The last time you visited your primary health-care provider, how long did your visit take? Take a moment to consider how long your physician was with you, and the quality of their presence in the room.
“I think the fundamental task in healthcare is human understanding.”
"My primary health-care provider doesn't seem to have time for me."
I was talking about this with some friends recently. “I think my doctor spent seven minutes with me, and I was luxuriating in that seven minutes,” someone said; another friend responded, “I get so angry with my doctor. Maybe they spend more than seven minutes, but they don’t make eye contact the whole time.”
Perhaps for you, the entire office visit took an hour, much of which was spent in the waiting room … with the nurse taking your vitals … or sitting in the exam room, alone. When I spoke to primary care physicians about this, they expressed their own frustration with the length of visits, and a strong desire to be more present with their patients. If they only had seven minutes, they certainly wanted to make them count.
Primary health-care provider visits are typically only 20 minutes long
Available data from the Centers for Disease Control shows that the average primary care visit takes about 20 minutes.
The 20-minute medical visit has not been the standard forever. In fact, antihistamines and randomized controlled trials both existed before we decided that 20 minutes was sufficient time to conduct a routine medical exam. When did we invent the 20-minute medical visit? Who decided that was a good idea, and how healing are these interactions?
One important marker on the journey to 20-minute visits occurred when President George H. W. Bush signed the Omnibus Budget Reconciliation Act (OBRA) in 1989. This legislation went fully into effect as of January 1992, and was aimed at restructuring how Medicare reimbursed for medical visits and procedures. Before the 1989 OBRA was signed into law, Medicare determined physician reimbursement based on “customary, prevailing, and reasonable” fees for services. After this act went into effect, Medicare established a standardized fee schedule for physician reimbursement. The OBRA essentially created more regulation around time spent and fees charged by physicians for their services.
Reasons for the 20-minute primary health-care provider visit
Let’s unpack this a bit. Under the “customary, prevailing, and reasonable” system, some researchers were concerned that financial incentives for performing medical procedures were excessive. Essentially, under this system, physicians could charge more for procedures than they could for spending time talking with their patients, performing evaluation and care management services. People were concerned that this unevenness in cost structure would lead to unnecessary surgeries and diagnostic tests.
The “fee schedule” was an attempt to level the playing field, so that physicians were reimbursed similarly between evaluation and management services, and more complex medical procedures. One hope was that lower reimbursement for procedures, and higher reimbursement for evaluation and management services, would result in lower surgery rates. Surgery is not always the best option in a patient’s care; often the evidence base to justify invasive procedures just isn’t strong, and these procedures are costly both physically and financially to patients. While there was certainly controversy, enough lawmakers, researchers, and providers were on the same page that the fee schedule went into effect.
What Medicare’s fee schedule did was to create a three-step process for physician reimbursement. This process still exists. The first step is for a physician to describe the condition of a patient using a diagnostic code. The second step is to describe what was done to treat the patient, and how long this took, using numbers as a shortcut. Physicians do this using Current Procedural Terminology (CPT) codes, which were invented by the American Medical Association (AMA). Of note, the AMA owns the copyright for the CPT® coding system and charges a licensing fee to medical practices who use it; this system updates annually and is an ongoing source of revenue for the AMA. The AMA CPT® Editorial Panel leads the process for updating CPT® codes regularly.
The third step happens with Medicare. Medicare assigns payment to physicians based on the “resource-based relative value scale (RBRVS).” As explained by Baadh et al., 2016, this scale was developed based on a research study authorized by Congress and conducted by Harvard University and the AMA in 1988. The purpose of the study was to estimate how much work physicians contribute to the various services they render. The study’s definition of work included: the physician’s time, mental effort, judgement, technical skill, physical effort, and psychological stress. These different aspects of work, along with professional costs for physicians to run their practice, were broken down into “relative value units (RVUs).” The idea is that these units stack; more difficult and time-consuming medical tasks garner a higher number of RVUs.
Diagnostic and CPT codes get matched up with RVU values, to measure physician work and justify physician fees. Initially, AMA coding guidelines for a typical office visit for a primary care patient reportedly suggested a 15-minute consult. In the United States, the average length of an office visit has gradually increased over the past few years, and now hovers closer to the 20-minute mark.
