Leveraging Time by Doing Less in Each Chronic Care Visit


So many primary care patients have several multifaceted problems these days, and the more or less unspoken expectation is that we must touch on everything in every visit. I often do the opposite.

It’s not that I don’t pack a lot into each visit. I do, but I tend to go deep on one topic, instead of just a few minutes or maybe even moments each on weight, blood sugar, blood pressure, lipids, symptoms and health maintenance.

When patients are doing well, that broad overview is perhaps all that needs to be done, but when the overview reveals several problem areas, I don’t try to cover them all. I “chunk it down”, and I work with my patient to set priorities.

What non-clinicians don’t seem to think of is that primary health care is a relationship based care delivery that takes place over a continuum that may span many years, or if we are fortunate enough, decades.

Whether you are treating patients, coaching athletes, raising children or housebreaking puppies, the most effective way to bring about change is just about always incremental. We need to keep that in mind in our daily clinic work. Small steps, small successes create positive feedback loops, cement relationships and pave the way for bigger subsequent accomplishments.

Sometimes I avoid the biggest “problem” and work with patients to identify and improve a smaller, more manageable one just to create some positive momentum. That may seem like an inefficient use of time, but it can be a way of creating leverage for greater change in the next visit.

I actually think the healthcare culture has become counterintuitive and counterproductive in many ways; it helps me when I focus intensely on the patient in front of me, forgetting my list of “shoulds” (target values, health maintenance reminders and all of that) and first laying the foundation for greater accomplishments with less effort in the long run.

Six months ago I wrote this about how I try to start each patient visit. And in my Christmas reflection seven years ago I wrote about the moment when a physician prepares to enter an exam room:

I have three fellow human beings to interact with and offer some sort of healing to in three very brief visits. Three times I pause at the doorway before entering my exam room, the space temporarily occupied by someone who has come for my assessment or advice. Three times I summarize to myself what I know before clearing my mind and opening myself up to what I may not know or understand with my intellect alone. Three times I quietly invoke the source of my calling.

It’s all about the patient, the flesh and blood one in front if you in that very moment and what he or she needs most from us today. In physics I learned that you get better leverage when your force is applied a greater distance from the fulcrum. In human relationships and in medicine it is the opposite; the closer you are, the greater leverage you achieve.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

3 replies »

  1. Pesto Sauce

    Your desciption of “the problem” just isn’t true.

    Under the Affordable Care Act vert few people have a $6,000 deductible.

    If you are picking a plan through Obamcare, you
    can choose a plan with a low deducgtible, a moderate deductible or No Deductible

    V. few people choose one with a high deductible unless they are very young, very healthy, and expect to never go to a doctor.
    They are buying insurance simply as a protection against a
    catastropic accident.

    Moreoever, those high deductibles are what you have to pay before surgery, or a hospital stay.

    They almost Never Apply to an
    appointment with your primary care doctor

    As for co-pays, under ObamaCare , co-pays to see a primary care
    doc are usually $10-$15.

    50% of Americans have insurance through their employers.
    In those plans, too, a $6,000 deductible before you can see
    an primary care doc is virtually unheard of.

    Please don’t use the Internet to spread misinformation that
    scares people & may well make them think that, even if they
    sign up for insurance, they won’t be able to see a doctor.

  2. This is a must-read for any family doctor.

    The idea of “working with patients to identify and improve a smaller, more manageable problem just to create some positive momentum”
    is brilliant.

  3. Completely agree, as a physician if you scattershot address the endless problem list you’ll never get your patient to understand, to commit to compliance, to make the effort. It’s their body, their life, you cannot babysit (and a society that encourages this is not a society I want to be in) I always say this is your homework assignment, check your blood sugar at this time, eat a green veg every day…. In a visit you cannot be “cured” of chronic illnesses that require life long management. Best to dive deep into ONE issue. The problem is in this brave new world of high deductible plans and per-visit copayments, patients will not come in for the counseling and medical visits that they need. They simply won’t. MCO’s are struggling with their social workers and phone nursing to do the same. Most are essentially uninsured because they cannot pay a $6000 deductible before “insurance” kicks in. Thus the doctor-patient relationship has been ridden hard and rough. We are now the bad guys delivering not only the bad news that they have diabetes, by the way your tests and exams were paid $0 by your ins. co. and you owe $455. Affordable care act? I laugh.