What does a standard 12 minute doctor’s visit mean? For one thing, it is meaning miserable physicians and patients. This is one of the major complaints as part of the litany of complaints many medical practitioners are expressing about their job. Patients also don’t like it, it makes their experience less enjoyable, they feel like their physician isn’t as engaged and they don’t connect as well; I know that a lot of medication adherence and following the medical plan depends on the quality of the relationship with the physician, so we might infer that this is important. There are some studies which have been done on visit length, but I can’t find something which has looked at outcomes as a function of visit length. The expansion of coverage under the Affordable Care Act may add more burdens to the limited number of primary care providers and force even shorter visits. Hopefully, more people will be drawn into primary care, and we will reach an equilibrium and improved care, but for now, the 12 minute visit seems to be part of life.
We are taught to try to be like Dr. Joseph Bell, the real life genius who inspired Sherlock Holmes. He used his attention to detail to diagnose patients from the subtlest of clues and occasionally to help the police with an investigation. However, that takes time, and requires asking a lot of questions and to see many different things.
As a second year student, I don’t see many patients, but I have had my own minor triumphs of diagnosis, but they only came through taking time and careful observation. I will describe two. One was an older woman, South Asian, brought in by her son and his wife. She had a history of chronic hypertension which had led to a stroke and retinal bleed, a few years before. Even basic diagnostics were difficult; it was hard to distinguish if she had cognitive problems through the translation efforts of her children (they spoke an obscure dialect, and didn’t have perfect English themselves), but she had a hard time following directions. For example, I tried to visualize her retinas (including her old retinal bleed) with the ophthalmoscope, but her very strong refractive problem, cataracts, and inability to stay still or follow direction made this an almost Herculean task. There is a bit of tendency to try to stop doing diagnostic maneuvers if patients are resistant and complicated, but they are often who need it the most. She had some difficulty walking (a foot drop, and flexed extensors on that leg) and maneuvering in general, and it was quite a task to remove her many layers of clothes to examine her heart. However, when struggling with communication and the physical maneuvers I was trying to pay attention to what I could learn from her movements, her many layers of clothing (even looking at the bottom of her shoes for asymmetric wear patterns) as we were trying to find out why her BP was so high and if she was in immediate danger of cardiovascular problems or another stroke. It turned out that she had started taking a beta blocker instead of her diuretic, which may have caused her recent spike in BP, so that we could solve. However, the many layers of clothing gave me another clue, and I asked to test her thyroid level. Hypothyroidism is not uncommon in older patients, but a lot of her decline in health and neurological function was attributed to her stroke. After she was treated and became euthyroid, she was like a different person, active and engaged. My attending (my senior physician boss) called it a very “good catch”, and I felt good for a while. As an early medical student, you often don’t have the opportunity to feel like you really helped someone. I was only able to identify a problem by taking time to talk to the patient, examine, listen, and most importantly think.
Another patient who came into the walk-in clinic looking for dental care. Let’s call him Peter Willets. Entering middle age, Mr. Willets has the lean, weathered face of someone who has spent a lifetime outdoors, in this case, working construction and enjoying a lot of outside activities. He’s garrulous, cheerful and witty as he tells me about the miraculous healing powers of grapefruit. He also has very bad teeth, and that is what has brought him to the clinic. Unfortunately, there is very little that we will be able to do for him, as we have poor ability to provide dental services. He may be better suited to get dental implants Rochester treatment at a clinic near him.
Near the end of the interview, I notice a band-aid on his wrist, poking out from the cuff of his fraying work shirt. I ask him about it, and he says it is a wart, but something makes me suspicious. I ask him to show me. It’s covered in a white coating, and I learn that he’s been putting Compound-W (Salicylic acid) on it. It doesn’t look like a wart. It is too dark. I have him wash it off in the small sink. I look closer, the lesion is asymmetric with an irregular border and some very dark coloring. Mr. Willets spends a lot of time outside, working as a window washer mostly with his forearms bare to the California sun. I suspect it is much more serious than a wart. When I present to the attending, I mention the “wart” and when he sees it, he makes a dermatology referral. Later I learn it was diagnosed as melanoma and excised. I don’t have access to very much follow up on Mr. Willets, but I know the dramatically different prognosis between early and late detection of melanoma. I am left to wonder what might have happened if he hadn’t come in because of his teeth. In many other clinical settings, a physician would not have had time to talk to Mr Willets, finding out he wanted dental care, he might have just been given a referral at the front desk, or given a cursory interview.
It’s only be careful examination and taking time that you can help your patients. Life isn’t an episode of House, so you don’t discover some hidden key clue to save their life in every 45 minutes of examination and discussion. However, if you do take more than 12 minutes, you can often uncover important information, sometimes something which may save someone’s life. Not every patient will benefit, but that means every patient deserves more time and thought, because the ones who do benefit, can benefit greatly.
[In any clinical story, I change the names and details to protect patient privacy]