As Family Physicians today we each take responsibility for a panel of patients. Some of them are healthy and only come to see us for physicals and episodic illnesses, but more and more of our patients have chronic illnesses like diabetes, heart disease, depression, fibromyalgia and chronic lung disease. Such problems don’t go away between visits, and as primary care doctors, our involvement with these patients doesn’t stop when their office visits are over.

We track these patients’ care in our disease registries in order to ensure that recommended testing and follow-up is offered at timely intervals.

As clinical reports and test results from specialists and emergency rooms trickle in, we review them to see if we need to make any changes in each patient’s care plan.

When lab results come in before a scheduled visit, we look them over to make sure they are normal enough that any needed action can wait until we meet with the patient.

We answer questions, verify and refill prescriptions, and we file countless reports with insurance companies and Quality watchdog organizations that grade us and probably some day will pay us for our patients’ blood pressures, cholesterol and blood sugar values.

Still, we – or in most cases our employers – essentially only get paid for the time we spend face-to-face with the patient, even though medicine these days involves a lot more work behind the scenes and in between visits. This mismatch between payment system and patient needs has made it harder for doctors to be generous with their time.

Health Maintenance Organizations (HMO’s) were supposed to revolutionize health care in the U.S. through capitation – paying doctors a monthly fee per member, based on the expected cost of taking care of various age groups. Today, almost none of our patients have this type of insurance.

What, then, do doctors get paid for in the office? Most get paid according to how many questions they ask patients, how many organ systems are reviewed and examined, and how complex or risk-filled the clinical situation is. Under that system, a doctor who needs to ask a lot of questions and do a detailed general exam gets paid more than a doctor who quickly reaches a diagnosis.

Some clinics get paid a fixed rate, so that a five-minute visit for a sore throat brings in as much money as 45 minutes spent with a complex, very ill patient. There, the temptation is to keep visits short in order to see as many patients as possible.

Face-to-Face time is what we get paid for, but it is part of a package where the other pieces may seem undervalued. We always have to watch how we spend our time. The challenge for all of us is to make the time we have with our patients, be it five minutes or forty-five, productive and therapeutic.

We can’t blame our patients for our lack of time. They didn’t create the system. They come to us for help with their fears and their ailments. They don’t generally ask for a certain number of minutes. They want and deserve technical competency, caring and compassion.  Those things aren’t measured in minutes. 

Neither is Quality.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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