Back to Front PageVOLUME 6, NUMBER 4

The Doctor Will See You Now:
Are Physician Office Visits Getting Shorter …
or Longer?

By Barbara A. Gabriel

Kenneth Ludmerer, M.D., has found that physicians repeatedly cite time constraints as one of the biggest obstacles to the delivery of quality patient care.

In 1999, Kenneth Ludmerer, M.D., wrote in Time to Heal - a seminal text surveying the history of the last century of medical education - that the transition to managed care marked the first time in American history that "a conflict appeared between the teachings of medicine and the environment of health care delivery." He wrote that capitated payment systems and ever-increasing productivity requirements created an atmosphere in which physicians were obliged to see as many patients as possible to maintain their salary levels and fulfill their managed care contracts.

In this new environment, wrote Dr. Ludmerer, time became a precious commodity, and the increasing lack of it threatened both the very existence of the doctor-patient relationship and the quality of medical care itself.

"Like good teaching and good research, good medical care cannot be provided on the fly," he wrote. "Problem solving - figuring out a diagnosis or determining the best treatment for the individual patient - requires time for the physician to think and reflect."

Dr. Ludmerer's observations confirmed well-publicized anecdotes about doctors' time being consumed at the expense of their patients by an endless supply of paperwork and administrative burdens. In a 1998 editorial titled "Doctor Discontent," Jerome P. Kassirer, M.D., then editor-in-chief of the New England Journal of Medicine, emphasized that lack of time compromises both patient care and physicians' clinical knowledge: "Given that office visits are short … patients could suffer from a lack of attention to concomitant illnesses and to psychological needs, as well as from an erosion of their relationship with their physician. Patients could also suffer if their physicians become less expert and less up to date in their fields."

Physician testimony has borne out the observations of Drs. Ludmerer and Kassirer. In survey after survey, doctors express dissatisfaction with managed care and its impact on the amount of time they have to devote to patient care. In a 1999 Kaiser Family Foundation/ Harvard School of Public Health survey of physicians and nurses, 83 percent said managed care had decreased the amount of time doctors spend with their patients, and 72 percent replied that the quality of health care declined under managed care. When asked to reflect on their own experiences, 58 percent of physicians said that spending more time on administration rather than directly with patients was "a great concern."

Perception vs. Reality

David Mechanic, Ph.D., of Rutgers University, has aroused both interest and controversy with his study indicating that physician office visits have gotten slightly longer under the managed care system.

"The assumption is that managed care has eroded patient confidence through many mechanisms, including forcing doctors to spend less time with patients," says David Mechanic, Ph.D., a medical sociologist who is a professor and director of the Institute for Health, Health Care Policy, and Aging Research at Rutgers University. "It's a consensus that I myself shared."

Then one day Dr. Mechanic ran across a claim on an HMO trade group Web site that stated the contention that doctors were spending less time with patients was a myth. The group cited data from the American Medical Association (AMA), and Dr. Mechanic decided to investigate the data for himself. Using the Socioeconomic Monitoring System (SMS), an annual survey conducted by the AMA to collect nationally representative information about physicians' practices, Dr. Mechanic estimated the average duration of doctors' office visits between 1989 and 1998 by dividing the average number of hours physicians reported spending with patients in their offices each week by the average number of patients physicians reported seeing.

The results surprised him. In a recently published article in the New England Journal of Medicine, Dr. Mechanic reports that the SMS data indicate that the average duration of physician office visits increased by 1.1 minutes over the period of time he studied - a period, he notes, "characterized by the rapid expansion of managed care."

But Dr. Mechanic admits that such an approximation is "crude" at best, being based on physician estimations of past aggregate time periods. So he consulted another source he considered more accurate. "The National Ambulatory Medical Care Survey (NAMCS) is a survey of visits after they occur," explains Dr. Mechanic. "For each visit that's sampled, a form is filled out by the physician or his or her staff, providing detailed information, including the face-to-face time the patient had with the doctor. We obtained NAMCS data spanning the same 10-year period. Although the numbers are somewhat different, we found the exact same pattern." NAMCS data indicate that the mean duration of visits in 1998 was 2.0 minutes longer than in 1989.

Dr. Mechanic hypothesizes from his findings that it is the perception physicians have of time spent with patients, rather than the time itself, that has changed with managed care. He cites a number of factors that he believes contribute to physician consensus that face-to-face patient time has decreased.

"There is increased competition for patients among health plans," Dr. Mechanic says. "Some health plans monitor patient satisfaction with surveys and adjust physician remuneration accordingly." Doctors understand they have to spend a reasonable amount of time with their patients to ensure their satisfaction, explains Dr. Mechanic. The resulting pressure may lead to a feeling that the time they devote to patients is inadequate.

