Time and agenda

Dr. LawsonI have recognized a recurring theme among physicians. “Medicine is not what it used to be,” a colleague had once said. 

I would hear statements like, “I used to be able to take care of my patients without having to convince anyone or insurance companies of the value of my work. I could see so many more patients in the past than I can now. Now they want us to document the BMIs and our counselling in the chart. Meaningful use? I think I spend more time charting than actually seeing patients. Maybe I need a scribe.”

The ever-changing scope of medicine, and its various requirements undoubtedly have had an effect on the practice of medicine. Many providers find it challenging to balance all the requirements with actually spending quality time with their patients. With the frequency of new regulations, it is not hard to imagine the disillusion some feel.

There doesn’t appear to be enough time for the issues that patients want to discuss, and there don’t seem to be enough appointments in the day to accommodate all the patients that need to be seen while also returning other patient calls and addressing labs and phone messages.

Combining that with patients’ complaints of higher copays for doctor visits and therapy, one may be tempted to sacrifice a quality patient experience for a perceived sense of efficiency (or in come cases, just getting through the day) so you can get back to sorting out the pile of paperwork on your desk while keeping a seemingly positive outlook so the office runs smoothly.

Listening to them reminded me of an experience I had during residency training that informed my outlook on patient visits and time management. 

I was advised of the immense value in negotiating an agenda at the beginning of every patient encounter and inasmuch as it made sense to me, there were times I felt like I could do without it, counting on the encounter turning out OK anyway.

One particular encounter did not turn out OK.

I had a patient who was brought to the clinic by a representative from the adult foster home where he lived. He was accompanied by a female family member who was visiting from out of town. I entered the encounter room and noticed various things: a form that needed to be filled out, bottles of medication that needed to be refilled, and in the relative’s hand a list of all the issues that they wanted to address.

I surveyed the room and I felt it was my job to do the best I could for him. To me then, that meant trying to deal with all his concerns in the time allotted. I wanted to save them the “stress” of coming back for multiple visits.

After introducing myself and my role, I took the patient’s medication list, which was outdated, and started updating it in the patient’s electronic health record (EHR) from the laptop computer I had in my hand. After a little while, I turned to them and asked, “What is the first thing on your list?”

“What is the next thing on your list?” 

“Why are you taking this medication?”

“This rash, when did you first notice it?”

“You would need a letter for what exactly?” 

And on it went.

I tried to deal with all the issues as best and as quickly as I could while documenting simultaneously. I was getting overwhelmed, and only realized it when I heard myself raise my voice in frustration at the request for yet another note saying he could use a chap stick when his lip is dry: “Of course he can use a chap stick. Why do you need me or a note for that?”

I stood up slowly while trying to figure out a delicate way to end the visit. The relative looked at me, and said, “We are not finished yet, we still have a few other things to discuss.” I was behind on my schedule; I was feeling flustered. I advised them that they would have to come back for the remaining things. Looking visibly irritated, she started gathering her things. At this point I wished I had negotiated an agenda with my patient at the beginning of this visit.

I left feeling dispirited, the patient and his companions left feeling dissatisfied, and I felt unappreciated despite spending an hour and 35 minutes with them. Plus, I had even managed to make my next patient unhappy by being late to his appointment. I was disappointed with the encounter, the patient, the relative and myself and it definitely did not feel like I connected with my patient despite the amount of time spent.

I kept recalling my attending physician saying that agenda-setting not only makes you more efficient, it gives you control while making the patient feel empowered and involved in the management of their care in the little time you have with them. Since then I have approached my patient encounters in the following way...

1. Acknowledge: “Thanks for coming in today, Mr. Johnson.” 

2. Set expectations: “We have about 15 minutes together today.” 

3. Negotiate: “Tell me the things you would like us to address today so we can determine what we can tackle in the time that we have together.” 

4. Appreciate: “Thank you for working with me on this.” 

With increases in healthcare costs and deductibles, it is important that patients feel valued and listened to and not hurried during an appointment. It is important for them to know we are their advocate. Primary care reimbursement rates for services provided drives primary care providers to see large numbers of patients, sometimes at the expense of a quality relationship.

Negotiating an agenda with the patient in a shared decision making mode is patient-centered. Limiting my use of the EHR while with the patient ensures they feel that my focus is primarily on them and their concerns. Getting my team involved in different aspects of the patient encounter-from my front office staff being trained to make registration easy and straightforward, to my medical assistant getting and updating their medical record and uploading the medication for me to review-frees up time to focus on patient care. By the time the encounter starts, it is solely focused on patient care.

This is just one of many aspects of patient care and we have to work constantly on ways to improve our communication and patients’ perception. Ensuring that support staff can work to the top of their qualifications enables them to serve as integral part of the care team and handle the necessary communications with patients. We may not have unlimited time with our patients, but we should endeavor to let the limited time we have count.

The next time I had a complex patient with multiple issues, I walked into the encounter room, with confidence and a smile I said, “Hello Fred, thanks for coming in. We have about 30 minutes together today; tell me what you would like us to address …”