One Visit, One Problem?

The other day I received my copy of the periodic newsletter of our neighboring Canadian medical society. It made me realize that both countries’ primary care doctors, in spite of our entirely different health care systems, are facing some of the same issues.

The bulletin warned Canadian doctors not to enforce a one-problem-per-visit policy, but to offer more comprehensive care to their patients.

The way doctors and clinics are paid in most settings here, two short visits are reimbursed at a much higher rate than one long and complex visit that takes up as much or more time. When patients feel the pinch of copays, travel costs and lost time at work for doctors’ appointments, tensions between the agendas of health care consumers and providers are inevitable.

It can be challenging enough to provide a healing atmosphere in a busy clinic. When doctors feel so much pressure that they become mercenary about their time, any hope of healing is lost.

I never understood the logic behind the one-problem-per-visit way of rationing health care. I do accept that the time we have to spend with our patients is finite, but there is usually some wiggle-room. I tend to be upfront with patients about how much time they were scheduled for. Some patients require extra time for even the seemingly most straightforward problem, but I have many patients who can bring up several problems and allow me to address them in a fifteen minute visit.

A patient with abdominal pain and joint stiffness may have an inflammatory bowel disease that explains the two seemingly unrelated symptoms.

A patient with pneumonia and a raging grief reaction needs both issues addressed in that visit, most likely with early follow-up for both problems.

A person with uncontrolled diabetes never has just high blood sugars; there is always a multifaceted story behind the numbers. That story often touches deep seated issues like self worth and depression.

Doctors in today’s health care machines, not just in our country, seem to think of themselves too often as widget makers, and not as healers. If we deliver only cookie-cutter health care, perhaps every aspect of our work is measurable and more of a commodity than a unique, personalized service. But, by reducing ourselves to generic providers of mass market care, we breed discontent among our patients and burnout within ourselves.

My wife often points out that when I hurry to do things around the house, I become less efficient and actually get less done than if I just plod along and do what needs to be done without fretting about it. In my work, I have just that ability. I am blessed to most of the time be able to enter the exam room with a mind free from the clutter of busy-ness and engage with my patients in an unhurried manner. Sometimes, when I am running late, I will enter the room and literally sigh before sitting down with an apology about running late because of a tight schedule. Patients invite me to relax, and I show them that all my attention is on them at that moment. Not being scattered allows me to accomplish more in a short time.

We need to always think of ourselves as “selling” our expertise and experience, not just our time. An appointment of any length can be effective or ineffective. A brief but well planned visit, where we enter the room prepared and where our documentation in the medical record doesn’t detract from the patient interaction, is more satisfying to the patient and the doctor, and gives some room for connecting with the person behind the symptom.

If we don’t fully master our EMR technology, we will be distracted and ineffective during the visit, and we could fail to document our clinical thinking well enough to be effective in follow-up visits.

I also think we as physicians need to always value the personal aspect of the work we do in order to be of any real help to our patients. If everything about our care is ever so correct, but bland and uninspired, we invite demands for more, as patients feel unsatisfied. If we spend our allotted fifteen minutes delivering exceptional care, our professional satisfaction will carry us further. Our patients will not feel cheated the way many do when we are too stressed to even recognize their needs, let alone begin to address them with skill and compassion.

3 Responses to “One Visit, One Problem?”

  1. 1 Lisa January 4, 2014 at 3:09 pm

    I saw my doctor several times in the year before I was diagnosed with breast cancer. She inforced that policy, so blood work visits were only for blood work, etc. Even when I went in for a physical I was handed a piece of paper that stated the appointment was only for a physical. No other problems would be addressed. As a result, she never addressed the overwhelming fatigue I had experiencing for months. Until I found the lump, that was the only symptom I had. I often wonder if she had addressed it the time I went in fo a blood pressure check or when I went in for strep throat if the cancer would have found earlier.

  2. 2 Sven Found January 9, 2014 at 12:12 am

    In Ontario Canada, the regulations state that the physician will be paid for one problem per visit. All other problems addressed during the same visit are reimbursed at ZERO dollars.
    That’s why it’s one problem per visit.
    Should the doctor provide his or her time and expertise for free? Especially when they have overhead to pay and their fees are being cut (a reality since 2012 in Ontario). Let them bill (charge) for each problem and you can bring up as many issues as you would like. Medicine is a business. It always has been. Don’t like it? Put all the doctors on salary.

  3. 3 Doctor hotel January 9, 2014 at 7:02 am

    I am doctor by profession and I have also seen these problems many times in my all medical life. This issue is really important and we should have to improve our health industry by taking good steps.

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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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