Excellent internal medicine takes time


Editor's Note: Dr. Centor is Chair, ACP Board of Regents, 2014-2015, and is guest-writing this month's President's Message.

Over the past 7 years, first as a member of the ACP Board of Regents and now as the Chair of that board, I have talked with many internists. During these conversations, I try to listen carefully and understand the issues that concern our members.

The first thing that I notice when talking with colleagues is that, as internists, we generally like spending time with patients and dislike the associated paperwork. As our Senior Vice President for Governmental Affairs and Public Policy, Robert B. Doherty, has reminded us, the Star Trek franchise has always had doctors as part of its many shows. Those doctors made famous the phrase, “I am a doctor, not a ...”. In 2014, we could say, “I am a doctor, not a data entry clerk, not a telephone operator, etc.”

What also comes through is the frustration that occurs from inadequate time to spend with each patient. Whether in the office or at the hospital bedside, we need adequate time to take a careful history and do the appropriate physical exam. We need time to explain to patients what we are thinking and what we are planning to do to investigate their problems.

Many patients have multiple problems. As the number of problems increases, we must spend more time with the patient, yet our current payment processes ignore time as a standard for payment (excluding intensive care). Our payments treat visits as types.

Internists often feel pressure to see patients in less time than the patient needs and deserves. This conflict creates great discomfort. Too often we resolve the conflict through ordering more tests and consults.

Time is our friend and our enemy. When we have appropriate time with a patient, we do a better job. The problem here comes from deciding what appropriate time means. How do we quantify patient time?

We have all heard friends talk positively about a physician who spends enough time talking and listening. Patients do not want us to rush. They want our full attention.

So internists (and many other specialists and subspecialists) face a conundrum. Our payment system “penalizes” us for spending extra time with a patient, yet the patients and we know that we should. We believe that spending adequate time would obviate some diagnostic testing and referrals.

We must highlight this problem. When internists spend inadequate time with their patients, they experience discomfort. Patients become dissatisfied.

We must focus on the quality of the visit, not as measured through performance measures, but rather through an assessment of encounter quality. We need time for thoroughness and reflection.

Internists care for many complex patients. Our patients often have multiple medical conditions and often also have psychosocial complexity. Our patients need more time than they did when I finished my residency in 1978. We can do more for our patients both diagnostically and therapeutically. We have more potential preventive strategies. But we cannot provide the highest quality care in 15- or 20-minute increments.

We must explain to insurers (including the Centers for Medicare & Medicaid Services) that we cannot do the job properly under the current conditions. We must lead our profession in examining processes for allowing us to spend enough time with patients and less time with paperwork (or computer work). The American College of Physicians will continue to make these issues clear.