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OB/GYN Editorial OCTOber 2004

Physician's Time: The Neglected Health Care Resource

Michael Harel, MD

In his famous novel Cancer Ward, Aleksandr I. Solzhenitsyn, the winner of the 1970 Nobel Prize for literature, composed an exchange by two physicians following a medical malpractice case:

Doctor A: What other way is there of dealing with us doctors? I remember once a surgeon sewed-up a swab into a patient stomach—they just forgot about it! Somewhere else they injected a physiological saline solution instead of novocaine. There was another case where they let a leg go dead inside a cast. Somebody else made a mistake about dosage [and] gave ten times the right amount. We do sometimes transfuse blood of the wrong group. We do inflict burns. What other way can they deal with us? They should pull us by the hair, like children.

Doctor B: Here's the answer! Of course doctors must carry greater responsibility, but at the same time their patient quota ought to be lowered by two or three times. Look at outpatients: nine patients an hour! Isn't it appalling! Give us a chance to talk to each patient in peace and quiet, and to think in peace and quiet as well. When it comes to operations, a surgeon should do one a day—not three.¹

Obviously, in the Soviet Union as far back as 1968 (then under a centralized noncommercial one-payer system), there were some who were able to recognize the rationing of time as a cause for the poor quality of medical care.

Similarly, James Reason, in his book Human Error, analyzes the different patterns leading to the commitment of errors and cites the works of Wreathall (1982) and Hannaman (1984) in identifying “time for thinking” as a factor in problem-solving, and plotting “the speed-accuracy trade-off” function in assessing the influence of time on the performance of various industries.²

Although it is generally recognized that increased productivity can shorten the time per unit of production for most other industries, it is also being argued that the medical industry behaves differently. In his book Cost Disease: The Arts and Other Victims, William J. Baumol, the Princeton economist, classifies health care with the group of low-productivity industries, together with the Arts and education. He claims that rationing time per patient in a basic doctor-patient encounter is like rationing time in playing a piece of music or teaching a subject in school: It cannot be done with impunity.³

The administration of health care follows well-established principles. Government carries the major burden in promoting health by, among other things, assuring the quality of air, water, sewage system, and food supply; subsidizing research; and licensing new medications and technologies. The remaining health issues are taken care of by the medical profession through its physicians. The physician brings to this endeavor his integrity, education, skills, training, capacity for critical thinking, and his time. When all things amenable to change by education or selection are kept constant, the time per patient becomes the crucial variable affecting the ultimate product.

In an optimal doctor-patient en-counter, wherever and whenever it takes place, the patient will present his complaint; a full or interval history will be taken; an examination will be conducted; a differential diagnosis will be considered; the options for further work-up or different treatment modalities will be discussed; and finally, the patient's remaining questions will be answered. The physician-patient encounter is therefore time-consuming.

Although the time per patient will vary somewhat from physician to physician and from patient to patient, each doctor surely knows his own time requirement, which, if crossed, will result in inadequate evaluation and shortcuts in one or more of the above steps.

Shortcuts do not have to be outrageous. They might involve brushing off a change in bowel habits, performing a speedy breast examination, skipping a rectal exam, not following up on a loss of height, missing the initial signs of depression, or overlooking a lab report.

An inadequate encounter will not necessarily result in mismanagement of the case or in malpractice. Most patients coming to a doctor's office are essentially healthy, have chronic or easily diagnosed problems that are routinely managed, or have quality of life issues that are not life-threatening. However, if there is a "ticking bomb" hiding in the crowd—be it an early ovarian or breast tumor, early depression or osteoporosis, or impending heart attack—it has a greater chance of being missed, and the further one deviates from his time requirement zone, the higher the probability for error.

The consequences to the individual physician might consist of frustration, loss of self-respect; burnout, early retirement, and the anguish of malpractice litigation. The consequences to a particular patient could be worse with increased morbidity and its associated loss of quality of life, time at work, and income—or increased mortality, as avoidable medical errors were estimated to kill a significant number of Americans each year.⁴

A public debate on the subject of physician time is long overdue and should not be underestimated or brushed aside. Many physicians find themselves practicing within a system of price controls determined arbitrarily by for-profit health maintenance organizations and government administrators. Such an outdated economic model, long abandoned as being unworkable by most other industries all over the globe, is being repackaged and applied to the medical industry under the banner of "Health Care Reform." The main option it provides us when costs are rising, is the increase in our daily patient load, which, beyond a certain limit, must affect time allocation.

At what point will this process begin to erode the quality of medical care is the important question—the one our politicians are inclined to avoid and postpone until they are out of office, leaving the rest of us, doctors and patients, to deal with the consequences.

It is being generally overlooked that while other industries will react to price controls by rationing their products, the medical industry will ration its time. This is the time dilemma facing the medical profession and, at the end of the day, it will be up to the individual doctor to make the choice he can best live with.

Michael Harel, MD
New York, NY

References

1. Solzhenitsyn A. Superb initiative. In: Cancer Ward. Bethel N and Burg D, trans-eds. New York, NY: Bantam Books; 1969:365-366.
2. Reason J. Assessing and reducing human error risk. In: Human Error. Cambridge, England: Cambridge University Press; 1990:224-226.
3. Baumol WJ. Health care, education, and the cost disease: a looming crisis for public choice. In: Towse R, ed. Baumol's Cost Disease: The Arts and Other Victims. Northampton, Mass: Edward Elgar Publishing; 1997:510-521.
4. Brennan TA. The Institute of Medicine report on medical errors--could it do harm? N Engl J Med. 2000;342(15): 1123-1125.

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