Time Management in Primary Care

When it comes to Urgent Care medicine, I consider myself quite efficient. I was able to manage several beds simultaneously and tried to not get bogged down by relatively simple chief complaints. This was necessary in order to keep the patient flow moving smoothly.

But time management in Primary Care is a totally different problem. You can spend an endless amount of time with a patient in the Family Medicine clinic – there is no single chief complaint that can be addressed.

In the Urgent Care setting, patients often have 1-2 complaints and want to get out of the room as soon as possible. If you can figure out the exact reason the patient is there (it’s often not the actual chief complaint) you can end the visit and everyone is happy.

Primary care is the waste basked of healthcare. It’s where many patients go to address or complain about certain health problems which they may not be ready to tackle. No judgement on my part, just human nature.

But as physicians we tend to fall into that trap. And we fuel the flame because we feel good about babying the patient – often because there seems like there is nothing else to do for that patient.

Time Management in Primary Care

Time management in Primary Care medicine is a tough skill to learn. I suppose we learned a little in residency but nobody really sits you down and teaches it to you. At least no expert.

Instead, you flounder and let the day’s schedule dictate how things will go. You will spend 15 minutes with one patient, 30 with the other, and 1 hour with the next.

Time management in Primary Care isn’t important if you have a private practice with concierge patients. You’ll have 1 hour per patient, if not more. And by 45 minutes both of you will be too exhausted to continue talking to each other.

In a Community Health Center or a traditional insurance model practice you will need to ration your time with the patient. This is not just for the sake of the next patient but also your sanity.

A complicated patient, especially one who is new to the practice, is brought back several times to address each of their chronic diseases and each of their personal concerns.

Time Spent Per Patient

At this Community Health Center (FQHC) there is this patient questionnaire which every patient fills out in our clinic. It’s 27 questions about their diet, exercise, mental health, dental health, etc.

I am supposed to address each item on the list and mark off whether I took any action on it. Obviously none of my patients will answer the “Do you have guns at home or in the car?” with a “Yes, 1 Oozie and a Glock”.

Same is true with the drug questions. My meth skin popper patient who came to seem me today for an infected injection site answered no on the form. Of course, who in this world is stupid enough to put something like that down on paper?

Regardless of how ridiculous such intake forms are, we are required to hand them out to patients and address them. It’s not the clinic’s fault, it comes from all the different management organizations who have their noses in the patient-doctor relationship.

But it is such forms and agendas which make the time spent per patient limited, making it that much harder as a Primary Care doctor to manage my time in the Primary Care clinic.

Time Spent Per Patient

The other day I had a rather manipulative patient who was trying to get a certain medication approved by her Medicaid insurance; the dreaded preauthorization game we have to play as physicians.

I ended up on a wild goose chase and spent nearly an hour of my time trying to cater to her request and I ended up not getting anywhere. In the end I’m at fault for spending all of that time with her.

I took time away with other patients. I had to rush through other visits. And I also shortchanged myself. I stayed an hour after clinic to catch up on charting.

Time Rule in Primary Care

There is not set rule of how much time you should spend with a patient. But you are likely getting paid an hourly rate to work in that clinic. Most of us aren’t paid for performance, or at least not significantly.

Some are paid for how many patients they see. In such a model it makes perfect sense to funnel as many patients through as possible. A rather perverse incentive if patients are complex.

Specialty Care

A local endocrinologist here sees 35 patients per day. Can you imagine that? How is that possible if you’re managing type 1 and type 2 diabetics? Not to mention the PCOS or and thyroid disorder patients.

That’s how the Kaiser Permanente model is able to somewhat succeed. They have one unified method of managing most patients. Sure, you can get a little creative but you’re essentially stamping each patient with the same workup and treatment.

Prioritizing Care

With the limited time that I have in Primary Care I can usually only prioritize one strategy. We’re not even talking about chief complaints; even something as simple as a cold requires 20-30 minutes to be properly addressed.

Not only do I need to address the cold & flu symptoms but educate the patient on how to recognize something benign versus serious in the future. And I have to go over safe home remedy options.

Medication Adjustment

So for most patients who are already on 10 different meds, my strategy is to spend time titrating their meds.

• LDL high – increase the statin
• A1C high – increase the insulin
• Hypoglycemic events – decrease short-acting insulin dosage

And each titration requires a new visit. I have to wait for the medication to take effect, bring the patient back for repeat blood work, and reassess. It often feels like trudging through mud.

Logistical Problems

I have to prioritize my agenda because my paycheck and medical license depends on it.

If there is enough time then I’ll address their questions, too. But there rarely is enough time.

In any case, patient questions usually will be logistical questions such as problems with getting a particular medications refilled in the right amount at the right pharmacy. Or when they should follow up again and how to obtain their records from a recent hospital admission.

As a Primary Care doctor your goal is to have a patient who is stabilized on their medication. Which won’t happen when your patients go through various health changes, career changes, when they move, or when they deal with mental health problems.

Rarely do patients ask meaningful health related questions. I can’t even remember the last time someone asked me “how could I have prevented this” or “what can I do in order to come off of these medications”.

Preventative Care

Finally, you need to talk about preventative care such as dietary changes and exercise. Wearing seat-belts, safe sex practices, guns in the home…

How do you create time for that? Should you just skip it and leave the room early to bank your extra time?

Or should you stay in the room and sacrifice your peace for the sake of preventative care of that patient? Knowing that each advice you give leads to more questions and might tease out another problem which you’ll have to go back and document.

Competing Interests

What makes time management in PC so difficult is that the patient and I have competing interests.

My Chief Medical Officer has told me that as a Community Health Center we are audited for the A1C’s we check and the Flu shots we give. So I must address that or else we lose funding. Which means I’ll lose my income opportunity at this clinic.

