A Novel Proposal: Let’s Trust Our Doctors

A Novel Proposal: Let’s Trust Our Doctors

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flying cadeuciiHow would you react if you sent your sputtering car to the auto mechanic, and they stopped trying to diagnose the problem after 15 minutes? You would probably revolt if they told you that your time was up and gave back the keys.

Yet in medicine, it’s common for practices to schedule patient visits in 15-minute increments — often for established patients with less complex needs. Physicians face pressure to mind the clock while they examine you.

That’s not to say that your physician “clocks out” as soon as your 1 p.m. appointment hits 1:15, or that all appointments last that long. What it does mean is that patients and doctors may be deprived of the opportunity for more meaningful discussions about the underlying causes of their problems and plans to improve them. A woman in her 50s who presents with high blood pressure and obesity might need medicine. But a longer conversation about the stresses of being the primary caregiver to her father, who has Alzheimer’s, could help provide strategies to help her look after herself.

When you see a new patient every quarter hour, there is often scant time to get to these root causes, to make accurate diagnoses, and develop the best treatment plans. And there is the danger that you miss a major diagnosis altogether.

The 15-minute appointment arose not out of evidence that it improves patient outcomes but out of production pressures — both the need to meet patient demand and to see enough patients to stay profitable.

Unpopular among patients, these production pressures have few fans among physicians either. A Mayo Clinic report stated that 54 percent of physicians meet the criteria for burnout in 2014 — up nearly 10 percent from three years earlier. Running on a treadmill all day in 15-minute sprints likely contributes to this phenomenon. Onerous documentation requirements and other pressures don’t help, either.

Some patient problems could be solved in 5, 10 or 15 minutes, but others cannot. What if health care trusted its physicians enough to take the time they need with patients and no more — and then monitored and paid for results? Could we realize better care while reducing costs, because patients are getting the right diagnosis sooner, and not coming back after their problem has been missed and their condition has worsened?

It’s not clear whether alternative payment models will achieve this. Concierge practices, in which patients pay a hefty annual fee in exchange for greater access to their physicians, may work well for those who can afford it. While this model is beyond the financial reach of many, a related model called direct primary care — or “concierge care for the masses” — is more accessible. Patients pay a monthly fee of anywhere from $25 to $85 to cover their primary care services, according to a Health Affairs report in December, and are encouraged to have insurance to cover more serious health issues. Patients and physicians might have 45 minutes to spend in an appointment. Because direct primary care usually does not bill insurance, it results in less checking boxes and more conversation.

A criticism of these models is that they may exacerbate the larger physician shortage, because physicians are responsible for significantly fewer patients than in a typical practice. Yet we need to evaluate their impact and see if their lessons might help us reclaim the patient-physician encounter.

This post first appeared in The Wall Street Journal’s blog, The Experts. Peter Pronovost, MD leads the Armstrong Patient Safety Institute at Johns Hopkins.

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17 Comments on "A Novel Proposal: Let’s Trust Our Doctors"


Member
Jul 26, 2016

I am now 3 1/2 years into my direct care practice and am up to 725 patients. My care is better, my life is better, my patients are far happier (as are my nurses), and I can spend the time to avoid the “more care is better” mentality that dominates our medical culture. I recently attended a DPC (Direct Primary Care) conference and was happy to see that the focus was not just on the practice model’s financial implications, but was heavily pushing against the high-consumption mentality of care.

My practice is not full yet, and I don’t really know what my max will be. I hope to eventually add other services that will extend my panel size even more. As our incomes go up over time (and mine is getting closer to my pre-DPC income), the attractiveness of this model will rise sharply. Life is SO much better for the doctors and the patients in this model that I think many docs will switch and many new doctors will no longer avoid primary care due to its terrible lifestyle (I’ve gotten letters from many residents and medical students saying exactly this).

I am now able to practice the kind of medicine I imagined when I first wanted to be a doctor. It is the first time where the care of my patients is at the center of everything, not the wants and needs of some third-party payor. I do think there is some work to scale up the size of DPC practices, as a panel of under 1000 patients is not tenable if scaled up to the whole PCP population. But I really do think that the quality of care we can give is so much higher and the decreased consumption we promote (since we no longer profit from sickness and procedures), the folks who matter will start to believe that this is more than just a cottage industry. That was my goal when I started my journey 4 years ago.

