Opinion | The Myth of the Comprehensive 20-Minute Visit

Usually, 20 minutes just isn’t enough.

For so many of our patients, who have multiple complex medical problems, getting through it all in a 20-minute appointment just isn’t feasible — starting with the fact that they are often late due to transportation issues: the Access-a-Ride van didn’t pick them up in time, or they got caught in traffic, or the bridges were a nightmare.

And then there’s always a long line at check-in, as well as patients navigating the tablets that require them to do electronic check-in, with the barrage of questionnaires that they need to complete before they are granted entrance to the practice.

So finally, after they had their insurance information confirmed, after they’ve gotten their wristband printed out with their name and date of birth and medical record number on it, after they’ve had their vitals checked by the medical technicians, by the time they get in to see us they are usually frustrated, and we are usually frustrated, because their allotted 20-minute appointment time is almost up.

In an idealized world, all of this stuff would be streamlined, we’d have navigators to make sure patients did their pre-visit planning, support staff to make sure their medication list is up to date and their contact information is correct, that they are enrolled in the patient portal, and that all their questionnaires are completed.

I’ve written before about how in almost every appointment, we providers have an agenda for a visit and patients have their own agenda, things that we and they want to address. That includes pressing issues and concerns and new medical complaints, as well as the ongoing management of their chronic medical conditions and their health maintenance items.

And then there’s the forms, paperwork, prior authorizations, and pharmacy formularies, all of which need to be dealt with. We’ve built up a system that tries to squeeze all of this into a 20-minute doctor’s appointment, and it just doesn’t seem to be something that any of us can live with.

Our patients are frustrated with the model of primary care in this country, and seemingly rightly so. Clearly, we, the primary care providers, are equally frustrated, bogged down in all of the above as well as in the minutia of having to deal with the administrative burdens, the electronic medical record headaches, and the barriers to care our patients face.

I long for the day when we can use those 20 minutes to provide care.

Sometimes it’s just talking, sometimes it’s just listening, sometimes it’s the mythical and magical annual physical exam that lets patients know someone is watching out for them, sometimes it’s a focused physical examination and synthesis with the patient’s history to help come up with a plan to move their health forward. But all the other stuff seems to get in the way of getting this done, and it feels like we’re all running on a hamster wheel, us in one direction and sometimes our patients running in another — or at least on parallel wheels where we don’t seem to be communicating or moving forward.

So many efforts to redesign primary care have focused on building up things to measure someone’s ideas of quality and outcomes, that lay more and more administrative burden on those trying to take care of patients.

I think it’s time that we listen to what our patients want, as well as what the primary care providers actually trying to provide care for them think is best, to redesign healthcare so that much of it can happen beyond the confines of that 20-minute appointment. There have got to be better ways than what we have right now to fully assess what our patients need, and what we in the healthcare system can provide for them, to help move their health from their current state to the best place we can get them to.

We need a team working with us, everyone from pharmacists, nurses, and social workers to community health workers, care navigators, and subspecialists, along with smart systems that spot trends and help make sure we don’t miss out on things that our patients need. We need effective patient management teams and population health reports that lead to pre-visit planning and post-visit care and follow-up that ensures that everything gets done.

If we slather all of this on top of our patients, they’re more likely, we hope, to get their vaccines, to get their mammograms, to take their medications as directed, to actually start that exercise program and make those diet changes, and to quit smoking — to do all of those things that have been shown to really make a difference in their lives. But if we keep trying to squeeze all of this into 20 minutes, then we’re going to keep getting the outcomes that we’ve seen so far, trillions of dollars spent on healthcare and so many no better off, and everyone feeling frustrated and burned out.

So I think it’s time we stop and pause and rethink and redesign, hopefully so we can get back to a world where we are truly in the healthcare delivery business, and not in the business of healthcare.

It may take a minute. Or 20.

Please enable JavaScript to view the

comments powered by Disqus.