Balancing Efficiency and Caring: Addressing More than One Issue in a Visit

An established patient makes an appointment with her primary care provider to evaluate progressive shoulder pain, not getting better in spite of taking ibuprofen three times a day.  The next available appointment was 1 month away with a new clinician working at the office.  The patient accepts that appointment.  By the time she is seen, she is starting to also have significant abdominal pain and weight loss.

When she arrives at the appointment, the medical assistant asks her why she is there, and she says she made the appointment for shoulder pain, but she now also is worried about the abdominal pain and weight loss.  The doctor comes in and tells the patient that he will only address one problem for the visit, asking the patient to choose the problem.  The doctor says that he has a policy of only addressing one acute problem at a time.  The patient decides on to have the shoulder pain addressed, the physician diagnoses probable rotator cuff injury and prescribes physical therapy, telling her to continue taking the ibuprofen.  The patient is advised to make a return appointment to have the abdominal pain addressed.  She is given an appointment 6 weeks into the future.

The patient calls Partnership to complain and requests re-assignment to a new primary care provider.  The case is referred for investigation as a potential quality of care issue to PHC’s peer review process.

Comments on limiting a visit to one complaint:

In this particular case, the “policy” of only addressing one problem clearly led to a significant quality of care issue (missed diagnosis of NSAID-induced gastritis or peptic ulcer disease), in other cases we have observed from patient complaints, this “policy” may not harm a patient medically, but nonetheless represents a very non-patient-centric approach to patient care, resulting in what we characterize as a quality of service issue.

As clinicians, we have a duty not just to efficiency (keeping our schedule moving along), but to provide excellent quality of care, and to demonstrate respect and caring for these patients.  Experienced clinicians know this and have developed mechanisms for maximizing both efficiency and caring/respect/excellent outcomes.

Approach to the patient with multiple complaints:

The vast majority of physicians and health centers in our network do an excellent job of balancing efficiency and caring.  In a recent conversation about this topic with clinician leaders from throughout our 14 counties the following best practices emerged:

  1. Agenda Setting. Develop a process for jointly setting an agenda for the visit.  This may include a reminder of the length of the appointment, listing all issues that the patient would like to address, and then a brief review of these at the beginning of the visit, to jointly decide which complaints are the highest priority and which can be safely deferred until the next visit.
  2. Develop systems to maximize the continuity between the clinician and their team with their assigned patients.  Continuity of care improves the efficiency of the acute visit as well as follow up visits.  PHC’s performance improvement team has worked with consultants to successfully help several PHC area practices improve continuity and reduce waiting time for appointments.  For more information, see http://www.tantauassociates.com/ (consultant with expertise in this area) or http://www.aafp.org/fpm/2013/0900/p12.html (link to articles and written resources).
  3. Quick Follow Up. For patients with more complaints than can be addressed in a visit, schedule a follow-up visit to address unresolved issues as timely as possible (or appropriate), with instructions on what would constitute emergency escalation of symptoms.
  4. Regular appointments. For complex patients with many medical issues, schedule routine appointments at an interval that allows the clinician to address both the chronic diseases and new acute issues on a timely basis.  This may be every 2 to 12 weeks, depending on the patient.
  5. Adequate staffing. Ensure sufficient clinician staffing to meet the needs of your assigned patients.  If you are having challenges meeting the needs of your assigned patients due to clinician illness or attrition, reach out to the PHC Provider Relations department to let us know; there are several options to help balance supply and demand in cases like this, but we need to know about them!
  6. Lastly, and perhaps most importantly, experienced clinicians should mentor new clinicians on how to address multiple issues effectively.

If someone in your office is allowing patients to only bring up one issue per visit, please review these best practices with them.  When PHC becomes aware of such complaints, we will forward them to the Medical Director or the office manager of the practice/health center to be addressed.  PHC Regional Medical Directors or Quality Improvement staff can be resources for smaller practices if needed.

A key frame of mind we expect from our hardworking and dedicated clinician network:  PHC members may have limited options for open practices for primary care, but this does not excuse poor quality of service.  We expect our entire clinician network to provide high quality of care, high quality of service and practice efficiency.

Robert Moore, M.D., Chief Medical Officer

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