20 minutes

What does 20 minutes to you? To me, during the work day, it is the length of time I have to spend with my patient who is here for anything but a complete physical. It doesn't matter: cough, cold, diarrhea, feeling suicidal, family crisis, swollen knee that needs fluid taken off, or discussing the test results that reveals a possible malignancy. I often joke about having to solve the world's problems in 20 minutes -- that is primary care. Of course, I exaggerate a little and jest a little, but only a little.

Er... did I mention, I usually run late and work through most lunches? You might wonder what the problem is: why can't we take more time with our patients? The answer is logistic, philosophic and economic and part mystery (to me, anyway). I understand but I don't understand. Ever been there?

One problem is advanced access: the number of days it takes to be able to see your doctor if you call, the first available appointment to establish care, or for follow up or for an acute problem. You could go to the ER or urgent care, but then, why have a doctor if you can never get in to see him or her when you need him/her? The other aspect is economic: primary care is reimbursed not for the amount of time you spent, but for the type of visit (office visit, often called an E & M [evaluation and management] visit) and the number of diagnosis made. These are paid at a much lower rate that a procedure of equivalent time by most payors (the government, insurance companies and such). Consequently, the only way to 'break even' (balance the cost of running a clinic that does primary care) is to see more patients in a given day.

Again, I don't understand it all. It sometimes seems like a factory (with terms like productivity, number of patients seen per unit time or in our world RVUs generated (RVU=revenue value units).

I try to spend as much time as the situation seems to require. I do not look at the clock or 'kick' a needy patient out because their 'time's up'. Consequently, as the day advances, I fall behind and my patients may get a bit flustered because they showed up on time for an appointment and find that they have to wait an extra 20 to 45 minutes.

By the way, there is no allocated time for phone calls, emails, pages, filling out forms or signing prescriptions to be called in. Those are squeezed in as you walk out of one room and before you walk into the next. You also need to document the visit (we dictate our clinical notes) and bill (to register the diagnosis).

Pause.

It's madness. It's a sisiphial task. It's frustrating. But, I LOVE what I do, I LOVE seeing patients and (hopefully on most days) making a difference and yes, sometimes, on a good day, I do solve the world's problems in the magical 20 minutes. :-)