American College of Physicians: Internal Medicine — Doctors for Adults ®

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A New Year's resolution: learn how to savor time

From the December ACP Observer, copyright © 2005 by the American College of Physicians.

By C. Anderson Hedberg, FACP

Time is a brisk wind, for each hour it brings something new .... but who can understand and measure its sharp breath, its mystery and its design? Therefore the physician must not think himself too important; for over him there is a master—time—which plays with him as the cat with the mouse.
—Paracelsus (1493-1541)

As December arrives, yet another year has rushed by, giving all of us an opportunity to look back on the one that's ending and toward the next. As the holiday season approaches, many of us will have a chance to enjoy a brief respite from busy work routines to spend time with our families. This makes the coming days an excellent time to contemplate our lives as physicians, spouses and parents.

Like Paracelsus before us, today's physicians have a keen interest in the subject of time. The feeling of not having enough of this precious commodity is familiar to us all. Pressure on our time in the office continually grows due to an ever-expanding list of administrative, regulatory and business chores.

At the same time, our patients visit us with new requests, lists of questions and concerns, and high expectations. We conduct a careful history and examination, educate them about diagnostic and therapeutic options, and involve them in decision-making. We offer screening, prevention and health maintenance—along with the compassion and humanism that breeds trust.

While all this clearly takes time, no one wants to wait. I have always thought that managing a day of medical practice is a high-stakes art form that is not easily understood or quickly learned, but can be gradually mastered through years of honing skills. Working as a physician requires juggling a crowded office schedule, nonstop phones, patient emergencies, urgent hospital visits and everything else that is part of modern practice.

Unfortunately, the administrators who may make our schedules—but do not practice—do not understand this. My internist father, an expert clinician and my mentor, often told me to expect a crisis every day. I never imagined how right he was.

Preserving patient relationships

The most important issue in any discussion of time is the doctor-patient relationship. Studies show that both patient and physician satisfaction are directly related to the time we spend face-to-face during office visits. Many also believe that greater satisfaction for both correlates with a higher quality of care.

Although some surveys have suggested that doctors are spending slightly more time with patients than in previous years, doctors feel under more time pressure now—probably because they have many more tasks to squeeze into a patient encounter. With reimbursement often stagnant at best, internists are trying to see more patients to keep up with rising office costs. While this may meet our financial needs, it only increases the pressure we feel.

For most of my nearly 40-year career, I allowed 45 minutes for new patient visits and 30 minutes for follow-up visits. Over the past few years, however, I have had to reduce my established patient visits to l5 minutes.

While this approach works when I'm treating routine medical problems, I often find myself rushed and falling behind with longstanding and complex patients. Needless to say, I'm flabbergasted when I hear of internists scheduled to see patients every 10 or even eight minutes! I do not believe this is really internal medicine, which should entail thoroughness, expert counseling and knowing your patients well.

As I talk to internists around the country, I consistently hear how much satisfaction they derive from their relationships with patients. Unfortunately, many external forces now work against the doctor-patient relationship. Immediate Past Regents Chair Eric B. Larson, MACP, expertly delineated these in an article in the Feb. 1, 2003, issue of the American Journal of Medicine.

Many proposals have been put forward to relieve the pressure of time in our professional lives. The ACP Practice Management Center has been working on office redesign, with the goal of providing more efficient processes that rely on electronic health records and can improve quality and safety.

The College has just received a nearly $1 million grant from the Physicians' Foundation for Health Systems Excellence to open a new Center for Practice Innovation in our Washington office to address these goals. While a strategy that incorporates electronic health records holds considerable potential, we need to make sure that any solution preserves time for the human interaction between doctor and patient.

Making time for scholarship

An equally important and enduring quality of internal medicine is our keen sense of scholarship--a lifelong pursuit. As a specialty, we are distinguished by our interest in and mastery of current concepts of pathophysiology and treatment.

Time is a critical factor in reviewing and refreshing that knowledge, whether through reading, continuing medical education or contact with clinical conditions.

While we need time to practice and learn, it is just as important to regularly spend time away from our professional activities. As a group, unfortunately, American doctors have a reputation for being addicted to work, driven by the understandable ethos that we must be available at all times. (See "Re-discovering the need for personal renewal.")

The reality is that as humans, we all have limits. Some wise minds have recently pointed out, with good supportive data, that overwork is not only personally unhealthy but also potentially dangerous for patients.

As I mentioned in last month's column, I am convinced that a group of collegial internists working flexible schedules can maintain a reasonably balanced lifestyle. That includes time for our families, friends and recreational activities.

I hope that with the holiday season and year's end approaching, you take a moment to examine your relationship to time and the complexity of your life. I would also urge you to adopt a goal now included in ACP's Mission Statement to "support healthy lives for physicians" as your own.

As Linda Hawes Clever, MACP, a longtime advocate for the healthy lives of physicians, observed in the Jan. 4, 2000, issue of Annals of Internal Medicine:

We must not allow waves of exhaustion and cynicism to wash away millennia of service, altruism, and discovery. Keeping in close touch with our values; renewing our spirits, relationships, and skills; and taking the lead in matters of science, health, and ethics have helped to preserve our profession, and ourselves.

Happy holidays and a healthy New Year for us all!

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