Michael Bader: Waiting for the doctor is bad for everybody
There is no longer any debate about the correlation between the quantity and quality of the time your doctor spends with you and your satisfaction with his or her care — and there is no question that your satisfaction level correlates with your willingness to return for follow up appointments and with your overall compliance with your doctor’s treatment plan.
Waiting times are also key predictors of satisfaction, but patients are willing to tolerate longer waits if they get more time with their doctors. Overall, the personal quality of your medical care — the ease of access, the amount of attention you get, the degree to which you feel heard — is a crucial predictor of good health outcomes.
When your doctor is able to spend “quality time” with you, both parties benefit. You feel that you matter, that you’re cared for. And your doctor is happier as well. After all, most primary care providers didn’t’ go into medicine in order to deliver assembly line service dictated by financial and resource constraints. They went into medicine in order to help people and make a good living while doing so. These satisfactions are radically reduced when doctors have only 10 minutes to spend with a patient who is frustrated because he or she had to wait 3 weeks to get an appointment and has been waiting for 30 minutes in a waiting room prior to being seen (for a more thorough discussion of these findings, from both sides of the stethoscope, check out local writer and physician, Jeff Kane’s excellent book Healing Healthcare: How Doctors and Patients Can Heal our Sick System, or, for a brilliant discussion of how the doctor-patient relationship affects end of life care, read Atul Gawande’s bestseller, Being Mortal: Medicine and What Matters in the End).
The economics of outpatient medical care, whether delivered in a clinic or private practice, is toxic to doctors as well as patients.
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Given the strength of these findings, and the indirect costs as measured by compromised health outcomes, it is striking that debates over health care today are dominated by concerns about issues other than the actual quality of care. Conservatives recite the mantra of “choosing and keeping your own doctor” as if free choice were the only issue, while liberals advocate universal access, as if the only concerns that matter are whether you can see any doctor, not the quality of the care once you get there. And this, despite the fact that most people in America do have insurance of some kind. We rail against the shameful lot of the uninsured, but who speaks up for the poor quality of care for those who have good-enough coverage?
The fact remains: doctors who have the freedom to spend time with their patients, getting to know them and really listening to their medical and non-medical concerns get better outcomes, prevention, compliance, and follow — up, which saves the system untold millions of dollars in medical costs. What’s good for the hearts and souls of everyone involved turns out to be good for the bottom line as well.
So rather than assume that the way things are is the way they have to be, that the economics of medical care are fixed, as if they are part of the natural order, perhaps people who want to reform health care in America ought to be focused as much on the “care” part of health care as they are on its availability.
And there is a mountain of research that can guide us as we do so. Several years ago, the New York Times ran an article about the movement within primary are medicine to develop systems that allow doctors to spend more time with their patients. New technologies enabling doctors to electronically record, store and manage records, handle appointments, bill insurance companies, refill prescriptions and communicate directly with patients can allow physicians to spend more time seeing fewer patient while maintaining their incomes. One physician moved from a large clinic where she was required to see 25 patients a day to a smaller more efficiently run practice where she saw 12. Instead of only treating presenting symptoms, she was able to better understand her patients’ entire history. Another doctor made house-calls (Baby-boomer readers: remember house calls?), managing most of his practice through special software on his laptop. Both providers maintained regular contact with their patients via email.
It’s not that there aren’t experiments out there that can show us a new way to conceptualize health care. It’s that we think that the way things are is inevitable.
But behind all of the experiments for creating the conditions under which the quality of the doctor-patient relationship can be deepened, lay the transformative power of relationships, a power that manifests in greatly improved medical outcomes. For many people who do have decent coverage, getting in contact with a doctor is difficult, mediated as it is by labyrinthine office procedures, phone queues, or office policies that simply prohibit it. Once an appointment is made, not always a simple matter, patients often wait for a long time. They wait again in crowded waiting rooms. And when they eventually see their doctors, they are often unintentionally made to feel that their problems, questions, and concerns are taking up too much of their providers’ time which is apportioned in five to 15-minute increments. Referrals to specialists often take weeks or months. Follow-up is usually left to the patient who may or may not be proactive enough to do so.
If the patient doesn’t become passive and give up, the result is what psychologists call an “anxious attachment” to the doctor and to the medical system in general. Lacking a secure sense that they are understood and reliably cared for, patients that don’t frankly give up become, instead, cynical or nervously dependent and needy and fail to really internalize the treatment and care that is being offered. Treatment outcomes suffer, prevention strategies founder, hospitalizations and emergency room visits increase, and everyone involved—including taxpayers — pays the price.
The bottom line is that health care reform should put fixing the doctor-patient relationship at the top of its agenda. The benefits to all of us are incalculable.
Michael Bader, DMH, is a psychologist in private practice in Grass Valley. He can be contacted at firstname.lastname@example.org.
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