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Did you know that according to a 1998 study, it's not unusual for a physician to wait only 18 seconds before interrupting a patient who is trying to describe a medical problem? Doctors who have studied the problem acknowledge that the failure to take the time to get a full medical history and list of symptoms can result in improper diagnoses and inappropriate tests and treatments. It would seem logical that it would also lead to waste and higher health care costs.
While it might seem that the solution is simply to train doctors to improve their bedside manner, some doctors say that the real problem is that their working conditions and compensation scheme actually discourages them from spending time talking to patients.
I first learned about this problem while listening to an NPR interview last month with Lisa Sanders, a physician whose New York Times column about hard-to-diagnose medical cases reporttedly inspired the creation of the popular television medical drama, House. Sanders described a recent workday in which she saw several patients with chronic health conditions, such as diabetes, and treated another patient's ingrown toenail. Sanders said that the removal of the toenail turned out the the most lucrative procedure of her day, despite the fact that the other patients she saw had more serious health issues.
Like Sanders, retired cardiologist Bernard Lown argues that effective health care reform has to remove obstacles that keep doctors from spending time listening:
My thesis is straightforward: When doctors give short shrift to listening and conversing with patients, health care costs mount.
According to a May, 2009 article in Physician's Practice, doctors are hiking their patient loads to make up for decreased reimbursements from both Medicare and private insurers. Preventive care was one of the casualties, as illustrated in the opening anecdote about the struggle endured by Philadelphia primary care physician Charles Winfrey:
Whitney and his partners at the University of Pennsylvania practice were trying to make up for declining reimbursements by seeing more patients and working longer hours. In fact, Whitney was so overworked he had taken to sleeping on the office sofa to get an early jump on the previous day’s paperwork. It was during one of his office overnights in 2003 that Whitney had his epiphany.
“I remember laying there unable to sleep thinking ‘This is ridiculous. I’m sleeping on the couch to get work done.’ I didn’t have any emotional energy left for my family,” he recalls. “First we cut out the fat, then the meat, and then the organs of what we did. The amount of time we could spend with each patient was shrinking and the priorities were the sickness..."
These revelations made me wonder about the validity of analyses that I've read recently saying that preventive care will not lower the costs of health care. a 2008 study published in the New England Journal of Medicine found that preventive care can actually increase health care costs, not decrease them:
Sweeping statements about the cost-saving potential of prevention, however, are overreaching. Studies have concluded that preventing illness can in some cases save money but in other cases can add to health care costs.3 For example, screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures. Preventive measures that do not save money may or may not represent cost-effective care (i.e., good value for the resources expended). Whether any preventive measure saves money or is a reasonable investment despite adding to costs depends entirely on the particular intervention and the specific population in question. For example, drugs used to treat high cholesterol yield much greater value for the money if the targeted population is at high risk for coronary heart disease, and the efficiency of cancer screening can depend heavily on both the frequency of the screening and the level of cancer risk in the screened population.4
However, promoting wellness isn't simply a matter of ordering the right screening exams - especially if the doctor isn't taking the time to find out the whole stories. Patient counseling is part of the mix. If doctors aren't spending time with patients, they can't give appropriate guidance. And that seems like a formula for unnecessary patient suffering, and expense.
