Time-poor

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I want to apologise to my patients for running late in clinic yesterday. Since reducing my NHS, or clinic time, from 50% to 20% of my work week and moving onto a yearly job plan I stopped cancelling clinics. I now move them to ‘ad hoc’ slots at a different time of the week. This may increase my workload, but it also means that I don’t have to overbook clinics, which I used to do in the past whenever I would cancel a clinic.

This means that occasionally I have extra clinics with more complex patients. Yesterday was one of these clinics. A clinic with patients who simply needed time. Time to discuss and deal with complex problems. Time to formulate complex management solutions. Time to spread hope. Time to try and be a good doctor. Time to build trust. Time to get to know the patient in front of you. Time, time, time …… a most precious commodity.

When I went back to my office in the afternoon I estimated that in addition to the 4.5 hours of face-time in yesterday’s clinic I will need another three to four hours of administrative work to implement all the actions points resulting from the decisions taken in the clinic. For example, one medical report I agreed to write for a patient to support their employment tribunal, will take me at least an hour as it will need to be researched and well-referenced; it needs to be comprehensive so as to be lawyer-proof. 

Coincidently, I read the Shattuck lecture in this week’s NEJM on the tube this morning. It was written by John Noseworthy, a colleague and fellow MSologist. The theme is on how to preserve the patient-doctor relationship in the current work environment. Although this was written from an American perspective all the issues raised are relevant to the NHS. The core theme of his lecture is time. John mentions ‘time’ a remarkable 27 times in the lecture. I would urge you to read it. I think John is highlighting an existential crisis for physicians and the relationship they have with their patients. The crisis can be summed up in one phrase, ‘time-poor’

Help! 

John Noseworthy. The Future of Care — Preserving the Patient–Physician Relationship. N Engl J Med 2019; 381:2265-2269

Excerpts: 

….. First, it is critical to enable physicians to spend adequate time with patients who need extra time, such as those with diagnostic uncertainty, those whose treatment plans are failing, and those at the end of life….. 

…… At the same time, Americans are grappling with vast societal problems, such as unacceptably high maternal mortality, the tragedy of gun violence, and the opioid crisis, as well as disparities in access to such essential services as early childhood education and healthy nutrition. When their own health is affected, they seek answers from many sources, including the Web, social media, walk-in clinics, pharmacists, and others — or end up adrift in a fragmented health care system, where they don’t get enough time with their clinicians and they suffer from the lack of a single trusted professional who can help them bring together disparate data points to arrive at unifying answers and a plan….. 

…… Attending to the business and financial aspects of health care is necessary, but this focus too often overshadows the human side of medicine. A key attribute of physicians is the commitment to caring for others — the desire to reduce suffering and make a meaningful difference in the lives of patients, often at their time of greatest need…..

….. Many physicians struggle to use technology in a way that enhances their enjoyment of their practice, and they resent spending more time doing clerical work than seeing patients….. 

…… I would suggest ….. allowing more time with patients when needed and designating coordinating physicians to reduce the fragmentation of health care — merit similar consideration. 

……. I believe the patient–physician relationship will remain fundamental to the future of health care and that we therefore need to invest in it once again. Healing begins when patients and their physicians build trust — a process that often takes time, especially when the patient’s health and future are in jeopardy. There is no app for that. The medical profession will have to be creative in finding ways to serve our patients better….. 

…….. Insufficient time with patients in need and the lack of care-coordinating physicians are emblematic of the fragmentation of health care, which leads to massive waste, delays, missed opportunities for cure, medical errors, and enormous dissatisfaction on the part of patients and physicians alike….. 

…… “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary.” These two principles — which map directly to my “adequate time with patients who need it” and “coordinated care” — have guided the Mayo Clinic since its inception….

….. Patients who have complex medical issues or multiple coexisting conditions frequently fall through the cracks in our health care system. They often express frustration that no one is taking responsibility for their total care. At the same time, all physicians understand that patients who require extra time present a challenge in a busy practice. Without a system that anticipates this need, either time is granted and the patients who are waiting to be seen next are inconvenienced or time is not granted, which both frustrates the patient who has a complex problem and delays answers…… 

…… The leaders who are responsible for fostering an institution’s culture can take the principles of adequate time and coordinated care into account when they contemplate practice redesign, management of schedules, institutional support for various types of visits, and expectations of physicians. …

….. With the pervasive emphasis on costs and efficiency, physicians have seemingly given up on unhurried time with patients. But we can rethink this norm and fight for our patients. A sound clinical and business case can be made for spending more time with certain patients. ….. 

…… Having adequate time is often essential for reaching an accurate diagnosis and developing an appropriate treatment plan, and conquering those tasks efficiently can ultimately help bend the cost curve in health care….. 

