Fiscella K, Epstein RM. So Much to Do, So Little TimeCare for the Socially Disadvantaged and the 15-Minute Visit. Arch Intern Med. 2008;168(17):1843-1852. doi:10.1001/archinte.168.17.1843
There is so much to do in primary care, and so little time to do it. During 15-minute visits, physicians are expected to form partnerships with patients and their families, address complex acute and chronic biomedical and psychosocial problems, provide preventive care, coordinate care with specialists, and ensure informed decision making that respects patients' needs and preferences. This is a challenging task during straightforward visits, and it is nearly impossible when caring for socially disadvantaged patients with complex biomedical and psychosocial problems and multiple barriers to care. Consider the following scenario.
Mrs S is a 52-year-old housekeeper with poorly controlled diabetes mellitus, hypertension, and obesity who missed her last 2 visits because of job conflicts. She has not reached her annual insurance deductible and pays for the visit out of pocket. She speaks limited English, and the receptionist translates. Dr M explores her complaints of fatigue, daily headaches, back pain, and conflict with her husband after his job loss. Dr M conducts a thorough medical history and physical examination and concludes that Mrs S's poorly controlled diabetes mellitus, night shifts, work, and depression are contributing to her symptoms. He recommends mental health counseling, but Mrs S declines. Dr M recommends an antidepressant and adds 2 new medications for diabetes and blood pressure and reviews their purposes and adverse effects. Mrs S politely acquiesces, knowing she cannot afford them and doubting their benefit. The receptionist interrupts Dr M to tell him he is behind, and he quickly concludes the visit. Mrs S leaves the office still worried about her health and the costs of care. Because the visit takes 30 minutes, her office fee does not fully cover visit costs. Dr M despairingly notes that none of Mrs S's preventive or chronic disease quality measures meet local standards. He considers discharging her from his practice for nonadherence to avoid being penalized under pay-for-performance.
As illustrated, constraining care to 15-minute visits for socially disadvantaged patients virtually ensures the perpetuation of health care disparities. Socially disadvantaged patients, often referred to as vulnerable or underserved, are at higher risk for multiple risk factors because of shared social characteristics.1 They include members of racial and ethnic minority groups and persons with low literacy and low socioeconomic status.2 These groups, although distinct, overlap considerably, resulting in concentration of risk for patients.3
In this article, we illustrate how the 15-minute office visit discriminates against socially disadvantaged patients and propose fundamental reform in primary care structure and payment to address the problem.
The average office visit in the United States lasts for about 16 minutes,4 not enough time to effectively address multiple complex problems.5 Typically, 5 minutes are spent on one problem and a minute or 2 on the remainder.6 Providing all recommended preventive and chronic disease care takes far more time than is available during 2 adult primary care visits per year.7 To provide guideline-concordant care, a physician caring for a usual panel of patients would need to spend 35 hours on preventive health care during a typical week,8 another 50 hours on patients' chronic care needs,9 and unknown hours for acute care, in addition to the 8 hours primary care physicians currently spend on patient care outside of office visits.10 These time constraints severely limit informed decision making5 and confirmation of patient understanding,11 and commonly result in omission of discussion of adverse medication effects and costs.12,13 For socially disadvantaged patients, who more commonly have multiple, complex, biomedical, and psychosocial problems, care is worse.12,13
Caring for socially disadvantaged patients poses unique challenges, requiring more time and greater team work (Table 1).14 Communication across differences in language, culture, and health literacy takes time.26,50- 53 Socially disadvantaged patients experience worse physical54- 56 and mental health,22,57,58 including more impairments in vision, hearing, and cognition that slow communication.15
Review of the main parts of the office visit illustrates the key challenges of caring for socially disadvantaged patients during 15-minute visits.28 Initiating the visit involves establishing rapport and identifying the reasons for the visit. Achieving rapport across races, ethnicities, and educational levels can be challenging.29,59 Eliciting all the reasons for the visit and negotiating an agenda may take longer because socially disadvantaged patients have more concerns,14,16 symptoms,15 and illnesses.60 Patients with low health literacy may not recognize key symptoms as readily.61,62 Time pressures may undermine physician empathy63 and patient trust,64 particularly among marginalized patients.65
