Many questions, little time: Physicians' tight schedules at odds with patient demands

Jim Jirjis, MD, remembers a patient who came in with a long list of questions -- 17 to be exact.

He set aside 40 minutes for the physical exam, but the visit lasted 90 minutes, much to the disappointment of other patients in his waiting room.

Several years later, Dr. Jirjis is more savvy on how to cover a lot in a little time: He often asks patients to pick their top two or three concerns and deals with those during the encounter. The patient who had 17 questions now comes in with three or four.

"What happens is the important [issues] may be shortchanged if the doctor wants to get through 12 things," said Dr. Jirjis, director of general internal medicine and chief medical information officer at Vanderbilt University Medical Center in Tennessee. "Most patients understand you only have a certain amount of time."

A new national study of older patients found that physicians handle an average of six patient problems during a routine office visit, leaving precious few minutes to address them all adequately. About five minutes was devoted to the main topic, and the remaining concerns received about one minute each, according to the survey published online Jan. 24 in the journal Health Services Research.

Some of those remaining topics may have deserved more time, said lead study author Ming Tai-Seale, PhD, MPH, associate professor, School of Rural Public Health, Texas A&M Health Science Center.

Researchers reviewed videotapes of 392 visits to 35 primary care doctors by patients age 65 and older between 1998 and 2000. They examined the length and content of the encounters.

The study said physicians essentially have two ways of handling a time-consuming problem a patient presents. They can extend the visit, taking time away from other patients, or limit time spent on other problems.

Most physicians restrict time on other problems, researchers said.

Dr. Tai-Seale said older patients often have chronic illnesses and other concerns that may need more time for evaluation and treatment. When visit lengths are rigidly set, patients with more health concerns and who require more history-taking and counseling could end up getting less time than they need, contributing to lower quality of care.

Dr. Tai-Seale said reimbursement systems do not encourage physicians to spend more time on patients with multiple problems. Incentives in physician payments favor procedure-based patient care over time-intensive evaluation and management care, the study said. "A payment system that offers physician flexibility in interaction content and time can be very desirable for providing patient-centered care," the report stated.

Making the most of a visit

Dr. Tai-Seale recommends that patients bring a list of concerns to the doctor, share the list at the beginning and then ask the doctor to identify three or four issues to address during the visit.

"It would be good for [physicians] to find out from their patient what they want up front for the doctor to discuss," she said.

Dr. Jirjis said physicians should communicate to patients that they care about all of their problems. But when a doctor walks in the room, he or she should determine what the patient's expectation is and if that matches the time the doctor has.

Dr. Jirjis typically asks a patient how he or she is doing and if there are questions. He prioritizes the main concerns and covers those with the patient. Less-pressing issues can wait for another visit, or the office staff or nurse may follow up with the patient.

Systems approaches also can help maximize a doctor's time with a patient, physicians said.

For example, with open-access scheduling, which allows same-day appointments, doctors can spend additional time with a patient who requires a longer visit. A disease-management system prompts office staff to call a patient later with reminders about getting flu shots or coming in for blood pressure checks.

"That's a structural solution to this problem," said Warren Newton, MD, MPH, chair of the Dept. of Family Medicine at the University of North Carolina.

Patients won't be satisfied if the doctor never answers their main questions, physicians said. Dr. Newton said he makes sure he finds out what the patient wants during the visit, then negotiates what he and the patient will discuss. "That's easier said than done."

Family physician Sam Awada, MD, said doctors should not cringe when they see a patient come in with a list of concerns. But sometimes a physician might need to educate patients that they have a time constraint of about 15 minutes.

During the visit, he encourages patients to ask questions and take notes so they can research conditions further on the Internet.

"We always welcome educated patients, but there has to be a realistic expectation from the patient that we have other patients to see," said Dr. Awada, chief of family medicine at St. John Macomb Hospital in Warren, Mich.

Better communication between physician and patient, he said, makes for a better visit.