Leveraging Time by Doing Less in Each Chronic Care Visit

So many primary care patients have several multifaceted problems these days, and the more or less unspoken expectation is that we must touch on everything in every visit. I often do the opposite.

It’s not that I don’t pack a lot into each visit. I do, but I tend to go deep on one topic, instead of just a few minutes or maybe even moments each on weight, blood sugar, blood pressure, lipids, symptoms and health maintenance.

When patients are doing well, that broad overview is perhaps all that needs to be done, but when the overview reveals several problem areas, I don’t try to cover them all. I “chunk it down”, and I work with my patient to set priorities.

What non-clinicians don’t seem to think of is that primary health care is a relationship based care delivery that takes place over a continuum that may span many years, or if we are fortunate enough, decades.

Whether you are treating patients, coaching athletes, raising children or housebreaking puppies, the most effective way to bring about change is just about always incremental. We need to keep that in mind in our daily clinic work. Small steps, small successes create positive feedback loops, cement relationships and pave the way for bigger subsequent accomplishments.

Sometimes I avoid the biggest “problem” and work with patients to identify and improve a smaller, more manageable one just to create some positive momentum. That may seem like an inefficient use of time, but it can be a way of creating leverage for greater change in the next visit.

I actually think the healthcare culture has become counterintuitive and counterproductive in many ways; it helps me when I focus intensely on the patient in front of me, forgetting my list of “shoulds” (target values, health maintenance reminders and all of that) and first laying the foundation for greater accomplishments with less effort in the long run.

Six months ago I wrote this about how I try to start each patient visit. And in my Christmas reflection seven years ago I wrote about the moment when a physician prepares to enter an exam room:

I have three fellow human beings to interact with and offer some sort of healing to in three very brief visits. Three times I pause at the doorway before entering my exam room, the space temporarily occupied by someone who has come for my assessment or advice. Three times I summarize to myself what I know before clearing my mind and opening myself up to what I may not know or understand with my intellect alone. Three times I quietly invoke the source of my calling.

It’s all about the patient, the flesh and blood one in front if you in that very moment and what he or she needs most from us today. In physics I learned that you get better leverage when your force is applied a greater distance from the fulcrum. In human relationships and in medicine it is the opposite; the closer you are, the greater leverage you achieve.

10 Responses to “Leveraging Time by Doing Less in Each Chronic Care Visit”


  1. 1 Larry Bauer October 21, 2019 at 8:29 am

    I tried to post a comment but it does not accept the FMEC website http://www.fmec.net as a URL and thus I can not post a comment

  2. 2 acountrydoctorwrites October 21, 2019 at 8:32 am

    It worked. I had to “approve” it.

  3. 3 Laura October 23, 2019 at 3:00 pm

    “Three times I summarize to myself what I know before clearing my mind and opening myself up to what I may not know or understand with my intellect alone. Three times I quietly invoke the source of my calling.”

    Thank you for these words. I am a pharmacist, and these words resonate deeply with me. I always try to remember the relationship with my patient, and why I am there.


  1. 1 Leveraging Time by Doing Less in Each Chronic Care Visit – Health Econ Bot Trackback on October 25, 2019 at 10:44 am
  2. 2 Leveraging Time by Doing Less in Each Chronic Care Visit | Health Advice and more Trackback on October 25, 2019 at 10:51 am
  3. 3 Leveraging Time by Doing Less in Each Chronic Care Visit – Site Title Trackback on October 25, 2019 at 11:07 am
  4. 4 Leveraging Time by Doing Less in Each Chronic Care Visit – BrighterLife Trackback on October 25, 2019 at 11:10 am
  5. 5 Leveraging Time by Doing Less in Each Chronic Care Visit – Techno Hub Trackback on October 25, 2019 at 1:58 pm
  6. 6 Leveraging Time by Doing Less in Each Chronic Care Visit – Health Benefits Trackback on October 25, 2019 at 2:26 pm
  7. 7 Leveraging Time by Doing Less in Each Chronic Care Visit – Health News Trackback on October 25, 2019 at 2:48 pm

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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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