Time Well Spent: Care Rooted in Connection
The amount of time you spend with your doctor will determine the strength of your relationship with them and the benefits they may offer you, but few of us get enough of that precious resource. I was listening to a podcast recently that touched on the topic of the loneliness epidemic that has been impacting millions in the US and across the globe. Modern communication technologies from the railroad to the smartphone have put us into contact with more people than ever before but often at a superficial level. It is not the quantity of relationships you have, but the strength of the bonds. Quality relationships with our family and friends are an often cited antidote to the dilemma. Psychological and sociological studies have confirmed that time spent together is perhaps the most important component to building new bonds and nurturing our existing ones. I am building Sana Sana Clinic on the solid foundation of a strong relationship between myself as a primary care doctor and my patients. I have been setting up the time slots in my clinical schedule prioritizing the time I have reserved for my patients. Initial appointments and annual physicals are 60 minute slots as a standard, and up to 90 if needed. Follow up and urgent visits are slotted at a half hour minimum. My patients will have the time with me that they deserve. Time spent together is such a critical ingredient in relationships, why would it be any different with your primary care doctor?
Conducting the medical interview or history is one of the most foundational steps in medical school towards becoming a doctor. First year medical students, who usually only have limited exposure to non-actor patients, are brought into a hospital ward to conduct medical interviews with hospitalized patients. The main goal being practicing their history skills and becoming more comfortable and confident with them. I am not sure if it was the same at all medical schools, but at Boston University where I went, these very early hospital interview visits were never rushed or capped on time, and they were structured that way quite intentionally. I was nervous when I conducted my first, as most students are at that point, but the patient I met with, Mr. B, was truly a delightful person and that anxiety quickly receded. He was recovering from pneumonia, but had been in the hospital for a weekend and was already feeling much improved, needing just a few more days of monitoring and IV antibiotics. Mr. B wasn’t much for watching TV, and was happy just for the company. He had been interviewed by a first year student before and was well acquainted with the process. Importantly, he knew there was no rush or limit to the time we both had. He calmly and patiently answered all my medical questions seated up on his bed across from me and my notebook. I was leaning over in a guest chair as I scribbled down in my notepad like an old time reporter. In between and during the questions, Mr. B told me more and more about himself as a person. After about 90 minutes spent together, I had a rich and detailed medical history along with a genuine picture of the man himself. That would not have been possible without the luxury of time we had together.
That luxury quickly eroded as I graduated from medical school. I entered Family Medicine residency and by the end was seeing patients in the now industry-standard 15 minute slot. I later began work at a major health system as a primary care doctor, where the pressure to watch the clock was even higher. The same is true for most of the profession, and the 15 minute slot is increasingly the norm, with the actual face to face time between doctor and patient being as little as 7-8 minutes. More time is spent engaged with the electronic medical system than the person seeking care. I was trained to ask open-ended questions, allowing my patients time and space to tell their story in their own words. This method takes a bit longer than a more targeted approach of narrow questions with short answers, but is a more natural and equal interaction that highlights the patient as a person and gives them a more active role in the interaction. I love this method, and my patients do too, and for years I made it work, but as the noose of time tightened, I found myself increasingly relying on focused and often yes or no questioning. The time pressure was self-perpetuating. Patients were waiting weeks or months for a visit, and the number of issues they wanted to address increased in both quantity and complexity. Even employing more narrow questioning, the demand to discuss and manage growing lists of concerns often resulted in breaking the constraints of the schedule to afford more time, at the cost of falling behind. The time crunch detracts from the quality of care, and leaves patients and doctors alike increasingly dissatisfied. The demand to see an ever growing number of patients in the same amount of time is often a major reason cited by doctors who have decided to leave the field of primary care entirely.
My father founded and still runs his own small produce business that has provided for me and my large family, and even as a medical student I envisioned myself one day opening my own practice. Before I had ever read much about the Direct Primary Care model, the dream of opening my practice was already tied with a personal mission to eliminate the time crunch. I wanted to build upon the strength of relationships and provide the quality of care I was trained to provide as a medical student, and none of that was possible without the key ingredient of time. As I researched different models for structuring my primary care clinic, it soon became clear the Direct Primary Care model offered me the solution I was seeking. Patient-doctor time is valued to the point that it is one of the model’s strongest selling points. It allows me to be the kind of doctor I was trained to be, and provide the quality of care to my patients that they have always deserved. As I write this, Thanksgiving is right around the corner. It is fitting to reflect on the ones we love and share a connection with. The strongest bonds are built on the time we spend together. I invite you all to cherish your time with family and friends, and maybe your doctor too.
References
Berg, Sara. “Primary Care Visits Run a Half Hour. Time on the EHR? 36 Minutes.” American Medical Association, www.ama-assn.org/practice-management/digital/primary-care-visits-run-half-hour-time-ehr-36-minutes.
Crist, Carolyn. “The Doctor Will See You Now, but Often Not for Long.” Reuters, 22 Nov. 2017, www.reuters.com/article/business/healthcare-pharmaceuticals/the-doctor-will-see-you-now-but-often-not-for-long-idUSKBN1DS2Z1.
Ganguli, Ishani, et al. “Association of Primary Care Visit Length With Potentially Inappropriate Prescribing.” JAMA Health Forum, vol. 4, no. 3, 2023, jamanetwork.com/journals/jama-health-forum/fullarticle/2802144.
Gottlieb, Lori. “The Friendship Formula.” Psychology Today, 1 Nov. 2019, www.psychologytoday.com/us/blog/let-their-words-do-the-talking/201911/the-friendship-formula.
Linzer, Mark, et al. “The End of the 15–20 Minute Primary Care Visit.” Journal of General Internal Medicine, vol. 30, no. 11, 2015, pp. 1584–1586, pmc.ncbi.nlm.nih.gov/articles/PMC4617939/.
Murthy, Vivek H. “The Loneliness Epidemic.” The New York Times, 30 Apr. 2023, www.nytimes.com/2023/04/30/opinion/loneliness-epidemic-america.html.
Pronovost, Peter. “The Risks of the 15-Minute Doctor’s Appointment.” Voices for Safer Care, 21 Apr. 2016, armstronginstitute.blogs.hopkinsmedicine.org/2016/04/21/the-risks-of-the-15-minute-doctors-appointment/.
Rabin, Roni Caryn. “15-Minute Doctor Visits Take a Toll on Patient-Physician Relationships.” PBS NewsHour, 21 Apr. 2014, www.pbs.org/newshour/health/need-15-minutes-doctors-time.
