[smartdoctor] entering dangerous territory.
- From: "BARI" <bari.sita@xxxxxxxxxxx>
- To: <smartdoctor@xxxxxxxxxxxxx>
- Date: Wed, 22 Oct 2014 19:58:22 +0200
From: smartdoctor-bounce@xxxxxxxxxxxxx
[mailto:smartdoctor-bounce@xxxxxxxxxxxxx] On Behalf Of dr Zlatko Sušanj
Sent: Wednesday, October 22, 2014 6:23 PM
To: smartdoctor@xxxxxxxxxxxxx
Subject: [smartdoctor] Re: [smartdoctor] Koliko pacijenata može doktor sa
SIGURNŠĆU vidjeti/pregledati dnevno?....nakon trideset pacijenata ulazite na
opasan teritorij...
Ne sjećam se da sam ikad izašao iz opasnog teritorija. Ridiculous
cid:B68@goomoji.gmail
Your Middle Name Is Danger,Ida
2014-10-22 11:18 GMT+02:00 BARI <bari.sita@xxxxxxxxxxx>:
….good medicine simply can’t be practiced in five to seven minutes.
I would argue that if any practice has a significant amount of patients over
the age of fifty, then seeing more than about twenty-five to thirty patients a
day is irresponsible. …..once you go above that number in one day you’re
entering dangerous territory.
Koliko pacijenata može doktor sa SIGURNOŠĆU vidjeti/pregledati dnevno?Ida
How many patients can a doctor safely see a day?
<http://www.kevinmd.com/blog/post-author/luis-collar> Luis Collar, MD |
<http://www.kevinmd.com/blog/category/physician> Physician | December 31, 2013
Today’s question is a simple one. How many patients can a physician see in one
day and still be thorough? Don’t get me wrong; I’m all for efficiency. But we
need to recognize when efforts at efficiency become “medical sloppiness” or,
frankly, malpractice.
With health care policy and insurance reimbursement what they are today, it’s
not uncommon to encounter physicians seeing forty, fifty, and even sixty or
more patients a day in the outpatient setting. The truth is, though, no matter
how experienced the doctor, no matter how technologically streamlined the
practice, one physician can’t maintain medical accuracy at that frenetic a
pace. Many physicians like to think they can because they manage to see every
patient on their schedule and do their thing. But, in most instances, good
medicine simply can’t be practiced in five to seven minutes.
Sure, there are cases where that is all that’s required. A young, healthy
patient, a simple physical, or a stable patient that just needs a medication
refill can usually be handled that quickly. But I often see physicians trying
to care for medically complex, older patients on multiple medications in the
same fashion. The rationalization is usually that, with enough experience, one
can take care of these patients just as quickly. But the issue, then, becomes
precisely what constitutes “handling” a patient.
A patient with a complex medical history always requires more time. Trying to
argue otherwise is simply intellectually dishonest. You can’t take a history,
no matter how focused, reconcile all current medications looking for undesired
interactions or required modifications, review labs, monitor patient progress,
look for better therapeutic approaches, address new issues, encourage
communication, conduct a thorough physical exam, and spend time on health
counseling / preventive care in five to seven minutes. It just can’t be done
that quickly with these patients.
I’ve worked in offices where this level of “efficiency” is touted as the
future, the result of effectively leveraging new technology. But the truth is,
as much as it pains me to say it, it’s just bad medicine. And the argument that
a particular practice doesn’t have that many complicated patients is, in most
cases, yet another fallacy.
Complicated patients are not to be confused with medically interesting
patients. Many of the most common chronic illnesses that find their way into
physicians’ offices are, in fact, not interesting or exciting for seasoned
medical professionals. After all, diabetes isn’t exactly extraskeletal myxoid
chondrosarcoma or any of the “sexy” hemorrhagic fevers, but that doesn’t mean
it isn’t an exquisitely complex illness requiring a thorough clinical approach.
So the average primary care physician may not have many “medically interesting”
patients, but they probably do have many complex patients. I would argue that
if any practice has a significant amount of patients over the age of fifty,
then seeing more than about twenty-five to thirty patients a day is
irresponsible. Seeing three to four patients an hour yields a number somewhere
in that range. And while some patients can be “handled” more quickly than
others, once you go above that number in one day you’re entering dangerous
territory.
If you look at the available data and the current incidence of obesity, heart
disease, hypertension, diabetes, and depression to name a few, then any
practice serving patients over the age of fifty must, by definition, have a
good number of complex patients. Although common, none of these illnesses are
“simple.” Quick refills, not listening, not asking probing questions, shoddy
physical exams, not looking for all possible signs and symptoms of disease
progression, poor or no counseling, and not actively staying ahead of a disease
are all poor practice. More importantly, those practices lead to poorer patient
outcomes and increased health care costs in the long run. That is particularly
true with this patient population.
The challenge, of course, is that our current system still rewards speed and
procedures much more richly than patient interaction and thorough analysis.
Although not a new concept, as reimbursement continues to decrease necessarily
(Medicare’s pockets aren’t as deep as they used to be) and more patients gain
access to the system, addressing the question of “medical speed” will become
increasingly important.
Admittedly, the thoughts presented here are only based on anectdotal evidence
collected over several years of working with numerous physicians, in multiple
settings, and at several different hospitals. However, I do believe there is a
trend here. The more “evolved” our health care system becomes, the more
pressure is placed on physicians to leverage technology and see more patients,
the more bad professional habits are being developed. Technology can help
increase efficiency, but it can’t yet replace ample time with an interested,
compassionate, well-trained physician. Not every patient requires thirty or
forty minutes, but if we’re going to be honest, forty or more patients a day is
simply ridiculous.
I would challenge all physicians to honestly evaluate how long they spend with
complicated patients. More importantly, I’d be interested in knowing how they
define a complex patient. And I would question any definition that doesn’t
include even the most common chronic illnesses. No matter how “boring” these
may be, their intrinsic complexity and impact on public health certainly
justify more than a few minutes of diagnostic effort, even with routine
follow-up visits.
I would also encourage all patients to expect more from their doctors than a
couple of questions and some quick advice in five to seven minutes. If you’re
there for a simple cold, then maybe that approach is appropriate. But if you
have a chronic illness and are concerned by some new symptoms or recent changes
in your overall health, you should expect much more from an office visit.
And finally, I would encourage all policy makers to recognize the valuable role
physicians play in our society. We need policies that encourage them to do
their jobs properly instead of punishing them for it. Ultimately, though, it’s
up to physicians to choose. I hope they are true to their training and show
humility in the face of complex, albeit common, diseases. It’s a shame to
simply toss all that “medical school stuff” out the window simply because the
system is currently what it is.
Luis Collar is a physician who blogs at <http://sapphireequinox.com/blog/>
Sapphire Equinox. He is the author of
<http://www.amazon.com/gp/product/0615900070/ref=as_li_qf_sp_asin_il_tl?ie=UTF8&camp=1789&creative=9325&creativeASIN=0615900070&linkCode=as2&tag=kevcom-20>
A Quiet Death.
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