Thursday, July 21, 2005

It is all about time-not enough time and the best doctors do poorly

DB's Medical Rants recently wrote about his observation of a waning of intellectual interest in house officers which he at least partially attributed to the pressure of too much to do in too little time. I do not know if the waning he observes is entirely due to time pressure but that is a major factor. You can be the best trained, the best informed , the smartest, the most caring physician in the world and if you are seeing 4 new complaints in a hour, you will screw up. It is only a question of how often and how badly. A few years ago I was in the unusual and fortunate situation of seeing patients in the same manner I saw them 20 plus years ago. I had 45 minutes for a new patient and saw a patient who was in the office for the periodic "health consultation" and physical exam. He was 53 years old, previously healthy with the complaint of " losing strength". He noticed it mostly in his arms as he had embarked on a strength building program several months earlier and now could not now do as many reps with as much weight as he could a few weeks earlier. He had seen his insurance company PCP who fielded the complaint, focusing on the hand ( i guess thinking the patient was complaining of hand pain rather than weakness, ordered a hand exam (did no PE ) saw him back in a week and told him he was "probably getting old". There is no doubt he was getting old unless the laws of the universe were abrogated in his case,but on the exam in my office, he had no DTR's in the lower extremities, and decreased sensation in the legs. DTR's were decreased in the arms. I referred him to a neurologist in a anarchronistic clinic where in the neurologist still has one hour for a new patients and quickly the dx of chronic inflammatory demyelinating polyneuropathy was made and treatment begun with impressive clinical improvement. I knew the PCP and knew him to be a well trained , well respected seasoned physician. I believe it was a matter of time.
Physicians have allowed their practice terms of engagement to be dictated by others either directly as in some HMOs or large clinics or indirectly by insurance plans controlling the fees to the point where physicians decide that in order to survive economically they have to increase their output by seeing more patients in less time. Their job satisfaction plummets, patients get short changed if they get any change at all and the error rate accelerated with the risk of malpractice rising with it and patient satisfaction tanks. This may not apply to all physicians and practices but it is closer to the rule than the exception.
I do not know if DB's observation of decreasing curiosity in trainees is all a function of time pressure or not. I have also seen in recently trained IM docs and FPs in a practice setting in which time pressure was not the rule. If it is seen in house officers, who are time and task pressured now, what will happen in private practice when the time crunch is worse because their income may depend on it?

No comments: