DPC Provides the Gift of Time (for Physicians and Patients)
My colleague, Dr. Jack Forbush, recently posted a piece on this site entitled, “The Twelve Gifts of Direct Primary Care”. The first one he listed was time. So, so very true!
My medical malpractice carrier offers a “free” book once or twice a year. This past year they provided, When we do harm: A doctor confronts medical error, by Dr. Danielle Ofri. As I read the book, a few passages really stood out now that I’m about five years into my DPC journey. All the passages relate to the problem of not enough time in our broken, fee-for-service system. The passages are a little lengthy, but I think you’ll find their worth the time to read. The first passage is about the time problem for physicians relating to diagnosis:
If you had the luxury of an hour with each patient, you would have the time to diligently sort through each and every possibility. But the reality is that you have just a few minutes to push the majority of diagnoses to the bottom of the list, come up with the most likely few at the top – being careful, of course, to keep in the rare but life-threatening possibilities – and then explain to the patient what you think. You can order labs, x-rays, and the like, but those results won’t come until later. You need to offer the patient, right now, the most likely diagnoses, as well as a plan for how to start treatment and/or further investigation.
It’s a tall order, and an incredibly stressful one. Most textbooks treat diagnoses as a leisurely intellectual process. Medical students are taught to run through each organ system of the body and then consider all the plausible ways that organ system can get pillaged – via trauma, via infection, via metabolic derangement, via cancerous transformation, via toxic exposure, via genetic abnormalities. It’s a thrilling academic exercise, especially if pondered over with a steaming cup of tea and a plate of crumpets with jam while the sun eases its languid way across the firmament. Gentle strains of Chopin in the background don’t hurt either. pp 33-34
While I don’t mind tea, I prefer coffee. And Chopin isn’t my jam. But, I do have 30 to 60 minute visits with my patients that allow me the gift of time to listen carefully, ask clarifying questions, examine fully, and consider comfortably. This helps improve diagnosis and reduce error.
When it comes to diagnostic error – perhaps the toughest nut to crack – I think about the need for similar distraction-free zones [as Ofri notes some hospitals have implemented for their staff] in order to think critically about a patient’s diagnosis. The crush of EMR documentation, however, snuffs out any possible semblance of contemplation. Our current model of indentured EMR servitude saps the vigor of even the most committed clinician. If we want medical staff to apply Graber and Singh’s cognitive discipline about creating a differential diagnosis, questioning data that don’t fit, examining our thought processes for bias, doubling back to ensure we didn’t miss anything crucial – well, our neurons will need some time and space to strut their stuff. Something will have to give. Either we decide that there needs to be more time in a visit (which is ultimately a financial decision) or we have to radically scale back the documentation demands to allow clinicians time to actually think.
With all the talk of how the digital revolution will rescue healthcare, and how creative disruption will bulldoze us into a technology-infused Nirvana, I look at the idea of medication safety zones and find it mildly ironic that one of the biggest “innovations” in patient safety is the concept of peace and quiet. But there you have it: one of the key ways to decrease medical errors is to allow nurses and doctors time and space to think. Uninterrupted. pp 233-234
There it is! She hits on a few key concepts. The ridiculous amount of documentation that doesn’t actually help our patients or our colleagues. How that documentation burden is tied to financial reimbursement in the broken, fee for service system. And how that system robs physicians of time (and patients of safety).
The periodic membership model of DPC eliminates this problem (as long as the physician chooses a reasonably sized panel). DPC docs don’t need long notes. We don’t need to submit a note to anyone to be paid. Notes go back to serving the purposes of having a similarly trained individual be able to take over care of your patient, should the need arise, and to serve as a record of the care you provided should you be sued.
Refreshingly, the report [the 2016 IOM report on diagnostic error] did not simply point the finger at the incompetence of individual physicians, as both lawsuits and popular media tend to do. Rather, it described a Borgesian healthcare system that seems almost intentionally designed to stymie the diagnostic thought process. It noted that our reimbursement system favors procedures over thoughtful analysis. That is, more revenue is generated if I order an MRI for all my patients with abdominal pain then if I spend extra time talking with them and sorting out the details.
If I review a case with a colleague to get a second opinion, or call a radiologist to discuss whether a less expensive ultrasound would suffice, that would not be reimbursed in our current system. If I make additional phone calls to a patient after the visit to elicit further clarifying information, that too would be ignored by the billing system.
Talking about reimbursement may reinforce the stereotype that doctors care only about money. But in reality, if something is not reimbursed, it’s hard to get it done because there are only so many hours in the day. For time-pressed clinicians, the system makes it faster and easier to simply order MRI than to think longer and deeper about our patients’ cases.
So bravo to the IOM for recognizing that diagnosis can be a team sport, and that time spent analyzing a case is as critically important as tests and procedures. The report explicitly presses insurance companies to reimburse for the cognitive side of medicine to eliminate the financial distortion that overwhelmingly favors procedures over thinking. pp 69-70
Right! This book was written in 2020. That’s the same year I grew weary of holding my breath for “the system” to change; the year I switched to DPC. Five, almost 6 years later, there is no meaningful movement for “the system” to favor the cognitive side of medicine over procedures, or to even equally reimburse for it. While some may point out that telehealth visits are now are reimbursed, and increasingly systems are charging patients for portal messages, there’s still no margin put into the typical fee-for-service physician’s schedule for those tasks. They are still being crammed in before work, over lunch, and during “pajama time”, as well as whenever there’s a free moment between patients. There’s no (gift of?) time allotted for that work!
The gift of time that DPC provides is not just for physicians. As Dr. Ofri notes, when physicians have time to think, they spend less money on diagnostics. When physicians have the time for close and repeated follow up for complicated cases, they can proceed through an evaluation in a timely, sequential order rather than an expensive “shotgun” approach. The “shotgun” approach is convenient for the physician and profitable for healthcare systems, but it bankrupts patients and increases all of our costs as we pay hefty taxes into government subsidized healthcare programs. Not to mention that DPC regularly provides and finds significantly lower costs diagnostics when they are needed – a double savings. Patient’s value those financial savings, as well as the relational experience of DPC.
While Dr. Ofri and I agree on much of the diagnosis of the problem, I suspect we differ on the treatment. As she notes in one of the quotes above, the treatment comes down to financial priorities and decisions. She wants third party payers to reimburse for cognitive work. Our broken, fee-for-service healthcare system does not want to financially reward physicians for doing this work; it costs them more – the shareholders will lose. The DPC model, in a free market, is the solution because it does reward this kind of work. And that gift of time provided by the DPC model benefits both physicians and patients.
If you haven’t already made the switch to DPC and you want more of your time, now is the time to switch. The friendly folks at the DPC alliance can save you time navigating that transition. It’s high time that I stop now that I’m out of time. Thanks for your taking your time to read and consider this.
- Ofri, D. (2020). When we do harm: A doctor confronts medical error. Beacon Press.
