Disenchanted Doctors Changing Office Visits
With many patients "fed up" with long waits for doctors' appointments, "jammed" waiting rooms and "rushed" visits, some physicians -- "annoyed themselves" -- have launched a movement to "placat[e]" patients by improving the "age-old and often disheartening" experience of visiting the doctor's office, the New York Times reports. Some changes include a new method of scheduling, group office visits that allow patients additional time with doctors, scheduled telephone calls from doctors instead of office visits for patients with chronic diseases and providing patients with online access to their medical records. After several years of testing, researchers have found that the innovations can "greatly alleviate" doctors' and patients' "irritations" and save "substantial" amounts of money, prompting some medical groups to begin implementing the practices. For example, the
Institute for Healthcare Improvement, a Boston-based, not-for-profit education and research organization, has formed a national coalition of 23 medical centers that use a variety of the new changes to improve care and study their effectiveness. Despite the potentially "overwhelming" benefits, supporters admit that the innovations face "real hurdles," with many doctors unaware of the new methods and some "hesitat[ing]" to use them. "This isn't rocket science," Dartmouth Medical School's Dr. John Wasson said, adding, "With most people, you can make dramatic improvements if they get a little more attention and are told how to manage their own issues."
Faced with a heavy patient "backlog," Dr. Mark Murray, a family practice doctor at the Kaiser Permanente medical center in Roseville, Calif., decided to "clear out the warehouse" -- moving the oldest appointments "off the books" by working longer hours and then offering patients appointments with their own doctors the day they called. Within a year, the "crush" of patients at the clinic had vanished. "In this department where in the past we were totally and completely saturated, we were now voting at the end of the day to see who would go home early," Murray said. Other medical centers began asking Murray for help, and in 1999, he stopped practicing medicine and started a consulting business on alleviating patient backlogs in doctors' offices with "open access scheduling." However, many private practice physicians fear the program because they consider a "warehouse" of waiting patients a source of income. "They think the warehouse is filled with money," Murray said, pointing out that the waiting patients, "filled with ill will," will begin to "loo[k] elsewhere for health care." He also said that open access would generate as much revenue as the old system.
At a Kaiser Permanente clinic near Denver, geriatrician Dr. John Scott said he felt that his patients received "short shrift" and developed a system of group visits. "Every time I closed the door on a patient, I knew there were other things that should be addressed," Scott said, adding, "but in 20-minute visits, you just don't have the time." He concluded patients would receive proper attention if doctors examined a group of them at the same time. To test the program, Scott designed a pilot study involving 321 elderly patients, with a variety of chronic medical complaints, who averaged more than one office visit a month. Scott and his colleagues provided half the patients with their usual care and the others with an additional monthly group visit with their doctor. With "encouraging" results, he expanded the study to 800 patients and will publish his findings in a medical journal. Both studies found that patients offered group visits "stayed healthier," had "significantly fewer" visits to the emergency room and to specialists and had a "slower rate" of physical decline. "We tell the doctor: 'This is what's happening to you. When you're answering questions with your hand on the doorknob, you're giving the message with your body that you couldn't care less about the patient,'" Scott said, adding that the program also saved more than $12 a month for each patient.
At Dartmouth, Wasson developed a study to determine whether telephone calls from a doctor could substitute for some office visits. The study involved 497 men with chronic diseases, ages 54 and older, at the Veterans Affairs General Medical Clinic in White River Junction, Vt. Half the patients continued with usual office visits, while the others had to wait twice as long as usual between office visits but received three 10-minute scheduled telephone calls from their doctor. After two years, patients who received the calls had 19% fewer office visits, used 14% less medication and had fewer admissions to the hospital and shorter stays when admitted. In addition, their medical costs dropped about 28%.
However, many doctors in medical practices with a combination of managed care and fee-for-service patients remain reluctant to implement the program because they receive no payment for phone calls. "[T]hey don't want to eat up their fee-for-service time with calls," Wasson said. Dr. Donald Berwick, president and CEO of the Institute for Healthcare Improvement, said that doctors' compensation often proves a "major stumbling block" to new innovations. "I met with about 100 doctors the other night and I described this stuff to them," Berwick said, adding, "They love it. They all want to go there. But you should have heard the concerns they had. They say: 'I'd lose my shirt. Many of the visits we have are completely useless, but I only get paid for patient visits.'" Berwick continued, "It's discouraging. I know this is better for patients. I know it is better for physicians. I know the costs will go down. But whether we can get these changes made is anybody's guess. I tell the practices to just do it. But there is a very, very cautious attitude that says that the status quo always wins" (Kolata, New York Times, 1/4).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.