment then ask the doctor to identify three of four issues that can be dealt with during that visit.

“I spoke with several physician colleagues who said they were trained to do that in medical school,” Tai-Seale said. “But in actual practice they don’t often use that strategy. They try to address all the concerns that a patient brings up and end up not being able to really address any of the topics adequately.”

For the study, researchers used videotapes of 392 primary care doctor’s office visits between 1998 and 2000. All of the patients were 65 or older. Each time the patient or physician raised a new issue, it was treated as a topic. Both physical ailments and psychosocial topics were tallied.

Tai-Seale said older patients often have multiple chronic illnesses and psychosocial concerns that can require in-depth history taking, evaluation and counseling. Sorting out the troubles of one patient with diabetes, High Blood Pressure and knee pain is demanding work. But Tai-Seale said reimbursement arrangements often do not encourage doctors to spend the time.

“Procedure-based medicine pays better,” she said. “That’s just the way the U.S. health care system is set up. Just injecting some medicine into the knee joint pays more versus counseling a patient to exercise or engage in lifestyle management that could help a patient lose weight and reduce pressure on the joints.”

Tai-Seale’s research also revealed that the length of doctors’ visits seem constrained by fairly regimented schedules. “Even though the content of the visits varied quite a lot, the length of the visits varied very little,” Tai-Seale said.

John Beasley, M.D., a family physician in Wisconsin, said, “The reality is that we all have time on our schedule blocked and it’s usually a 15-minute increment. But I think the feeling of most doctors is that we kind of expand that time more or less depending on the complexity of the patient.”

Beasley, professor emeritus with the University of Wisconsin’s Department of Family Medicine, has studied the dynamics of the doctor-patient encounter, but was not involved in the current study.

Beasley said Tai-Seale’s study uncovers the complexity of what goes on during a routine medical visit.

There is an illusion that primary care doctors deal with and diagnose one discrete problem during a typical office visit, Beasley said. “Most of what I’m really doing with my elderly patients is problem management - trying to integrate care of multiple problems.”

“This is complex stuff,” Beasley said. “It would be nice to get administrators to understand that to do all of this in 15 minutes or 10 minutes is really a yeoman’s task, and doctors might do it better if they had a little more time.”

Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Services Research online, 2007.

Source: Health Behavior News Service

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