A requiem for the 15-minute appointment slot

The 15 minute appointment slot is dead.  To borrow from Monty Python, it is not resting, stunned or pining for the fjords, but definitely deceased, stone dead, is no more, has ceased to be, expired and gone to meet 'is maker, a stiff, bereft of life, run down the curtain and joined the bleedin' choir invisible.

In order to have more time to listen to and collaborate with patients, I decided to modify my scheduling template for office visits, eliminating 15 minute slots. I was promptly asked by a manager why I needed more than 15 minutes for simple acute problems like “?sinusitis” .

A ‘simple acute’ visit where the patient is concerned about sinusitis is an excellent example of why the 15 minute visit is no longer reasonable. When I started in practice (about 35 years ago) this standardized 15 minute visit involved the following: 

  • The nurse did VS, jotting them down in the paper chart.
  • I took a focused history of the current symptoms and did a brief exam.
  • I either told the patient they had a bacterial sinus infection and wrote an antibiotic prescription or that they had a virus and suggested otc antihistamine or decongestions, liquids, patience and time.
  • I checked a box on a a billing sheet for my charge.
  • I spent less than a minute to dictate a note.

These tasks comfortably fit into the 15 minute container that was the standard more than 3 decades ago. That world is but a distant and fuzzy memory, now long gone. The realities of both medical science and of medical practice have changed, and the allotted OV time needs to change as well. Here is how a typical "? sinusitis" visit works now:

  • The nurse rooms the patient, requires 2 identifiers, has to open the EHR, obtain and type in VS, review and update the medication list (medication reconciliation is required at each visit), perhaps do some required protocols (screening for fall risk, for depression, for immunization status).
  • The clinician has to log into Centricity (our EHR).
  • The clinician has to review and correct medication reconciliation, and sometimes follow-up on yellow button protocols. (For example, at risk for falls will suddenly appear at the top of the problem list, the nurse does not inform me so I have to look through every note for things added by the nurses in order to remove, correct or address them.)
  • Fix the problem, medication and allergy lists. (Yes, it is mandated that the clinician review and update the lists at every patient contact. I do this consistently, and it takes time.) Most patients will have at least one error or outdated problem or medication, or an uncoded allergy. Some have complicated lists with many errors. I saw a chart this week with hypersomnia entered 3 times, migraine entered twice and chronic headache entered twice, as well as 2 uncoded meds on the allergy list.
  • Pursing smoking status and cessation advice (part of a sinusitis evaluation) are no longer a clinical task with 5 seconds documentation in a dictation, but requires multiple clicks to navigate to a specific page, doing several clicks on that page, and then navigating back.
  • Instead of 30-60  seconds to dictate a note, at least 3-4 minutes is spent navigating Centricity and typing. Since I am giving patients a copy of their note, this has to be accomplished during the visit, not on my time at home at night. In addition, much of what I am required to document in the note is not for medical care, but for billing and quality audit.
  • Instead of simply treating with an antibiotic, the majority of patients need education about viral versus bacterial illnesses, sinus congestion with URI and allergy, the natural history of the illness, and discussion of the very limited role (and risks) of antibiotics, and the other slower but safer treatment options (mucinex, liquids, decongestants, steroid nasal spray, steaming sinuses,sinus wash). 
  • Sinusitis must be added to the problem list with additional clicks to make sure it has a stop date.
  • Creating the prescription from a drop down for a common medication is faster than writing a prescription (if neither the dose nor directions need to be adjusted) but now I also have to ask about printing it or sending it electronically, then verify the pharmacy, often changing the selected pharmacy to the one on the patient's way home.
  • Checking that the patient understands and agrees with the treatment plan (e.g, review or teach back) and has no questions or concerns, and then typing the treatment plan and patient instructions so it can be printed and given to the patient.
  • Navigating to the electronic orders, picking the charge, linking it to the diagnosis, signing the order, then navigating back and signing the visit.

It is not reasonable to attempt this in 15 minutes. (Though there are certainly times where a 15 minute appointment is appropriate, but they are rare.) And this assumes, of course, that the patient is too polite (or we are too rushed) to ask questions or mention that they have another concern. 

No one would think of putting a 1977 transmission, brakes or engine into a 2014 automobile. For the same reasons, I cannot approach the care of patients with a 1977 mind set and time frame. 



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