Death of the 15-Minute Doctor Visit
Why Doctors' Offices Run Like Broken Factories
Have you ever experienced this?
You arrive on time after getting up early to make a 9am appointment with your primary care doctor. Upon arrival you join the line and wait to get checked in.
As you turn away from the desk to find a seat with the obligatory clipboard and paperwork you have completed a thousand times before in hand, you hear the receptionist say "9AM appointment" with your doctor. Wait, what?
You heard it right; that was not deja vu.
Your appointment was double-booked; your doctor has two appointments for the same time slot in their schedule.
When you get double-booked, it means:
1) The amount of time dedicated to you and your visit has now been split in half. Your doctor now needs to be done in half the time or suffer the wrath of the practice administrator for being ‘suboptimal.’
2) You will now only get a few minutes of face time with your doctor. A fifteen-minute office visit is actually only about seven minutes factoring in time is spent reviewing the chart and documenting the visit in the electronic medical record. When your doctor double books a 15 minute appointment slot you now likely only have about four minutes of face time with your doctor if you are lucky.
3) Your doctor is guaranteed to be late for one of the two 9 am appointments even though you did your part and got to clinic on time.
4) If your doctor spends the "full" fifteen minutes with each patient, they will now be late for all other patients that morning.
All of this assumes that every concern the doctor sees that day will be routine, non-emergent, and without interruption. It also assumes that for each patient, there will be only one concern.
How does this even happen? Why don't they respect my time and effort?
Usually an administrator is betting that either you or the other patient will not show up for their fifteen-minute appointment. Because doctors get paid by insurance companies for billable encounters in traditional healthcare, the incentive is to overfill the schedule and try to get doctors seeing as many patients as possible.
Even worse, insurance companies place large administrative burdens on primary care offices in the form of paperwork and prior authorizations so that you get your care and your doctor gets paid. The only way to handle all of the extra paperwork is to hire billing and coding staff, as well as practice managers and administrators to oversee the business. This increases the overhead or 'cost of doing business' significantly. In many cases these costs may swell to nearly 65% of revenue. As a result, physicians are pressured to see more and more patients in the same amount of time just to keep the lights on.
So what's the big deal? Patients are still seeing doctors, right?
Yes, and no.
The traditional, fee-for-service clinic, as we know, focuses on filling slots in a schedule. Some of these slots are reserved for "same-day" concerns. However, these slots are so few, and book so quickly, that patients calling the office looking for a "same-day" appointment are often actually scheduled to be seen much later. In my own previous practice my next available appointment was several months out. If you did not have my cell, physically come to clinic to ask to see me, or were unsuccessful in getting a staff member to put you through to me, you were either seeing an urgent care or waiting until my next available appointment. I ultimately found this to be unacceptable.
When the barrier to seeing your doctor is so insurmountable, and the experience while you're there so underwhelming, many patients would rather wait to see if they get sicker than spend a day of missed work in a waiting room. This increases the likelihood of an expensive urgent care or emergency room visit later with doctors who don't know you or your history. Patients are seeing doctors, yes, but not their doctors that know them.
It is increasingly difficult to practice primary care as we were taught. We are now often placed between our patients and the large systems we work for. Unfortunately physicians now must grapple with compromising their standards in a system that doesn't let them practice medicine the way they were trained and trying to do what is best for patients. All throughout medical school, we are taught to build trust with patients while getting to the root of the problem, and even swear an oath to do so. But in the standard office visit in a traditional healthcare practice, that ideal becomes largely unattainable. Doctors feel as if they are simply rushing to move widgets on the conveyor belt of health care. This is one of the big factors in current burn out among physicians. Administrators, armed with spreadsheets, admonish doctors for their "inefficiency" should they choose to halt that conveyor belt and spend more time in the exam room. Doctors may have used that time to comfort a patient with depression or a recent cancer diagnosis, but all the spreadsheet shows is a "defective" physician employee.
For doctors practicing in this system, every day becomes a gut-wrenching choice between, on the one hand, taking time with patients but constantly running behind, or, on the other hand, simply following the schedule as written, and connecting with no one. In response, doctors are leaving medicine because they would rather quit than do a bad job. They understandably refuse to stomach the cognitive dissonance of knowing what good care is and then being repeatedly pressured to compromise on that ideal. That then makes things much worse for the doctors who stay and an even worse experience for patients that are now competing for the few remaining doctors.
All patients are not all alike and life does not fit neatly into a fifteen-minute time block. Allowing a patient only one concern per visit does not constitute good care and results in a bad experience for both the doctor and patient.
Albert Einstein is credited with the quote "Insanity is doing the same thing over and over again and expecting different results.” Many health systems currently meet this definition.
The expectation to repeatedly hurry through an over-scheduled day and merely hope that tomorrow will somehow be different, without actually instituting systemic change, is perhaps the greatest example of widespread delusional thinking that exists currently in medicine. But it is, unfortunately, the status quo, and reflects a much larger institutional problem: that doctors' offices are run like broken factories. We cannot expect a different outcome without first changing the process.
Your healthcare can be different
By creating conditions that that are conducive to long-term doctor-patient relationships you will never have to be double booked again- no more stuffed waiting rooms, five-minute time slots, or one-problem appointments. I have decided for me and my patients the answer is direct primary care (DPC).
DPC is personal. When there's no bulky EMR, no required documentation for the 'quality metrics', no insurance-mandated note to fill out, and no double-booking allowed, your doctors can design a schedule around reality. This means the death of the fifteen-minute office visit. When you have a concern, your doctor is on-time, 100% present, and can even spend an hour with you if needed.
DPC is accessible. The truth is, many things doctors treat in the current health care system don't need an in-person visit every time. The reason most doctors in the current health care system won’t treat you without a visit is that there is no way for them to get “credit” if they do. You just need a doctor who is accessible. Because I am available via text and phone, you may not even have to leave your home or office. No more complicated phone call trees and "dial this extension" nonsense. No more sending a message to the portal and never getting a response. You get my cellphone and email, and I’m here when you need me. I intentionally make space for true same-day and next-day visits, too.
DPC is affordable. For about the cost of your monthly cell phone bill you receive great primary care. You can check out our membership costs and find a plan that works for you. Additionally Shreveport Direct Care can save you on medication costs (1000 generics free included with your membership) and imaging costs (deeply discounted cash rates instead if insurance inflated costs) as well.
DPC is lean and keeps costs low. Using a membership model for primary care means doctors have no paperwork from insurance companies, and thus no fleet of staff required to handle it. For businesses this means that they can devise health plans that decrease claims and potentially reverse the trend of sky rocketing health costs. This means DPCs can start small in the local community, rather than needing to be part of a larger, fee-for-service hospital system. We're seeing this local, startup trend with DPC practices all over the country.
The DPC movement is growing nationally because it realigns the goals of medicine toward serving the needs of the patient and local businesses. Doctors finally get to practice medicine the right way, and patients are finally getting treated with respect. When primary care gets redesigned so doctors and patients can connect with each other, you get better care.