What Does It Take to Be a “Good” Doctor?

“I want a doctor who will take the time to tell me directly what is wrong in a way that I can understand.”

So said the patient I was seeing in the hospital, in response to my question about what qualities are found in “good” doctors. In his succinct response, he captured two characteristics that too often are missing in doctors: adequate time spent with patients and good communication skills.

I have written about how hard it is for HIV-infected patients to find a “good” doctor.¹ Here I expand the discussion to focus primarily on the issue of time. These days, most of the care needed by HIV-infected persons involves general internal medicine issues, such as hypertension, diabetes, preventive care, adult vaccinations, and “healthy” lifestyle discussions. Consequently, the question patients often ask me is “can you help me find a good internist or family doctor?” What they mean by “good” is exactly what my patient expressed to me. And while “communication skills” are harder to characterize and improve or change, the issue of adequate time spent with each patient seems much more straightforward.

In other words, why don’t more doctors spend more time with each patient?

Ask the average doctor that question, and the response invariably will elicit a tirade leveled against the EMR, insurance companies (endless forms and prior authorizations), and the requirements by hospitals and insurers for more “complete” documentation. These are all valid points, in my opinion. Nevertheless, the EMR, insurers, bureaucrats, and regulators aren’t going away anytime soon, and all doctors are struggling with the same issues. So, why are some doctors able to spend more time with patients, and how can patients find those doctors?

Let’s start by asking a simple question: what is the maximum number of clinic/office patients that an experienced HIV-treater or internist should see in an 8-hour day without rushing from patient to patient?

I have asked this question of quite a few doctors, nurse practitioners (NPs), and physician assistants (PAs) in different practice settings, from private practices in wealthy suburbs to Ryan White–funded inner-city clinics. For example, the very talented and experienced group of practitioners at Grady Health in Atlanta (caring for a primarily indigent, advanced HIV-infected population) suggested 12 to 15 per day.

Currently, I average 12 per 8-hour day, but have the capacity to see as many as 15. On the other hand, in my former location, I was expected to see 25 per 8-hour day. The difference in the quality of care I can provide in my new setting compared with my previous setting is as different as night and day. The issue is time; patients quickly pick up on it, as do colleagues and clinic staff. I am more relaxed, my documentation is better, I am less frustrated, and I am substantially less likely to overlook important details or make mistakes.

Unfortunately, reimbursement for outpatient visits is not time-based (to a large extent). Consequently, spending twice as long with each patient typically does not result in getting twice the reimbursement. In most cases, reimbursement is the same whether 20 minutes is spent per patient or 40 minutes is spent per patient. I do not mean to imply that those health care providers who are seeing 25 patients per 8-hour day are “bad” or “greedy”: indeed, often it is the organization for whom the doctors are working that mandate such packed schedules. But I do not think that I will get much disagreement from health care providers or patients that 20 minutes per clinic/office patient, in today’s medical environment, is too short to do an adequate job, let alone a good one. In fact, many organizations and hospitals are now advising doctors to spend more time with patients (inpatients as well as outpatients), since the results of patient satisfaction surveys are becoming increasingly public.

In my opinion, adequate time (defined as an amount that does not result in rushing from patient to patient, cutting patients short, looking at the clock, etc) is a necessary component of what it takes to be a “good” doctor. It may not be sufficient, but it is necessary. And for patients looking to find a “good” internist, family doctor, or HIV-treater, start by calling the doctor’s office and asking how many appointment slots the doctor has in a half-day or full-day session. If the answer is more than, say, 8 per half-day, or 15 per full-day, go somewhere else.

References:

1. MacArthur RD. Five tips on finding a good HIV physician: experience does matter. The AIDS Reader. July 21, 2014.