The Death of the 15-Minute Visit
Why Doctors’ Offices Run Like Broken Factories
Have you ever experienced this?
You get up early to make a morning appointment with your doctor. You walk into the clinic, stand in line, and wait for the receptionist to check you in.
“9AM appointment with Dr. Smith,” the front desk confirms, as you’re given a questionnaire to fill out on a clipboard while you wait.
But as you turn to find an open seat in the waiting room, you hear the receptionist speaking to the person behind you in line:
“9AM appointment with Dr. Smith.” Wait, what?
You heard it right; that was not deja vu.
Your appointment was double-booked; someone put two appointments for the same time slot in the physician’s schedule.
When you get double-booked, it means:
1) The time dedicated to your visit has now been split in half among two patients. The doctor now needs to be completely done with your visit in seven minutes, not fifteen.
2) If a fifteen-minute appointment is actually only about seven minutes (since half the time is spent reviewing the chart and documenting the visit), then you now have about four minutes of face time with your doctor.
3) Even though you did your part, the doctor is, by mere function of the schedule, now running behind, and is guaranteed to be late for one of those two appointments at 9AM.
4) If the doctor decides to spend the “full” fifteen minutes with each patient, they will now be late for all other patients that morning.
**All of this assumes that every concern the doctor sees that day will be routine, non-emergent, and without interruption. It also assumes that for each patient, there will be only one concern.
Does this strike you as bizarre? How does this even happen, anyway?
Usually, it means an administrator was betting on one patient (either you or the person behind you in line) not showing up for that fifteen-minute appointment. In a world where doctors get paid by insurance companies for billable encounters, the incentive is to overfill the schedule.
What’s worse, insurance companies place large administrative burdens on family medicine offices, and so the only way to handle all of the extra paperwork is to hire billing and coding staff, as well as practice managers and administrators to oversee the business. This increases the overhead of the office, which in many cases swells to nearly 65%. As a result, physicians are pressured to run through patients and overbook the schedule in order to keep the lights on.
So what’s the big deal? Patients are still seeing doctors, right?
Yes, and no.
The traditional, fee-for-service clinic, as we know, focuses on filling slots in a schedule. Some of these slots are reserved for “same-day” concerns. However, these slots are so few, and book so quickly, that patients calling the office looking for a “same-day” appointment are often actually scheduled to be seen about two weeks later. When the barrier to seeing your doctor is so insurmountable, and the experience while you’re there so underwhelming, many would rather wait to see if they get sicker than spend a day of missed work in a waiting room. This increases the likelihood of an expensive urgent care visit later with doctors who don’t know you or your history. Patients are seeing doctors, yes, but not their doctors.
In addition, physicians are forced to grapple with constantly compromising their standards in a system that doesn’t let them practice medicine the way they were trained. All throughout medical school, they are taught to build trust with patients while getting to the root of the problem, and even swear an oath to do so. But in the standard office visit, that ideal becomes largely unattainable. Doctors feel as if they are simply rushing to move widgets on the conveyor belt of health care. Administrators, armed with spreadsheets, admonish doctors for their “inefficiency” should they choose to halt that conveyor belt and spend more time in the exam room. Doctors may have used that time to comfort a patient with depression or a recent cancer diagnosis, but all the spreadsheet shows is a “defective” physician employee.
For doctors in this system, every day becomes a gut-wrenching choice between, on the one hand, taking time with patients but constantly running behind, or, on the other hand, simply following the schedule as written, and connecting with no one. In response, doctors are leaving medicine because they would rather quit than do a bad job. They understandably refuse to stomach the cognitive dissonance of knowing what good care is and then being repeatedly pressured to compromise on that ideal.
We know that patients are not all alike. Life does not fit neatly into a fifteen-minute time block. Asking the nurse to coach the patient into having only one concern per visit does not constitute good care.
The expectation to repeatedly hurry through an over-scheduled day and merely hope that tomorrow will somehow be different, without actually instituting systemic change, is perhaps the greatest example of widespread delusional thinking that exists in medicine. But it is, unfortunately, the status quo, and reflects a much larger institutional problem: that doctors’ offices are run like broken factories. We cannot expect a different outcome without first changing the process.
So how do we get out of this mess?
We need to create conditions that that are conducive to long-term doctor-patient relationships. That means no more stuffed waiting rooms, five-minute time slots, or mandatory one-problem appointments. As doctors, it’s our responsibility to stand up for our patients. We can do better, and direct primary care (DPC) is answering the call.
DPC is personal. When there’s no bulky, insurance-mandated note to fill out and no double-booking allowed, doctors can design a schedule around reality. This means the fifteen-minute visit is a thing of the past; when you have a concern, your doctor is on-time, 100% present, and can even spend an hour with you if needed.
DPC is accessible. The truth is, many things doctors treat in the current health care system don’t need an in-person visit every time. They just need a doctor who is accessible. No more complicated phone call trees and “dial this extension” nonsense. You get our cellphone and email, and we’re there when you need us. We intentionally make space for true same-day and next-day visits, too.
DPC is lean. Using a membership model for primary care means doctors have no paperwork from insurance companies, and thus no fleet of staff required to handle it. This means DPCs can start small in the local community, rather than needing to be part of a larger, fee-for-service hospital system. We’re seeing this local, startup trend with DPC practices all over the country.
The DPC movement is growing nationally because it realigns the goals of medicine toward serving the needs of the patient. Doctors finally get to practice medicine the right way, and patients are finally getting treated with respect. When primary care gets redesigned so doctors and patients can connect with each other, you get better care.