Private insurers followed Medicare’s lead, which has created a primary care culture in which numerous brief visits are the norm. Reimbursement structure is not the only factor driving this culture. People are living longer; meanwhile, the shortage of physicians grows. After President Barack Obama signed the Affordable Care Act in 2010, access to healthcare and availability of insurance coverage arguably improved. The ratio of patients seeking care to physicians providing it is, unfortunately, skewed; physicians are working in a landscape of scarcity. There are not enough providers and there is not enough time to meet the needs of patients.
Meanwhile, physicians graduate from school with high amounts of debt, medical tools and equipment are expensive, and to keep their doors open and remain in practice, physicians need to bring in a certain amount of income each day; this equates to seeing a high number of patients. Studies conducted by the Commonwealth Fund show that on average, primary care physicians see between twenty and thirty patients per day, while across multiple developed countries job satisfaction for physicians is at an all-time low.
Our systems do not support healing interactions, here; rather, both patient and physician are set up to feel dehumanized, disempowered, and devalued.
In twenty minutes (or less), we can see and feel the cumulative effects of multiple presidencies, the legal system, academic and research institutions, and student loan and insurance companies. We also see and feel some of the effects of computer-based tech, the use of which has ballooned in medical communities since the invention of the first desktop computer in 1964, and documentation burden. With the aid of technology came widespread use of electronic medical records (EMRs). While research shows that the adoption of EMRs has not reduced the length of a physician’s visit, physicians are spending a significant amount of time documenting; in 2018, 32% of physicians reported spending twenty or more hours per week completing documentation and administrative tasks.
What this may look like in the exam room: the physician stares at their computer, ticking check boxes to create sufficient documentation to justify your visit. It feels as though they are talking to your insurance company, not to you. That stings.
What we may fail to recognize as patients is that often in these moments, physicians are hurting, too.
In a typical medical encounter, opportunities for feeling heard and understood by our doctors are diminished. It can be a difficult thing to talk about the body with sensitivity and compassion. When these conversations occur against a backdrop of scarcity and include typing, clicking, and clock-watching rather than a deep breath, open posture, and welcoming eye contact, we have a recipe for dissatisfaction and disconnection for both physician and patient. Our systems do not support healing interactions, here; rather, both patient and physician are set up to feel dehumanized, disempowered, and devalued.
What do we do about the 20-minute primary health-care provider appointment?
So what do we do? With all the different systems involved, it is natural to feel confused and hopeless. That said, there are many practical pieces of wisdom offered by physician Ronald Epstein in his book, Attending: Medicine, Mindfulness, and Humanity. Dr. Epstein freely acknowledges the difficulties we face as patients and providers as we navigate complex medical systems. He also notes that what we need in order to create a healing space isn’t necessarily more time; it is more presence. Depending on the quality of our presence in the room, perhaps seven minutes could feel luxurious.
Here are some suggestions that could help both patients and providers reclaim their sense of presence, power, and agency from the systems that challenge them, even for a few brief moments, based on Dr. Epstein's work:
1. Breathe. Take a conscious, deep breath before entering the exam room. Doing so activates your parasympathetic nervous system, which helps you relax and become more present.
2. Set an intention. Resolve to treat the person you are interacting with like a human being.
3. Slow down. If you are speaking, pause every few sentences.
4. Make friendly eye contact. Search for the other person’s gaze. You don’t have to stare into one another’s eyes, but you can use this as a check in, essentially asking nonverbally: Are you with me? Do you understand me?
5. Seek clarity. Some useful language here could be: “I just want to make sure I’m clear about _____.”
In addition to the above, outside of the medical visit: get informed about healthcare policy. Engage in advocacy efforts. Reading this article is a place to start; knowledge is power. Understanding where we’ve been helps us choose where we’re going.
As a patient, what is it like to think about stepping into your power, bringing more presence and compassion to your next visit? As a provider, what do you notice takes you out of presence with your patients?
What thoughts or suggestions do you have for improving our healthcare landscape?
Lilla Watson is an activist, academic, and artist. She states, “If you have come here to help me, you are wasting your time. But if you have come because your liberation is bound up with mine, then let us work together.” In this historical moment, healthcare providers and patients are truly all struggling; our liberation is bound up together. Let’s work to heal together, one visit at a time.
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