International variations in primary care physician consultation time: a systematic review of 67 countries
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  • Published on:
    Increased U.S. primary care consultation duration due to EHR burden?
    • Rani Marx, Epidemiologist Initiative for Slow Medicine
    • Other Contributors:
      • James G. Kahn, Professor

    We read with great interest the comprehensive review of primary care consultation duration in 67 countries between 1946 and 2016 by Irving et al (1). This review is especially timely given rising physician burnout, as well as dissatisfaction among both doctors and patients in the U.S. As the authors note, many physicians are frustrated by the limited time available to interact with patients.

    The increasing time of U.S. physicians with patients surprised us. Primary care physicians in the U.S. rank fifth out of ten high-income countries on dissatisfaction with time spent per patient (2). What explains this apparent mismatch of quantitative trends and satisfaction?

    One candidate explanation is that much of physician time is spent on activities other than communication with patients. According to an observational study in 2015 of 57 ambulatory care physicians (primary care, cardiology, and orthopedics) in 16 practices in 4 states, of time spent with patients in the exam room, 53% was spent face-to-face, 37% on the electronic health record (EHR) and desk work, and 9% on administrative tasks (3).

    Thus, we wondered if the U.S. trend in primary care consultation duration reported by Irving et al aligned with historical trends in EHR uptake. In the Figure [ ] we compare these two temporal patterns. Examination of the Irving da...

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    Conflict of Interest:
    None declared.
  • Published on:
    The problem is 'insurance'

    Physicians would happily spend more time with patients, just as restaurants happily serve appetizers, sides, and desserts, IF they were reimbursed for the extra time, but the insurance system was set up to deal with big, unexpected, single-diagnoses events, so doesn't address the complexity and time of a non-procedural primary-care visit.
    Direct-pay environments, where the physician can make $20/hr after expenses, encourage proper allocation of time, but the 'co-pay' environment, where the insurer caps everything at a 99214 (which one can perform in 4 minutes) so the patient with 9 interacting problems who you spend 40 minutes with and try to bill a 99215 (which may pay $100/40min versus $50/4 minutes, so you don't even meet overhead), you get a kangaroo-court "audit" where your services are deemed 'not medically necessary' and you are threatened with fines (or jail, in the case of Anthem/Medicare).

    So doctors do what they are paid to do, which is 4 minute visits.

    Conflict of Interest:
    None declared.