Gathering information about the illness, including key symptoms and psychosocial context, is more time consuming because socially disadvantaged patients may have more symptoms, more complex illnesses,66 and greater psychosocial stress.67,68 Exploration of patients' perspectives is critical to establishing a partnership and understanding patients' beliefs, but is also more time consuming across sociocultural distance.69
Physical examination may also take longer owing to greater illness burden and disabilities that slow the process.15 Preventive care involving disrobing (eg, Pap smears or breast and rectal examinations) is less likely to happen.70,71
Discussion of diagnosis and treatment involves exchange of illness-related information, confirmation of patient understanding,35 complex decision making, and promotion of behavior change.5,14 Each of these tasks may take longer because of differences in language,26,27 health literacy,24,25 health beliefs, culture,72 and levels of trust.65,73 Participatory decision making may seem unfamiliar to historically marginalized patients.74 In addition, primary care physicians frequently provide time-consuming mental health counseling to socially disadvantaged patients who do not have access to or are suspicious of psychiatrists or psychologists.75 Addressing barriers to specialty referral and adherence takes time.38,39
Closure of the visit—summarizing the diagnosis, treatment plan, and follow-up instructions—takes longer when communication barriers are present. Lengthening visits can help; longer visits are associated with increased empowerment among socially disadvantaged patients.76
There has been little systematic study of the effects of 15-minute visits on care for socially disadvantaged patients. However, time-pressured visits contribute to competing demands, clinical inertia, unconscious physician bias, and physician-centered communication.77- 79 Each of these likely contributes to disparities in care. Shorter visits are associated with diminished quality,80 and discussions of prevention and psychosocial issues suffer.81 Yet, socially disadvantaged patients receive shorter, not longer, visits30,82 and fewer visits per year.7
Clinical inertia refers to the failure to implement appropriate clinical action in the context of inadequate chronic disease control.83,84 Clinical inertia is exacerbated by multiple patient demands and time pressures85 and by physician suspicion of poor adherence.86,87 It takes less time to “wait and watch” than to implement a change in treatment plan.
Unconscious physician stereotypes affect care.31,88,89 Unconscious bias often emerges during periods of stress and time pressure.79 Physicians, challenged to address the complex needs of patients during a few minutes, more readily simplify these mental tasks by resorting to stereotypical thinking. Busy physicians may attend to data that conform to preconceived notions, such as nonadherence,31 on the basis of group membership and ignore disconfirming data. In addition, communication with socially disadvantaged patients may result in misinterpretations, even when both parties speak the same language.90 These misinterpretations are likely to result in lack of agreement about the illness, its treatment, and the patient's role in care.69 When decision making is rushed, clinical judgment relies increasingly on heuristics, cognitive short-cuts, that often fail to account for individual needs.91
Patient-centered communication mitigates some of the effects of social disadvantage on care.92 However, patient-centered behaviors, such as asking patients about their own beliefs, engaging patients in collaborative decision making, identifying adherence barriers, confirming patients' understanding, and using interpreters, take more time.26 Perhaps owing to time pressure, physicians engage in less, not more, patient-centered communication with socially disadvantaged patients.93
The potential consequences of 15-minute visits on socially disadvantaged patients include disparities in patient understanding and satisfaction, low adherence, and suboptimal preventive and chronic disease care.94- 100 Socially disadvantaged patients experience more adverse outcomes (eg, preventable hospitalizations and deaths),101,102 and physicians caring for them experience higher burnout.103,104
These disparities may be avoidable. Findings from randomized trials show that team-based, intensive interventions improve health care quality among socially disadvantaged patients and reduce health care disparities across a range of conditions.41 Multifaceted, nurse-led programs and culturally sensitive care may also be effective.42 However, most of these interventions extend beyond the scope of 15-minute physician-directed office visits. Findings, from externally funded research projects, require specific translation into clinical practice, including implementation of new care models supported by new payment systems.
