William Cayley: Planning for uncertainty

bill_cayley_2Martin Marshall could not have said it better in his recent blog—the idea of the 10 minute consultation is a travesty . . . except that sometimes it is not.

With the increasing demands on and increasingly complex expectations of GPs and family physicians, expecting everything to fit into a 10 minute visit is simply crazy. Yet there are times when that 10 minute visit (or less) is what the patient wants. In good generalist primary care or family medicine, when we present ourselves as comprehensive physicians there to stand with our patients in health and in sickness, in prevention and in treatment, it should be no surprise that many a visit goes beyond the stated “chief complaint” to a much longer agenda. On the other hand, sometimes our patients simply want treatment for one narrowly focused concern—a cold, a tick bite, a skin infection.

The challenge in primary care is predicting which visit will be which, and how in the world to schedule them. One option many systems take is to book out primary care physicians’ schedules with chronic care visits, then arrange for non-emergency acute care visits to be routed to an “urgent care” or other acute care clinic. This (seems to) effectively allow maximal utilization of primary care office hours, and is supplemented by efforts to minimize “no-shows,” but it means that when patients are sick (which is when they need “my doctor” the most), they are seen by someone else.

As I said, this “seems to effectively allow maximal utilization of primary care office hours”—which may be great from a business standpoint, but I think it falls short of being good medicine.

Our patients’ lives are complex and unpredictable, and so are their illnesses. Sometimes the follow-up visit for the chronically ill patient with multiple diagnoses takes a long time, but sometimes (if all is well) many issues can be handled quite quickly. Conversely, sometimes an acute care visit really is “acute” (or, to the point), but it can often be an entrée into many and varied other concerns.

In one effort to sort through this complexity and bring some order to what can be chaotic, our office has more than once sought to categorize the types of visits for which people see us, and the amount of time each doctor prefers to have for these. Such efforts usually seem to go well at first, but sooner or later fall victim to neglect, forgetfulness, or just the routine complexity of life.

Recently, I’ve tried a different and somewhat simpler approach. Rather than trying to predict the length of time each type of visit may be, I am now typically scheduling each patient for 30 minutes. Sometimes that is too little, but sometimes that ends up being too much. However, our office also tries to be as available as possible to our patients for truly acute needs (the knife cut sustained while baking cookies, the new onset palpitations, etc) and predicting those needs is impossible. What I have found, however, is that uniformly scheduling visits for 30 minutes, then allowing walk-ins and add-ons as needed, generally leads to an overall full day. The no-shows are offset by the “too-longs,” and the “short and concise” visits allow room for the walk-in lacerations.

This is surely not rocket science, and probably not all that profound either—and health economists may quibble that this is inefficient business planning. Be that as it may, while I certainly want our clinical business to stay afloat, I also want to be present and available (within reason) to render needed care to my patients when they need it.

Life is complex, and so is illness, but this seems to be one simple solution to accommodate that.

William E Cayley Jr practices at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.