Increased patient sophistication is another factor Dr. Mechanic cites as changing the doctor-patient dynamic. "Patients are coming in with information from the media, pharmaceutical advertising, and the Internet, and they have more questions," he says. "Answers and explanations take time, particularly as multiple treatment options are becoming available for the same illnesses."

Finally, Dr. Mechanic attributes the expectation that doctors do more during office visits - particularly in the area of patient education - to managed care's emphasis on preventive care. "Not only are today's doctors expected to provide quality medical care, but they're also supposed to be interested in health maintenance and health promotion," Dr. Mechanic explains. "Talking about weight control, smoking cessation, exercise, diet, cholesterol, and safe sex puts pressure on doctors to do more in a limited time period."

Goodbye, Dr. Welby

UCSF's Harold S. Luft, Ph.D., suggests that physician complaints about compressed office visits have more to do with their growing lack of control under managed care.

Although Dr. Mechanic's counter- intuitive claim that physician visits have gotten marginally longer in the age of managed care has garnered much attention - and some anger - he is not the first to make such an observation. In October 1999, Harold S. Luft, Ph.D., professor of health policy and health economics and director of the Institute for Health Policy Studies at the University of California, San Francisco, School of Medicine, published an essay in the Journal of Health Politics, Policy and Law titled "Why Are Physicians So Upset About Managed Care?"

In his attempt to account for physician dissatisfaction with the managed care system, Dr. Luft undermines the often-repeated claim that it has resulted in unmanageable patient caseloads and cuts in time spent in direct patient care with the same AMA data used by Dr. Mechanic. Dr. Luft found that the average number of patient visits per week had decreased from 120.9 in 1990 to 110.6 in 1997, and that the average time spent with patients increased from 24.4 minutes in 1990 to 26.4 minutes in 1997. He also found that the number of hours physicians worked per week decreased from 58.8 to 57.9 over the same seven-year time period.

Like his colleague, Dr. Luft was surprised by his findings. But he says that while his data source may be flawed due to inaccurate physician recollections, he maintains that "there's a difference between data being less than perfect and data being biased in a certain direction," the latter being unlikely in the AMA physician survey.

"I think physicians have always been busy," Dr. Luft explains. "But when they were running their own practices and doing their own scheduling, they had no one to blame but themselves. Now they can blame managed care."

"If you're paid a fixed salary or a capitation, and you've got a bunch of patients in the waiting room and, as a result, cannot leave the office when you wish, you think, 'I'm not earning any more for this.' So you feel like you're being pushed harder than you want to be," Dr. Luft surmises. "If you're paid fee-for-service, you can say, 'Well, I stayed the extra hour, but at least I saw four more patients, and that's some extra money in the bank.' The amount of time you spend in the office hasn't changed, but your perception of it has."

What this boils down to, Dr. Luft believes, is physician reaction to a loss of control. Like Dr. Mechanic, he adds that more informed patients who demand more of their doctors' time and pressure from managed care to counsel patients on preventive health practices contribute to the sense physicians have that they are no longer in command of the limited time reserved for direct patient contact. "It's no longer Dr. Marcus Welby dealing with patients who are quiet and pleased with whatever is done," Dr. Luft says.

A Question of Data

Although he calls their studies "intriguing," Dr. Ludmerer is skeptical of the accuracy of the findings of Drs. Mechanic and Luft. He especially cautions against using purely quantitative data to draw conclusions about physician practices.

"When you're examining a trend with solely administrative data, the way Dr. Mechanic did, the study lends itself to numerous unanswered questions that could completely change the results," Dr. Ludmerer says. "For example, who are the patients and how sick are they? What were the doctors doing with their time? As you start controlling for these factors, you get closer to individual patient experiences, and thus more accurate answers. I suspect future studies will not confirm Dr. Mechanic's findings."

However, Dr. Ludmerer concurs that today's physicians are expected to do more during office visits, and that physicians' perceptions about the amount of time they spend with patients can be skewed by those additional expectations. "My guess is that the length of time spent on office visits has decreased, but not as much as some people may think," he offers.

"Physicians are talking with patients more, taking their individual situations and preferences into account, and that requires time. But just looking at length of time is not the issue; it's whether physicians have enough time to do a good job with the patients they see. If you start looking at ideal office visit times as a unit established by the laws of nature, you're reducing patient care to assembly-line medicine."

Ultimately, Dr. Ludmerer says, Dr. Mechanic's study raises questions rather than makes its case. Public and physician reaction to the article confirms his observation. "I've written hundreds of articles," says Dr. Mechanic, "but I've never written anything that's received this level of attention."

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18 April 2001