There are a handful of options within current health care systems (Table 2). The most obvious are to schedule patients more frequently or for longer visits. However, health plans have increasingly shifted costs onto patients through higher copayments and reduced coverage,105 disproportionately affecting socially disadvantaged patients' ability to see physicians more frequently. In addition, many topics are best addressed in a single visit rather than spread out for a long period.106 Billing coding is based primarily on chart documentation rather than on patients' needs, including language, health literacy, cultural, or adherence barriers. Longer visits are undercoded.107
Time for paperwork, such as certification of disability or documentation of eligibility for social services, follow-up on abnormal test results, and out-of-visit medication management, is not reimbursed.10 Electronic medical records can improve documentation and increase reimbursement,108 but fewer practices serving socially disadvantaged patients have implemented them.109,110
Group visits offer a potentially viable alternative for some patients.111 These allow extended time for teaching, discussion, and sharing of experience among patients. However, most health plans do not pay for group visits, and some patients may feel uncomfortable talking in a group about their health or psychosocial concerns.112
Ultimately, improving care for socially disadvantaged patients requires more than just longer visits. It requires scrapping a care model predicated exclusively on physician-directed, visit-based care and replacing it with a new model, such as the Patient-Centered Medical Home (PCMH).
The PCMH arose from the need for a single physician or practice to assume responsibility for coordinating the care for children with special health care needs.113 The purpose of the PCMH is to provide access to primary health care teams built around patients' needs. It depends on appropriate team training and patient activation and is explicitly designed to enhance patient choice, quality, safety, and efficiency. The 7 core principles of the PCMH have been endorsed by the major primary care physician organizations, and there is growing support for it among payers and members of Congress.114 The first 6 principles represent historic primary care ideals: having a personal primary care physician, team-based care directed by a physician, whole person orientation, coordination of all facets of care, focus on quality and safety, and enhanced access to care.114 The seventh principle, payment reform, provides means for implementing these principles.114
The PCMH represents an idealized model of care for all patients,115 and many practices and organizations, including the Veterans Affairs Administration Health System,116 have already begun to implement many of its features.117 It offers particular promise for improving care for socially disadvantaged patients, as illustrated by the following description of an ideal practice.
A radically restructured primary care team might consist of 1 physician, 1 nurse practitioner (or physician assistant), a patient panel manager, and several registered nurses and medical assistants assigned a defined panel of patients. Tasks are distributed based on capability rather than traditional roles. Exploration of new symptoms and patient concerns likely occurs in-person with the physician, whereas other issues may be addressed through individual or group meetings with nurses and other health care professionals.118 Professional language interpreters are universally available and funded. Phone visits,119,120 and secure e-mail when feasible, are used to address some routine concerns and to monitor progress. A secure Web server facilitates patients' direct access to their medical records, including the ability to update health information,121 as digital technology diffuses to socially disadvantaged populations.122 More important, a member of the team, perhaps a nurse, is always available to supplement electronic communications, for example, when patients need to understand test results that are made available online. Providing patients with key information about their health along with the means to understand this information represents a critical step toward patient empowerment.123
These innovations reflect a radical redefinition of the roles of the health care team and patient. Patients are trained to provide critical health and health care updates through various modalities. Although many patients communicate electronically with the health care team from home, user-friendly computer kiosks are available in the office for patients who lack reliable Web access; these are also used for in-office demonstrations and training.124
Many traditional physician responsibilities are distributed among the health care team to ensure that the physicians' time is used wisely, for duties such as the assessment of complex problems, discussion of a new diagnosis, meeting with patients and their families, or deliberation about treatment options. A medical assistant updates medical data, reviews preventive care, and helps patients identify concerns before the physician visit.125 Routine preventive care is provided by the nurse through standing orders, allowing the physician to address more complex or unresolved concerns in greater depth.125,126 In the vignette, a certified interpreter would translate for Mrs S, and the team would quickly identify and address her suboptimal health care quality.
