A Country Doctor Writes:

Psychotherapy appointments have traditionally lasted 50 minutes with 10 minutes for paperwork. This has lead to the expression “The 50 minute hour”. More recently there has been talk of incorporating psychotherapy techniques in brief visits in Primary Care. The provoking title “The Fifteen Minute Hour” is from a book about addressing the emotional aspects of disease in Primary Care during brief appointments. The title and the concept seem relevant to much of what we do in my specialty.

In Primary Care we seldom spend more than 15 minutes at a time with an established patient. Yet we are required to cover infinitely more details and consider more outside authorities in every visit today than when I first started practicing medicine. Between health insurance and office administration, there are now many more mouths to feed from the office charges than there were then. Sometimes it feels like we are not alone in the exam room even for the short time we do have.

Except for doctors in concierge medicine or micropactices, most of us cannot change the amount of time we have with each patient. Even if we hope to change the system, the patients we see today deserve the best we can give them in today’s 15-minute visits.

This is what I do in my busy, rural practice:

I work hard to focus on a purpose for each visit. If neither the doctor nor the patient knows what they are supposed to accomplish in 15 minutes, chances are not much will get done. In my schedule, nobody has just a “follow-up” or an “office visit”.

Established patients come to see me for one of two reasons. They may have identified a problem, such as back pain, a cough or a rash, and made an appointment for this. They might also have a follow-up because I requested them to come back in 1 or 3 months for their blood pressure, diabetes or some other chronic problem.

I look at my daily schedule to see how they day will flow based on the stated reason for each appointment and my knowledge of each patient. This helps us see where we might be able to squeeze in (double book) someone. For example, an appointment for fatigue and weight loss is likely to use up more time than an appointment for an earache. Some individual patients typically tend to need more time than others. Knowing the purpose of each appointment also helps focus the staff and me. Schedule notations like “Follow-up Blood Pressure, bring cuff” (to compare the patient’s own equipment with ours) or “Follow-up Diabetes, do comprehensive foot exam” eliminate guesswork.

I also keep in mind that I sometimes have more than one opportunity to get the results I strive for. Short visits in Primary Care often occur in the context of a doctor-patient relationship that stretches over an extended period of time and possibly even spans generations. A teacher would not try to cover a semester’s worth of material in the first week or month, and then just spend the rest of the semester repeating and reinforcing that information. It is the same with many chronic conditions we treat. Together, the patient and I decide on a general plan of action. We then patiently make small adjustments over time until we see the results we aimed for.

I try to see patients with chronic conditions like Type 2 Diabetes every three months with fresh blood tests done a few days before the appointment. We go over the results together and work out the next steps in the patient’s care. Every visit includes an overview of the major components of the disease. In diabetes, this list includes blood sugar control, blood pressure, kidney function, cholesterol/lipid status, foot problems, eye problems, heart issues and depression. After the overview, we usually focus on the most pertinent issue, such as improving blood pressure control. Even if every area could use some improvement, it isn’t generally feasible to attack several issues at the same time. Doing one thing at a time tends to bring better results in the long run.

I sometimes schedule brief, very focused visits for one aspect of complicated conditions like diabetes. If I prescribe a new blood pressure medication for one of my diabetic patients, the standard of care may require a blood test shortly afterward. I naturally also need to see what difference the medication made on the patient’s blood pressure and how the medication was tolerated. The visit to check blood pressure and laboratory results is a quick, separate visit between the scheduled quarterly diabetes visits. Chances are in these types of highly focused visits with a limited agenda, there will be time for “extras” that might never get addressed if every visit is a very comprehensive one, crammed into 15 minutes.

I try to be flexible. Every week I see patients whose priorities have changed since the appointment was made. It is important, early in the visit, to determine the best use of our time. I might say, for example, “I had asked you to come back to follow up on your headaches. Is that still OK with you, or do you have anything else you’d rather spend our time on today?”

It is not unusual to see patients who are uncomfortable or upset due to something unrelated to the scheduled purpose for the visit. There is probably no better way to alienate a patient than forcing your own agenda when he or she is in distress and needs you to pay attention to that. Showing that you are ready to listen, by closing the paper chart or pushing away the keyboard, and making eye level contact aren’t “techniques”, but ways of giving the patient permission to take the lead.

The 15-minute appointment is the canvas we have to work with today in the art form we call medicine. I wouldn’t work the same way if I had a bigger canvas to paint on, but each piece of art has to fit its medium.