Correspondence
Changes in the Length of Office Visits
N Engl J Med 2001; 344:1476-1477May 10, 2001
- Article
To the Editor:
The article by Mechanic et al. (Jan. 18 issue)1 challenges the prevailing wisdom that the increased penetration of managed care is associated with a decrease in the length of patients' office visits with physicians. The data to support their conclusions were derived from the National Ambulatory Medical Care Survey (NAMCS) and the monitoring system of the American Medical Association (AMA). Although the numbers superficially suggest that more time is being spent with patients, no measure of the time physicians actually spent talking with and examining patients could be obtained from these studies. Although there may have been an “upward trend in the length of visits for both primary and specialty care,” I would suggest that the apparent increase in duration may be accounted for by the time spent in the completion of paperwork.
If such a study were performed in academic medical centers, such as the one in which I practice, it would find a dramatic increase in the time physicians spend documenting, and frequently duplicating, the work and findings of trainees. As pediatricians, we espouse emphasizing the quality, not the quantity, of parents' time with children. We should do the same for physicians' time with patients.
1 ReferencesLeslie L. Barton, M.D.
University of Arizona College of Medicine, Tucson, AZ 85724-50731
Mechanic D ,McAlpine DD ,Rosenthal M . Are patients' office visits with physicians getting shorter? N Engl J Med 2001;344:198-204
Full Text | Web of Science | Medline
To the Editor:
That the length of office visits, as determined by the methods used by Mechanic et al., has not declined over the period for which data were evaluated does not completely answer the question of whether or not managed care has reduced the duration of office visits, as is perceived by many physicians. The authors failed to measure the amount of time physicians spend preparing for patients' visits (e.g., reviewing charts and collecting relevant laboratory data) before actually entering the examination room, as well as the amount of time they require after each visit to complete paperwork, make necessary phone calls, and arrange insurance approvals on the patient's behalf before moving on to the next visit.
The quality of the physician–patient relationship cannot be measured solely by the number of minutes spent in the examination room with patients, particularly if part of that time is spent on administrative efforts that might be better performed either before or after the visit. That we physicians perceive our time with patients to be reduced may reflect our perception that the total amount of time available for each patient is reduced. The total time available for patient care is what really counts.
Elizabeth D. Simmons, M.D.
St. John's Hospital, Santa Monica, CA 90404To the Editor:
We commend Mechanic and colleagues on their thorough examination of the trends over the past decade in the duration of office visits. Even though physicians in most specialties spent the same amount of time (or more) with their patients at the end of the decade as they did at the beginning, only brief mention was made of the opposite finding for visits to psychiatrists.
We examined this important result in more detail with the use of the NAMCS1 and found that between 1985 and 1995, visits to psychiatrists in office-based practice became significantly shorter (38.1 vs. 42.8 minutes, P<0.001), less frequently included psychotherapy, and more frequently included a prescription for medication. These differences were even more pronounced for patients who were members of health maintenance organizations. Although these findings may reflect improvements in available pharmacologic treatments for patients with mental disorders, they may also indicate that psychiatrists have made substantial changes in their styles of practice to accommodate the increasing pressures of today's health care environment.
1 ReferencesSteven C. Marcus, Ph.D.
University of Pennsylvania, Philadelphia, PA 19104Mark Olfson, M.D., M.P.H.
Columbia University, New York, NY 10032Harold A. Pincus, M.D.
RAND, Pittsburgh, PA 152131
Olfson M ,Marcus SC ,Pincus HA . Trends in office-based psychiatric practice. Am J Psychiatry 1999;156:451-457
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We agree with Drs. Barton and Simmons that the quality of care cannot be measured solely by the time physicians spend with patients. Many factors contribute to quality, including the structure of the practice, the training and motivations of the physicians, and the nature of communication and follow-through. They suggest that reports of the length of visits might be inflated by the inclusion of time spent on paperwork, the review of charts, necessary phone calls, and other such activities before, during, and after visits, but the available data from the AMA do not confirm this hypothesis. The average number of hours that physicians spent in all professional activities declined significantly by 2.2 hours per week between 1989 and 1998. Moreover, the time spent on indirect patient care activities (such as reading x-ray films, interpreting laboratory tests, and consulting over the telephone) showed little change between 1996 and 1998. There is an almost universally shared belief that managed care has dramatically increased the hassle of working as a physician, but this belief is contradicted by the findings of the one study that has tried to examine the issue objectively.1
Expectations concerning the time needed during an average visit vary a great deal. Kaplan et al.2 suggest that 20 minutes is needed if patients are to be actively involved in treatment decisions. Visits to general practitioners in the United Kingdom, where the National Health Service system is known for its emphasis on primary care, averaged 9.4 minutes in 1997, up from 6 to 7 minutes in the 1960s. Although such visits seem short to us, in a recent British survey, most patients thought that doctors spent the right amount of time with them during their most recent visit.3
Office-based psychiatry is probably an exception to the time trends. As Marcus and colleagues suggest, the style of psychiatric practice is changing. However, if visits during which patients did not see a psychiatrist are excluded, the reduction in the length of visits is substantially larger when those visits are not covered by a prepaid health plan than when they are prepaid. There is evidence that managed behavioral health care is especially rigorous,4 including the aggressive downward negotiation of fees. Moreover, there is a substantial amount of substitution of psychologists, social workers, and nurses for psychiatrists in psychotherapy and counseling.
The time physicians spend with patients is only one of many factors that affect patients' satisfaction and the quality of care. Our study was not intended to assess quality. It sought to provide a reasonable evidentiary basis for the common perception of the effect managed care has had on the time spent with patients.
4 ReferencesDavid Mechanic, Ph.D.
Donna D. McAlpine, M.A.
Marsha Rosenthal, M.A.
Rutgers University, New Brunswick, NJ 089011
Remler DK ,Gray BM ,Newhouse JP . Does managed care mean more hassle for physicians? Inquiry 2000;37:304-316
Web of Science | Medline2
Kaplan SH ,Gandek B ,Greenfield S ,Rogers W ,Ware JE . Patient and visit characteristics related to physicians' participatory decision-making style: results from the Medical Outcomes Study. Med Care 1995;33:1176-1187
CrossRef | Web of Science | Medline3
Airey C, Bruster S, Erens B, Lilley S-J, Pickering K, Pitson L. National surveys of NHS patients: general practice 1998. London: NHS Executive, 1999:X-XII.
4
Mechanic D ,McAlpine DD . Mission unfulfilled: potholes on the road to mental health parity. Health Aff (Millwood) 1999;18:7-21
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Agnes Lo, Kathryn Ryder, Ronald I. Shorr. (2005) Relationship Between Patient Age and Duration of Physician Visit in Ambulatory Setting: Does One Size Fit All?. Journal of the American Geriatrics Society 53:7, 1162-1167
CrossRef