Member
rmcnutt
Jul 25, 2016

Who said physicians should practice primary care? Or nurses? Are we stuck in “group think”? Is the system a barrier rather than a trustworthy endeavor? Why is it so important that physicians be trusted; individuals should trust themselves. I am not anti-physician, for sure, but think the old idea of a what is a “physician” task is gone. My patients spend more time with other patients to inform than their physicians do. Maybe the world bypassed us and we just don’t know it yet.

Member

Once I discovered Nortin Hadler’s books I started to realize much of the conventional medical wisdom was wrong….and I was fortunate that my primary care doc went along with my choices, instead of considering me a difficult patient. This also happened in finance, when in business school I learned about Jack Bogle and Vanguard…..thereafter I understood I had to watch expenses carefully, and take what a financial advisor said with care……Bogle and Hadler…..both pointing out the experts’ conventional wisdom often is way off base….caveat emptor!

Member
Jul 25, 2016

As you’ve mentioned, giving more time to individual patients will result in a shortage of physicians. The population is too large for that. I believe that telemedicine and e-health is a good solution to this. Not only does it allows patients to monitor their health, it also allows them to connect with physicians, reducing the time factor. Of course, in some cases, physical presence is best suited, but if the technology is there and it is promising, what’s stopping one from using it.

Member

State licensing laws are a major problem…..the costs of docs getting licensed in multiple states along with all the applications etc….a proposal has surfaced that congress pass a law that says docs have to be licensed in the location where they practice…..not where the patient they are talking to is located. Simple and elegant solution!….but will be fought by the vested interests.

Member
Jul 29, 2016

Yes, the legal issues can crop up. Either the government should promote the telemedicine providers, or the hospitals can partner with these telemedicine providers. If the hospital has a license, there shouldn’t be any issue. Also, the doctor should be a licensed practioneer.

Member
Jul 24, 2016

Its all because of the American corrupt medical system. Doctors are being paid by patients, so more patients they receive, the more they get. The system should be changed to a constant payment, and doctors should be rated and rewarded by patient’s opinions.

Member
Jul 24, 2016

Okeee Dokeee, then. All part of the American Corrupt Economic System. The more customers you get, the more money you get.

Something to that effect?

“Doctors are being paid by patients”

Seriously? And all this time I thought it was those meddling 3rd party intermediaries comprising AHIP and CMS.

Member
Jul 22, 2016

I’ve struggled with this issue for years. I see both sides of it. Now free of my Blue Cross obligations, I probably would favor the concept. The following are pros and cons off the top:

Pros:

Reducing your insurance to only covering the “big” stuff is a great concept IF you have the money to cover the small stuff. Health insurance has ceased being pure insurance because it covers way too much, such as totally predictable annual stuff.

It gives PCPs time to spend quality time with patients and work on the counseling and preventive measures that we need.

It pays PCPs more, something I’ve always believed in

More rewarding work atmosphere and control for PCPs rather than the current rat race grind

Merit based. If the patient doesn’t feel like it’s worth the fee, she goes elsewhere. Quality and service take on a new meaning

Patients paying out of their own pocket puts skin in the game. They’ll use it more (usually good) and better (I think).

Cons:

One more thing that favors the affluent and not the poor

Reduces the available population of PCPs per patient

Doesn’t dovetail with Medicare or Medicaid as I understand it

Fewer people get treated and have access

I think the Pros have it.

Member
Jul 22, 2016

I’m in agreement with Margalit, which is no surprise. Here is the bottom line: we should be paid for our time. A physician who works 40 hrs per week should be able to make a living wage. We should be able to pay for a home, food, and an occasional vacation with our children. No matter what their insurance coverage. There should be a government mandate that ensures physicians are paid adequately for work instead of the other way around where they determine how much we are penalized.

Member
Jul 22, 2016

“What if health care trusted its physicians enough to take the time they need with patients and no more — and then monitored and paid for results?”