Supposedly this is in the best interest of the patient. But how does a politician or some HEDIS Measure algorithm know what’s best for my patient? They know better than me? Why don’t they come here and see the fucking patients, then.

The patient knows that they are powerless in the clinical setting. Sure, they can try some manipulation tactics and raise some hell. But in the end they are at mercy of my keyboard.

So the patient eventually gives in. They are told how to take their meds, told to “eat better” or “lose weight”, and make their next appointment. Do blood tests, imaging studies, rinse, repeat.

The Engaged Patient

Imagine a scenario in which the patient is engaged. As in, they have done their research and know about the side effects of their medications and know the general progression of their chronic disease.

Concierge Practice

The educated and self-directed patient won’t get much value from a clinician like me in a high volume Community Health Center. Again, my main concern is the documentation of disease and meeting numerical goals.

So, if they can afford it they will pay for a private physician who has a unique practice model such as a Direct Primary Care doctor or other type of concierge model practice.

This is still a tiny minority of the patient population. And an even smaller percentage of such patients know about Direct Care clinicians.

Asking the Right Question

The engaged patient will have their own questions which rarely will be logistical. These patients aren’t worried about a pharmacy snafu and don’t have excuses for not being able to eat healthy.

Not only do they have their glucometer with them, they’ll sit thee and teach me how to use it. Often, they have it all written out in a spreadsheet.

Their questions are about how to best optimize a health behaviors and minimize medications. They will ask you to tell them the real truth about a certain diet or a treatment option.

I learn as much from this patient as they learn from me. They are researching things from the patient perspective while I am researching things clinically. And in that patient-doctor visit we’re just comparing notes, coming up with a plan together.

Valuing Time

Time management for such patients is rarely a problem. They are aware of how much time you spent with them and they value their own time and don’t want to go over their allotted time.

The engaged patient isn’t stuck on weight loss for 7.5 years. They will either give up on it and optimize another aspect of their health or they’ll figure it out and move on to the next problem to solve.

The Solution

The solution to problem of time management in Primary Care isn’t to convert all patients into engaged patients. That’s simply not the trend in healthcare. It would also be unfair for me to expect others to change in order to solve a problem.

One of my Primary Care colleagues complains to me about how complex her patients are, how hard she works for them, and how little they appreciate her.

A different Primary Care colleague, however, goes into work, clocks in and clocks out. He checks off the lab numbers he needs to, offers his patients the advice they ask him about, and he collects his paycheck.

#1. Hands-off Approach

I have decided to take a similar hands-off approach, for better or worse. My patient will have to decide if they will be their own quarter back for their health or if they want me to make decisions for them.

The majority of the patients whom I have seen here for follow-up haven’t followed through on our treatment plans. I recognize that as a failure on how effective I am as a Primary Care doctor.

But the patient has a responsibility, too. With the hands-off approach we’re just going to focus on the numbers and the medications. Which to me is terrible for the patient but great for the policy makers.

I have a hard time feeling fulfilled in such a practice. It feels as though I’m just going through the motions and not even practicing real medicine. But this is exactly how medicine is practiced.

#2. Offense Medicine

You can throw time management out the window and let your schedule bulldoze you. This is offensive medicine, you’re doing everything possible for the patient, during every visit.

It’s taxing, it’s draining, but it’s fulfilling. You come home and you’re a zombie but you feel fucking great about yourself.

From those who do this I hear that their patients very much appreciate it and supposedly their have better health outcomes. But Dr. Mo is a little too jaded to believe that. Hope it’s true though.

#3. Shotgun Medicine

Shotgun medicine can also be gratifying for the clinician, probably because the patients seem to like it and it satisfied the problem of time management in Primary Care.

You order every test the patient wants. You prescribe all sorts of sexy-sounding medications like “Januvia” (good job, Merck). You order MRI’s and CT’s to the heart’s delight. And every other patient gets an ortho and derm referral.

You can plow through 75 patients a day in such Medicaid factories.

#4. Direct Care Medicine

If you can get the insurance company out of the equation then you don’t have to worried about HEDIS measures or other metrics.

You have to also get rid of Medicaid and Medicare. This weeds out the patients who want to pay for their health rather than put in the hard work.

But it also means that you can now spend the time needed to give them the tools they need to overcome their personal hurdles. What’s keeping them from cutting out the carbs? Why are they not able to make the time for exercise? What’s keeping them from cutting out the booze and cigarettes?

#5. Urgent Care Medicine

I love Urgent Care medicine. I love practicing it, I love learning about it, I love the satisfaction it brings to my patients.

There is one complaint and you address it. The time you have with the patient is often more than adequate, if you are efficient.

Time management in Primary Care heavily relies on building the patient-doctor bond before your patient is willing to open up to you. But in Urgent Care medicine patients accept the time limitation and often go there to alleviate a fear or just need an intervention – a breathing treatment, medication refill, Mag infusion, etc.

Hodgepodge Medicine

I don’t think you can mix the tactics from above. If you do, something will give, either your sanity or the desired outcome.

You can’t deliver good healthcare in 7 minutes. You cannot talk about diet or exercise in 5 minutes.

If you are working at a place like KP or a Community Health Center, admit that your time is limited and accept the numbers game you’ll have to play. There is no way to win the time management game in such models – you’ll have to sacrifice patient care.

If you believe that you have more to offer your patients then leave that system and get hired by a concierge or DPC practice, or start your own. But don’t just practice hodgepodge medicine, trying to mix all of the strategies from above.

Maybe I’m just being hardheaded or I’m in denial, but I refuse to believe that my diabetic patients will enjoy better health because I’m advancing them from metformin to glipizide to sitagliptin to insulin and then dialysis.