Following physician-patient encounters, medical assistants or nurses routinely follow-up by phone or in-person to elicit the patient's understanding of the diagnoses and treatment plans, correct misunderstandings, address barriers to care,127 and link patients to community resources such as patient navigation.128,129 In the case of Mrs S, the nurse, or perhaps a team pharmacist, would identify less expensive blood pressure medications and engage the patient with self-management groups or even community-based job training for her husband. Ideally, Mrs S would leave the visit feeling more empowered in self-management.
All abnormal laboratory test results as well as preventive and chronic disease care are tracked using electronic registries.130 Most important, all members of the care team are expected and funded to meet regularly for patient panel management, eg, to review reports, recall patients, and implement changes in treatment.131 In the case of Mrs S, the nurse would identify her nonadherence based on review of her electronic medication refill history, and the team would develop a plan for addressing it.132 Use of a team, particularly a culturally diverse one, to assess these complex issues outside of time-pressured 15-minute visits, minimizes implicit bias and facilitates deliberation of treatment options using decision-support tools and evidence-based guidelines.131
This transformation of primary care requires radical payment reform. Such reform must account for the greater health care needs of socially disadvantaged patients.133 Current fee-for-service payment, predicated on performance of a discrete procedure performed on the patient at a single point in time, is a poor fit for primary care.115,134 Exclusive fee-for-service payment is particularly detrimental for patients with complex needs who require not only longer visits but also care outside of visits or care by ancillary staff. There is emerging consensus that such payments represent a major obstacle to primary care redesign and quality improvement.135 It is less widely recognized that current payment models undermine a core dimension of health care quality—equity.
The PCMH principles suggest 4 potential sources of proposed revenue114: (1) current visit-based reimbursement, potentially expanded to include non–face-to-face patient visits; (2) payment for nonvisit care, such as care coordination, health information technology, remote clinical monitoring, and population-based management; (3) pay-for-performance, such as bonuses for improved quality; and (4) shared savings from potential reductions in health care costs.
Implementation of the PCMH for socially disadvantaged patients requires payments that recognize the actual costs of high quality care for these patients.115,133 Currently, such care is underresourced and often lower in quality.40,136
Ideally, “payments should recognize case-mix differences in the patient population being treated within the practice.”114(p775) For example, visit-based reimbursement might be based on the time spent with the patient rather than current complex coding formulas. Monthly payments per enrolled patient should be increased according to the social disadvantage of the patient population.115 This could be based on individual patient sociodemographic data, requiring notation of patients' race, ethnicity, educational level, and primary language.137 Alternatively, proxy information derived from patient addresses geocoded to US Census data can be used.138 Several European countries use the latter approach to increase payments to practices serving socially disadvantaged patients.138- 141
Pay-for-performance could be made more equitable by comparing practices serving socially disadvantaged patients with each other and by rewarding improvements in performance, rather than just achievement of benchmarks. The surest way to improve equity in pay-for-performance and to avoid the unintended consequence of worsening disparities142 is to allocate resources to practices based on patient need. Last, even basic PCMHs reduce Medicaid costs.143 These cost savings should be shared with practices.
A new model of primary health care should free physicians to attend to the most critical patient needs, for which they are ideally trained, and free them from tasks that could be performed by other members of the team. Although structural and financial changes are necessary, they are not sufficient. The health care workforce must be adequately trained to elicit and provide information effectively and empower, activate, inform, and involve patients in their care.
Physicians need training in new skills,144,145 and, most important, new roles. Physician training may partially mitigate time pressure. Training in specific communication skills can improve elicitation of patients' concerns146,147 and organization of the visit,148 while also reducing visit length. Physician training improves patient-centered communication skills,149 empathy,150 and responsiveness to patients' questions.151 Specific training in cultural competence may improve communication with socially disadvantaged populations.152
New communication skills are necessary to facilitate team-based care and to optimize care for socially disadvantaged patients.153 These skills include team leadership and management; panel management; communication within health care teams; giving feedback to coworkers; electronic communication with colleagues and with patients; longitudinal care; collaborating with off-site care managers, patient navigators, interpreters, and families; and customizing risk information for low-literacy patients (Table 3). In addition, training and guidance by an external practice enhancement assistant may be needed to facilitate practice change.172
It is especially important to train physicians and other team members to recognize, promote, and support patient participation in care, particularly among those who are socially disadvantaged. These changes represent a cultural shift from the traditional hierarchies within patient-physician relationships and among members of the health care team. These changes will not come easily and are best initiated early in training.
