Monday, May 3, 2010

Can 10 Minutes Be “The New Black?”


New England Journal of Medicine runs a column on “Becoming a Physician.” In the April 29, 2010 issue this piece by Susan Mackie, MD, explores “The Value of DNKs.”

For non-clinician readers:

DNK (pronounced "dink" and always uttered wistfully by the residents in my program) is the abbreviation that appears on our online schedule when a patient "did not keep" an appointment.

Dr. Mackie goes on to compare two clinics during her primary care residency at Beth Israel Deaconess Medical Center in Boston:

I thought about the previous day. Then, my clinic had felt frenetic, I had felt cynical, and I know that my patients had left dissatisfied. What had changed? There were many possible factors — from what I had eaten for lunch to the traffic my patients had fought on their journey in — but one difference stood out in my mind: DNKs.

…I began to suspect that the reason I felt I was a good doctor was largely the result of my two DNKs. DNKs create time.

She goes on to discuss the techniques her preceptor teaches to “make a 10-minute visit feel like a 60-minute visit.” Even though this doctor is merely a second-year house officer, she is not fooled:

Either I am not skilled enough to make 10 minutes be 60 minutes, or there is something real about clock time. I suspect it's the latter.

The real question, one that Mackie eventually touches: why would anyone consider a 10 minute visit adequate? No physician, no matter how experienced, can take any sort of history, do a meaningful exam, and provide treatment and advice in 10 minutes! When I started at my current institution, we scheduled 20 minute return appointments in our Pediatric Nephrology clinics. By the third appointment, we were late. Parents and children were cranky. Hell, I was cranky. We saw everyone, and eventually gave them the time they needed. But the schedule was, frankly, more of an ordered list than time slots.

We changed our return patients to 30 minute slots, extending the clinic day (on paper) by a bit. We marked charts with special considerations. Non-English speaking needing a translator? Anxious mom who will want to talk about everything at least twice? Child accompanied by a biological parent and foster parents? Longer slot or, even better, the final slot- when only my staff and I will  be inconvenienced. There are still days when the proverbial shit happens and we get delayed, but they are few and far between. We still see the same number of patients, generating the same revenue, but we do it much closer to the scheduled time. We all feel better!

Of course, I am in a subspecialty in an academic medical center. I am not in the position of running a private practice. Susan Mackie envisions her future in primary care:

Enthusiastically, and perhaps naively, I have mentioned to my mentors that I look forward to a future in which I will be able to share responsibilities with nurse practitioners and physician's assistants in such a way that my appointments with patients will be fewer, more thorough, and more satisfying for everyone involved. None of the experienced physicians I've talked to have confidently embraced this vision. Perhaps they have seen too many changes for the worse to believe that a change for the better is possible.

The problem with her vision? First, one has to generate sufficient income to cover all of the expenses for those NPs and PAs. Also, adding extenders may increase individual visit time with Patient X on a given date, but it means you are not seeing Patient Y. Many patients feel slighted if they do not see the doctor. And if you just stick your head in the door after an extender does the real visit, well, we are back to the 10 minute paradigm.

Like Dr. Mackie, I have no solution. The economics of current reimbursement policies mandate a certain number of visits each day to cover the costs of a business like a private practice. As patients become more complex, with more chronic diseases, these issues will only worsen. We keep expecting more for less in office practices; soon we will hit the wall.

In Harry Potter and the Prisoner of Azkaban, Hermione can manipulate time. Until we muggles can bend the laws of physics, we have to value the time a doctor needs with patients. 10 minutes can never be “the new hour.”

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  1. I think the future is definitely going to include bigger roles for PAs and NPs. My medical school has an outstanding PA program, and these students are extraordinarily bright and driven. With time, patients will come to appreciate how clinically astute PAs and NPs are. I'd much rather spend 30 minutes with an attentive PA or NP than with a distracted physician who can't even keep her eyes focused on me for more than a millisecond.

    I embrace a bigger role for NPs and PAs in the delivery of primary care.

  2. We also have a PA program, and I am impressed by many of our graduates. Our residency program director in pediatrics has often stated that NPs or PAs should be doing well child visits, freeing the general pediatrician to provide care for children with chronic diseases and treating common problems. The current practice model in urban areas seems to be pediatrician seeing as many patients as possible, and calling about or referring to specialists with anything out of the ordinary.
    Of course, using NP/PAs means the physician often has less of a relationship with the patient, and one of the drivers for becoming a primary care provider (per Mackie's article) is building patient relationships.

    I hope we can figure out an economically feasible way to improve the current situation.