Friday, January 15, 2010

Doctor Patient Relationships - Of Time, Health Care, and Doctor -Patient Communications

Yesterday’s blog “Medinnovationblog Joins “Waste-Not” Movement" elicited this exchange of comments between Steve Wilkins of Healthcommunications.pressword. com and me,

Steve said...

There is another contributing factor to the "waste" in health care today not addressed in your post. I am speaking of the sub-optimal state of physician-patient communications in the U.S. Since the late 1970's, researchers have written about the deleterious effects of biomedical-dominated communication style on patient adherence, trust and outcomes. If physicians and patients could do a better job "communicating" with one another many of the other problems cited in your post would resolve themselves.

I said...

You are mostly right. Doctors don't do a good job communicating with patients and vice versa. But I would argue, there is not a complete vacuum. Physician websites containing patient education information and platforms for interactive exchange are growing. And the Health 2.0 movement, featuring electronic patient empowerment is in full swing. Patient-doctor email exchanges are on the rise. And there are websites, like, which allow patients to share their complaints, history, and demographics before visiting the doctor. Also many doctors are now engaging in remote monitoring of patients once they are out of the office, at home, or at work.

Neither of Us Mentioned Time

One thing neither of us mentioned was time, more precisely lack of it, and the lack of physician rewards for providing more of it for patients, in patient-doctor communications.

Time is everything. As the late Peter F. Drucker, so cogently observed,

“The supply of time is totally inelastic. No matter how high the demand, the supply will not go up. There is no price for it, and no marginal utility curve for it. Moreover, time is totally perishable and cannot be stored. Yeterday’s time is gone forever and cannot be stored. Time is, therefore, always in exceedingly short supply.”

Time is Critical in Health Care

Nothing shows the importance of time more than the Haiti earthquake disaster. We have 72 hours to rescue the living and to supply food, water, and medical supplies. After those precious 72 hours, survival rates drop precipitously.

Take survival rates in heart and stroke. The earlier you open those clogged arteries, and the earlier you get oxygen to the heart and brain, the greater the chances of life and long-term viability.

Take access to physicians. In the U.S., we have a growing problem with time of access to primary care doctors. Universal coverage, Massachusetts style, now four years in the making. has made this access worse, if you go by these statistics, comparing waiting times in Boston and Atlanta.

The city with the longest average wait times to see a doctor, as you may already have deduced, is Boston. Average wait times to schedule a doctor appointment in Boston for the five medical specialties examined in a Merritt Hawkins’ survey are as follows:

Average Time To Schedule a Doctor Appointment
Boston, Massachusetts

Specialty Days

Obstetrics/Gynecology 70
Family Practice 63
Dermatology 54
Orthopedic Surgery 40
Cardiology 21

Source: Merritt Hawkins & Associates 2009 Survey of Physician Appointment Wait Times

By contrast, Atlanta, Georgia has the shortest average patient appointment wait times of the cities surveyed, as the numbers below indicate:

Average Time To Schedule a Doctor Appointment
Atlanta, Georgia

Specialty Days

Obstetrics/Gynecology 17 days
Family Practice 9 days
Dermatology 15 days
Orthopedic Surgery 10 days
Cardiology 5 days

Source: Merritt Hawkins & Associates 2009 Survey of Physician Appointment Wait Times

Responsiveness, Costs, and Inequities

Take national health system responsiveness. According to the World Health Organization, the U.S. has the most responsive system in the World, in terms of quick access, waiting times, and to such medical technologies as CT or MRI scans, open heart surgeries or stent placements, hip and knee replacement, or cataract surgeries. But responsiveness comes at a heavy price and lack of equity for some, as critics are quick to point out (C.J.L. Murray and J. Frank, “Ranking 37th – Measuring the Performance of the U.S. Health System, “ NEJM, January 14, 2010).

Where is Time for Communicating Going to Come From?

Which brings me to the question: “Where is the time going to come from for communicating with patients? “ Some of it may come from time saved by electronic communication - emailing, tweeting, facebooking, googling, automated telephone answering, or Q &A’s on practice websites – but that is not the same as face-to-face communications. Some of it may come from organizing or delegating time better. Some of it may come from the system supplying more doctors ( there will be an estimated 37 percent deficit of primary care physicians by 2025 and a 33 percent shortfall of surgeons).

Time and Primary Care Doctors

But for present primary care doctors, time is of the essence. In a 2008 survey of 300,000 primary care doctors conducted by the Physicians’ Foundation, 94 percent of doctors said the time they devote non-clinical paperwork in the last three years has increased, 63 percent said that the increasing paperwork has caused them to spend less time per patient, and 76 percent of physicians said they are either at “full capacity” or are “overextended and overwhelmed."

Give us more doctors and give doctors more time, incentives, and rewards for communicating with patients, and perhaps they will do the job better.

1 comment:

HealthMessaging said...

Great reply. You are correct of course with respect to citing "time" as a recognized barrier to improved physician-patient communications. With the competing demand of paper work, reporting requirements, etc, I do not see the length of the typical patient visit getting longer any time soon.

This is why I think the solution to better communications lies not in the quantity of time physicians spend with patients, but rather in the quality of time physicians spend talking with patients, including the use of agenda setting techniques, use of open-ended questions during the patient's opening statement, and so on. According to Marvel et. al's., 1999 JAMA article Soliciting the Patient's Agenda - Have We Improved?,the use of such patient-centered communication techniques add "6 second" to the visit.

The benefits? Increased patient trust, adherence, activation, satisfaction, fewer visits, and better outcomes. Not a bad investment for 6 more seconds!

In a recent posting on my blog Mind the Gap entitled "6 Seconds to More Effective Communications," I address the issue of time in more detail.


Steve Wilkins, MPH
Mind the Gap