…… But having the flexibility to spend more time with patients who need it reduces their suffering and helps both health care organizations and patients save money. It also boosts satisfaction for physicians. …..

….. The work of refocusing medicine on humans rather than finances needs to happen within individual practices, specialty groups, and hospitals. Physician leaders can work to achieve a consensus that problems involving issues of time and coordination are worth addressing and provide opportunities to identify innovative solutions….. 

….. Involving all the members of a team and rethinking the purpose of their work and the skills they bring to the practice. The amount of time and effort needed to change a practice’s workflow depends on the team’s maturity…..

……  Everyone, from the appointment secretary to the nurses and physicians, brings perspectives and insights that can contribute to effective change and collaboration, given sufficient time and trust in the team-building process. …. 

…. If the care team is empowered to collaborate on solutions, then technology can take its rightful place as a tool, rather than being a barrier, and tasks such as record review, order entry, and documentation can be offloaded from physicians, allowing them more time with their patients….. 

……… Building a partnership with administration for long-term support. Redesign efforts are always more difficult and time-consuming than expected. Even the Mayo Clinic, where teamwork is a bedrock principle, must provide constant support, resources, and institutional prioritization for taking time to work in teams — time that is always in short supply in today’s climate focusing on productivity and volume….

….. Revamping payer reimbursement so that it covers time spent with patients and performance of the coordinating physician role will require validation of new metrics, including the speed and accuracy of diagnosis to reduce fragmentation, the appropriate use of diagnostic services to reduce costs, and the use of innovative follow-up visits with various members of the care team, including assembled groups of specialists (using telemedicine and other digital connections as necessary), to improve adherence and outcomes, as well as new measures of patient and physician satisfaction……

CoI: none

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

13 comments

  • Gavin, you are an excellent doctor- perhaps try and attend less conferences – the environment will thank you (lower carbon footprint) and your MS patients and family, too!

  • This brings to mind the experience of a friend living in (very) rural Devon. In addition to the standard three-week GP appointment waiting time, she tells me that as you walk into the surgery there is an illuminated moving banner announcing to all: ‘YOU HAVE EIGHT MINUTES’.

  • I feel sorry for Good Doctors like You, who work in Bureaucratica.
    I think a Specialized Nurse Case Manager would be a great asset to your practice.
    They can follow through with paperwork, assessments, moral support, service coordination and referrals, follow up. I follow The NHS stories while some politicians in the USA are Proposing “Medicare for all” Government run healthcare services.

  • Prof G,

    Stop becoming a boer! Most people with MS lose their jobs. Think yourself lucky you have an interesting job. If you can’t stand the heat stay out of the kitchen! I don’t come on this site to hear your wingeing, but to hear some research news.

  • Sorry you’re having a rough “time”. It’s no different in the U.S.A., particularly in mental health. Insurance companies and Medicare decide who, what, when, and why as far as treatment goes and if the I isn’t dotted and the t isn’t crossed they won’t pay the provider. Also, huge cutbacks with detrimental results…facilities closing. I see and understand the stress. I’m grateful for the half an hour with my MS Neurologist.

  • One solution to the shortage of neurologist time I believe is more MS nurses. They have been proven to save the NHS money eg by reducing hospital admissions from urine infections. So its ridiculous that not all areas have them.

    These guys have excellent personal skills as well as the necessary medical knowledge, plus knowledge of local support organisations, practical advise for daily living etc. [Special shout out to the team at ******** who are amazingly profesional, helpful and all round fab!] Having them means I only need to take up the neurologists time when there are significant medical issues.

    Thank goodness for the NHS.

    • Sadly Joanne I have to say that your excellent experience of the ******* team isn’t universal. Following diagnosis the first ms nurse I met did not give any time or attention to anything other than spending the hour showing me the injectable DMTs and opening up the syringes and mimicking how to use them. I don’t know who was more traumatised by this myself or my husband! I managed to tell her I was wanting to receive Lemtrada and spoke about things such as reduction in brain atrophy. She replied to say that clearly I know more about these things than her, but these (injectables) are usually what’s given. That was it – end of! Since that time I’ve received good quality monitoring after having had lemtrada. However, I still find it disconcerting that when the checklist of questions is run through, I’m asked how my mood is in the same manner as how my bladder and bowel function are doing! I’m really glad when I read of PwMS positive experience of ms nurses and I understand they’re a lifeline or some. But, I’m sorry to say that they’re not all nurturing, nor as well informed as they perhaps should be.

      Prof G – do you envisage self monitoring and online consultations exacerbating the problem currently generated by time-poor direct contact with your patients or enhancing the capacity to utilise what time you have?

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