Socially disadvantaged patients can be empowered to take more active roles in their care.123,173 Individualized patient coaching, use of prompt lists containing commonly asked questions, and computer programs increase patient participation during visits (eg, question asking)174 and potentially improve adherence,175 symptom control,176 and chronic disease outcomes.123,177 Decision aids assist with informed decision making; they should be expanded to provide information while also encouraging patients to participate in discussions with their physicians about their care. Furthermore, although increased patient participation may improve care, it may also create tension in the patient-physician relationship178 unless physicians specifically endorse patient involvement.151 Although untested, patient activation combined with physician training in organizing the visit has the potential to improve care while also limiting visit time.148 Patient training can be effectively integrated, at multiple points in care by different team members, using various communication modalities. Improvements in technology will facilitate tailoring of training to the cultural, language, and health literacy needs of the patient.
Practice redesign requires strong physician leadership to implement new systems of care, reallocate existing tasks, and actively support new models of patient participation in care. Such reforms represent a fundamental cultural shift in the practice of primary care and cannot succeed without strong physician commitment to reform. Changes in payment models, implementation of health information technology, and training in collaborative care models represent necessary, but not sufficient, conditions for new care models. Success will ultimately depend on the willingness of physicians to champion practice redesign and quality, delegate traditional tasks to team members, and create genuine partnerships with historically disadvantaged patients.179
The mismatch between patients' needs and the time and resources available to address those needs is greatest for socially disadvantaged patients, thereby exacerbating disparities in access to, process of, and outcomes of health care. A couple of 15-minute visits per year is too little time to provide patient-centered, evidence-based, safe, high quality care for the average patient and particularly for socially disadvantaged patients. Therefore, elimination of health care disparities requires reform of primary care delivery so that care extends beyond 15-minute face-to-face visits. Work that has been the exclusive domain of physicians should include multidisciplinary teams caring for patients through multiple modalities. Such radical reform requires major changes in the structure of payment for primary care. In particular, health care resources must be allocated according to the health care needs of patients so that practices serving socially disadvantaged patients receive more, not fewer, resources. Only in this way can primary care “ensure that decisions respect the patients' wants, needs, and preferences and that patients have the education and support to make decisions and participate in care.”180(p7) However critical, payment reform alone is not enough and transformation of primary care will not come easily. Physician leadership and commitment, change in practice culture, new training programs for health care professionals and patients, and focused research are required to optimize care models for socially disadvantaged patients.
Correspondence: Kevin Fiscella, MD, MPH, Department of Family Medicine, University of Rochester School of Medicine & Dentistry, 1381 South Ave, Rochester, NY 14620 (Kevin_Fiscella@urmc.rochester.edu).
Accepted for Publication: March 30, 2008.
Author Contributions: Both authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Fiscella and Epstein. Analysis and interpretation of data: Fiscella. Drafting of the manuscript: Fiscella. Critical revision of the manuscript for important intellectual content: Fiscella and Epstein. Obtained funding: Fiscella. Administrative, technical, or material support: Epstein.
Financial Disclosure: None reported.
Funding/Support: This study was supported in part by grant U01CA116924-01 from the National Cancer Institute and grant R01 HL081066-01A2 from the National Heart, Lung, and Blood Institute.
Role of the Sponsors: The sponsors had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the manuscript.
Disclaimer: The views expressed in this paper represent solely those of the authors and in no way reflect endorsement by either funder.
Additional Contributions: Thomas Bodenheimer, MD, Rick Botelho, MD, Tom Campbell, MD, Jennifer Carroll, MD, Elizabeth Finigan, MD, Clint Koenig, MD, Gordon Moore, MD, and the anonymous reviewers provided helpful comments regarding earlier versions of this article.