Time

You can't see, touch, smell, or taste it, but we spend tens of billions of health care dollars on it every year. To many patients and their physicians, it is precious, maybe the most precious of all medical resources. Yet we know only a little about how to use it efficiently or about the impact of using more or less of it, and we spend virtually nothing for research on its diagnostic and therapeutic implications. It is, of course, time.

Physicians have always been busy people, although they have generally controlled the way they use their time. In 1993, for example, family practitioners were seeing, on average, one patient every 20 minutes; general internists were seeing one every 26 minutes [1]. These visit times were not long but perhaps were not unreasonable, particularly considering that they represented a mix of new and follow-up visits and that “fast” and “slow” British general practitioners had mean visit lengths of 7 and 9 minutes, respectively [2]. Recently, however, the invisible hand of the marketplace has squeezed appointment schedules in an ever-tightening grip: In late 1995, 41% of physicians in an important U.S. survey reported that the amount of time they spent with their patients had decreased during the previous 3 years [3]. This erosion of encounter time has taken its toll on physicians [1, 3]. Moreover, it is equally distressing to patients because patients value their physicians' “information giving” highly [4] and, as Howard Waitzkin has sensibly pointed out, “Information giving takes time. We cannot expect it to go well if we are too busy” [5]. It does not take a rocket scientist (in the current parlance) to understand why both patients and their physicians have become increasingly dissatisfied as visit lengths have grown shorter [2, 6].

Face-to-face encounters are where physicians and patients come to know each other over the years as people rather than as “cases” and “providers.” They are where physicians inform, motivate, and negotiate with patients. And they are also where physicians gather the information essential for diagnosis and management [7]. Indeed, it has been said with some justice that the medical history is, on the whole, more powerful than the computed tomographic scan. It also does not take a rocket scientist to recognize that if the time available for physician–patient interaction is severely constrained, the quality of medical management and outcomes may also be in serious jeopardy.

In this connection, the finding by Tamblyn and coworkers, published in this issue [8], that shorter office visits were associated with more inappropriate prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) is particularly disturbing. The intervening variable seemed to be physicians' failure during shorter visits to obtain the requisite history about potential contraindications to therapy. Other observational studies (not many are available) have confirmed a relation between encounter length and quality of care. For example, patients in one study [9] clearly asked for health-related information less often in shorter visits (less than about 19 minutes) than in longer ones. In a second study [10], practitioners' involvement with patients' psychosocial concerns increased from minimal in 13-minute visits to its highest level in 20-minute visits. In a study from Australia [11], longer office visits to primary care physicians were associated with a 60% greater frequency of inquiry about alcohol use, although not about smoking or medication use. And an analysis of more than 9000 consultations in practices in Scotland found that patients' feelings of confidence and ability to cope after a consultation were highly correlated with visit length [12].

In theory, of course, shorter office visits could be either a cause or an effect. For example, in the study by Tamblyn and colleagues [8], external pressure to limit encounter time could have caused physicians to skip items in the medical history even though they knew them to be important. Alternatively, failure to appreciate the importance of these items may have led some physicians to take less time with the history, hence the shorter visits. Observational studies unfortunately don't allow us to decide between these two explanations; only a controlled trial that systematically varies the length of visits and measures the outcomes will permit that. Fortunately, at least one such controlled study has been done. Some 10 years ago, Morrell and Roland and their colleagues [13, 14] randomly scheduled consultations in the practices of general practitioners in London to be 5, 7.5, or 10 minutes long. Using analyses of audiotaped encounters, they found that physicians spent substantially more time explaining patients' problems, proposing management options, discussing prevention, and providing health education when the encounters lasted 10 minutes or longer than when they were shorter than 10 minutes. And, importantly, more patient problems were discovered during the longer visits.

It would not be too much of a stretch, therefore, to conclude that the deficits in prescribing NSAIDs described by Tamblyn and colleagues resulted at least in part from constraints on office visit time. The idea that writing a prescription can be used to end some office visits is not new [15], nor is it so far-fetched: The written prescription can serve as a visible gesture of caring, as a tangible link between physician and patient after the patient leaves the office, and as an additional reason for the patient to return. And because rethinking prescribing, reviewing individual patients, using the potential of computer systems, and changing patients' expectations all take time [15], we should not be surprised if prescribing comes to be used more often as a “quick fix” for ending encounters as the amount of time scheduled for an office visit gets shorter.

A third-grader presented with this problem would probably suggest that we should simply allow more time for office visits, and it would be hard to disagree with that simple logic. Her elders, in their wisdom, would then point out that increased time for office visits will do little to help unless the time is used well, and they would also be right: Patients' hunger for attention can be almost limitless, and longer encounter times might “merely provide greater opportunities to plumb the depths of human misery” [16]. Next, the elders would make it clear that efficient and effective use of encounter time demands a high level of medical interviewing skill, something the medical education system in the United States has severely neglected [17, 18]; again, they would be right. They would then patiently explain that more time for encounters is expensive. And the sad truth is that our trillion-dollar medical care system seems to feel that time spent with patients is a luxury it simply can't afford.

But it does not have to be like that. Patients and their physicians can begin to make clear how important it is to them to have “enough” encounter time. Administrators, health planners, legislators, and payors can take another look at the damage inflicted on outcomes and on resource use-if not now, then later-if the screws on office visit time continue to tighten without limit. Researchers and the agencies that fund health services research can begin to reconsider the importance of understanding the interactions between encounter time and quality of care. And because time is money (we “spend” them both), it is everyone's job to figure out how and where to get the additional time [19]. Would it help to change the mix of medical staff and the jobs they do? How much time is saved by continuity care, that is, having patients seen by physicians and nurses who know them rather than by strangers? Is it possible that many patients don't need to return to the office as often as they do now? And is additional encounter time a better investment, after all, than certain invasive procedures?

Imagine a future in which the time available for office visits is determined primarily by the nature of the patient and the medical problem rather than by the dreams of system planners; in which there is time for taking an adequate medical history and doing the requisite physical examination; for actually discovering most of the patient's problems; for discussing management options and treatment effects to everyone's satisfaction; for providing screening, prevention efforts, and health education on a regular basis; for patients to feel free to ask for, and get, medical information; for medical staff to give needed attention to psychosocial issues; and for patients and their physicians to sense that they have had the time to see and hear, to be seen and heard. Bizarre! The very strangeness of the image says something about a medical care system that is out of control and drifting farther all the time from its basic purpose of caring well for patients.

We hear frequently that the “mainstream” U.S. health care system is the best in the world. But we also hear how our patients turn increasingly to “alternative” practices for care. Can it be that alternative medicine is attractive to patients precisely because its practitioners have discovered the value of time and give patients the time they need? It would be an irony indeed if the mighty medical kingdom we have created with our vast biomedical research establishment, our dynamic medical education enterprise, and our seemingly endless flood of health care spending were lost, or at least badly compromised, all for want of the horseshoe nail of time.

• Copyright ©2004 by the American College of Physicians