Monday, February 26, 2007

Clinical Innovatons - Innovative Approaches to Time --The Inelastic Asset

The New York Times recently carried this short word piece, which I quote in full: 1

Insights: The Ticking Clock in the Doctor’s Office”

“Patients on routine visits to their primary care doctors often have a lot of questions but not enough time to get good answers.”

“That is the conclusion of a group of researchers who reviewed videotapes of almost 400 visits in three medical settings. Their report appears online in the journal Health Services Research.”

“The problem is a result of pressure on doctors to limit visit lengths so they can see more patients, said the researchers, who were led by Ming Tai-Seale of the Texas A&M Health Science Center.”

“The patients whose visits were reviewed were 65 or older and had a range of incomes. The median time for visits, the researchers said, was just under 16 minutes.”

“During that time, patients tended to bring up six subjects. About five minutes was devoted to one major topic, with the others receiving as little as one minute.”

“With only about two minutes of talk time on even the major topic from each speaker,” the authors wrote, “we could not help but wonder how much is accomplished during such a brief exchange.”

“When a patient presents a complex problem, the doctor has two basic choices: extend the visit by taking time from another patient, or limit the time spent on other subjects.” “The second choice was the most common one, the study found.”

Drucker on Inelasticity of Time

This report brought to mind a profound passage by Peter F. Drucker, 2 my favorite social and managerial philosopher because it’s impossible to read the man without learning something.

“Effective people know that time is the limiting factor. The output limits of any process are set by the scarcest resource. In the process we call ‘accomplishment,’ that resource is time.”

“Time is also a unique resource. One cannot rent, hire, buy, or otherwise obtain more time.”

“The supply of time is totally inelastic. No matter how high the demand, the supply will not increase. There is no price for it and no utility curve for it. Moreover, time is totally perishable and cannot be stored. Yesterday’s time is gone forever and will never come back. Time is, therefore, always in exceeding short supply.”

Creating More Time for Patients

What can physicians do to create more time for patients and less time for hassles and paperwork?

Here’s a laundry list.

• Read The Successful Physician: A Productivity Handbook for Practitioners (Marshall O. Zaslove, MD, an Aspen Publication, 1998.)
• Buy a copy for each member of your staff.
• Read Managing Patient Expectations: The Art of Finding and Keeping Loyal Patients (Susan Keane Baker, Jossey-Bass, 1998.)
• Buy a copy for each member of your staff.
• Instruct patient to write top three questions in advance.
• Forbid interruptions.
• Consolidate answering of phone calls and emails.
• Encourage patients to ask questions about minor illnesses by email.
• Set aside “asymmetric” time to answer e-mails without interrupting patient flow and be paid for it too, a luxury you don’t have with phone calls.
• Have a nurse practitioner or physician assistant handle minor problems.
• Hire a “scribe” to take notes while you do the history.
• Get an electronic health record, and enter your findings via a touch screen or with key strokes.
• Install a piece of software, the Instant Medical History, so patients can narrate their history, guided by a clinical algorithm, before entering exam room.
• Ask your nurse how you could do things better and more efficiently.
• Delegate clinical tasks to others.
• Cross-train your staff to do different tasks.
• Re-engineer – go into a solo practice with a lean staff, lean IT systems, and a lean space.
• Cut overhead dramatically so you can spend more time with patients.
• Schedule group visits for patients with common problems.
• Become a concierge physician or go to a cash-only practice, charge a retainer fee for unlimited attention, slash overhead, eliminate third party payment, sharply reduce your patient load so you can spend more time with each patient.
• Reread The Successful Physician: A Productivity Handbook for Practitioners.

1. Nagourney, Eric, “Insight: The Ticking Clock in the Doctor’s Office, New York Times, February 6, 2007.
2. Drucker, Peter, The Effective Executive, Harper & Row, Publishers, 1966.
3. Zaslove, Marshall, MD, The Successful Physician: A Productivity Handbook for Practitioners, An Aspen Publication, 1998
4. Baker, Susan Keane, Managing Patient Expectations: The Art of Finding and Keeping Loyal Patients, Jossey-Bass Publishers, 1997.

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