So “health care” is not an entity that trusts or doesn’t trust. I would assume the reference here is to the health care “system”, a.k.a health insurers (public and private). And I assume said insurers are the ones who should “monitor”, define what the term “results” means, and finally decide what (or if) to pay, and this of course contradicts the concept of “trust”.

Here is a better idea. Pay physicians for their time at a respectable rate, or pay subscriptions fees if patients prefer that, and trust (for real) doctors and patients to manage their time together wisely. Let’s discard the systemic wisdom asserting that all people are stupid, that all doctors are crooks, that the “system” knows best, and that the “system” needs to insert itself into every little thing people do.

As to “direct” primary care or “concierge care for the masses”, most of it consists of venture capital backed, for profit, chains of employed clinicians contracting with insurers including Medicaid, to provide the primary care portion of a capitated health maintenance organization. Nothing here is direct or concierge, and very little is different from traditional HMOs, including the business case for cherry picking the healthiest patients ($25 per month won’t get you very far with a sick patient).

So let’s pause briefly before we all start cheering at the prospect of “thought leaders” finally embracing “direct” primary care (i.e. a private transaction between one doctor and one patient).

Member
Jul 26, 2016

Not sure where you get the idea of DPC being mainly venture capital backed. My practice (completely self-funded) is up to 725 patients and we are not full yet. I’ve gone to a conference for DPC physicians for the past two years and have seen a big jump in interest and awareness. The vast majority are either single docs like me, some are small groups. Certainly there are bigger groups like Qliant, but the biggest growth seems to be folks like me.

Member
Steven Findlay
Jul 22, 2016

Agree this is an issue that should be more front and center…both docs and patients hate it. CMS ought to be paying attention as MACRA rolls out.

Of course, what a lot of practices–large and small–do is have an assistant/sometimes a nurse do the “in take.” They bring up the EHR (if available), log in the visit, ask the reason for the visit, get an updated meds list, etc. This is typically a 5 to 15 min process. Then the doc arrives. Guess what? Often the doc is there only 5 to 7 minutes, or maybe 10. The visit is then (usually) billed as 15 to 20 min with doc…if FFS situation, or booked as such in managed/integrated care practices. In such instances, the problem is thus worse from a care and $$ perspective. And there are many busy docs who, for some hours during the day, see 7 to 8 patients an hour. On the other hand, it is a waste of time/inefficient for doctors to do the intake. And I’m a strong advocate for nurses and PAs doing more of the routine care, freeing docs up to pay attention to the more serious problems/patients. The VA is proposing to test this in a big way. Without question, we need a rethinking of THE VISIT…and how it can be reengineered to better meet needs of patients and population health.

Member
Perry
Jul 22, 2016

Steve,

What you just described is precisely the reason docs want to do Direct Pay. You can have a simple intake from a staff to do the basic history and vitals (or you can do all yourself). You don’t have to spend extra time or have extra staff inputting non-essential information. You can then spend as much time as it takes to take a history, do a thorough exam, and discuss options with the patient. It’s how medicine used to be practiced.

Member
LeoHolmMD
Jul 22, 2016

The rapid fire care that patients and physicians despise alike has been generated and reinforced by the corrupt, AMA endorsed Relative Value system. Regardless of if I treat 1 problem or 10 problems, the cognitive effort of physicians is reduced to “office visit”. Hence the inability to adequately dedicate time appropriately for patient care. Fee for service is not a bad idea when you actually recognize services as problems addressed or solved, rather that those procedures that are exalted by some chosen few. No one wants their surgeon rushing through their surgery. Why is rushing through office visits tolerated by anyone? This question needs to be directly addressed by those doing the price fixing in medicine. Then explain why Primary Care should not exit the system and actually serve patients they way they deserve for an appropriate price.

Member
William Palmer MD
Jul 21, 2016

Informed consent should include a consent by the patient to have a 15 minute exam. It is part of the care and deserves to have a discussion and an agreement signed between the payer and the patient. It is only fair that the patient know the style of her care in advance, just as she is entitled to know the possible risks and hazards.