A recent BMJ study highlighted the remarkable degree of international variation in how much time GPs spend with their patients.
In Pakistan, a patient with a laceration would barely have time to explain how it occurred, let alone have it sewn up.
Whereas in Scandinavia, by the time the consultation ends, the wound has already healed by secondary intention.
Of the 67 countries studied, Australia ranks pretty much where you would want it – our 15 minute slots put us in the top quarter. Generous enough for a country that can afford it, without being inefficient.
Half of the world’s population—predictably, the poorer half—spend less than five minutes with their primary care doctor.
A couple of minutes is all you get in Nepal or China, regardless of how long it took you to travel to the surgery in the first place. I suspect there’s not much chit chat about the family.
Reading about consultations long and short made me think of the book ‘Thinking fast and slow’. Its author, Daniel Kahneman, won a Nobel Prize in Economics, so presumably he can think pretty fast when he has to.
I taught some of the book’s concepts from the podium at GP17 last month, during a workshop called ‘The one-minute diagnosis? Think again!’
Our cutesy title was designed to highlight that, although pattern recognition gets quicker with experience, we risk falling into cognitive traps if we take too many shortcuts.
Think again, indeed.
Little did I realise that in Bangladesh, GPs mainly have to think again about their one-minute diagnosis because they only have 48 seconds for the entire consultation.
Yes, you read that right. If it takes you sixty seconds to announce your diagnosis in Dhaka, by then you’re telling the wrong patient.
I have little to say about this lightning-speed medicine except that, no matter how good you are, the health outcomes will be rubbish.
In a war zone or bus crash, 48 seconds might be enough for an alive-or-dead triage, but at some point in primary care, you’re going to have to start dividing all those time-consuming ‘alive’ patients into more nuanced categories.
That brings me back to Kahneman’s fast-slow dichotomy in our thinking patterns. Fast thinking is automatic, intuitive and easy; slow thinking is deliberate and methodical.
Every GPs loves a catch-up consultation involving simple patterns; ‘This eczema flared up when I ran out of cream.’ Bingo.
But a single utterance can wrench us into slow-mode: ‘…except my rash seems weird today, and I fainted twice this morning.’
An experienced GP will switch seamlessly between modes…but only if time allows. The problem with consultations lasting just a few minutes is that everything is corralled into fast thinking.
One quick symptom description, one ‘probability’ diagnosis, and a one-size fits-all treatment.
Countries whose doctors have to see 90 patients a day no doubt consider this better than many patients missing out altogether, and possibly that is true.
But the error rate must be enormous, and much of the treatment dished out would be so generic as to be useless or, not infrequently, harmful.
I am mighty glad I work in a system that caters for a bit of slow thinking. Some days, it takes me a full 48 seconds to remember where I left my pen.
Kahneman would be proud.
drjustincoleman 
Reblogged this on Dr Thinus' musings and commented:
I started my career as a GP in Clinics where we would sometimes end up seeing 100+ patients a day. Now, 20 odd years later, I realise how bad that medicine was.
Reality of course being that in some situations bad medicine was better than no medicine at all
LikeLike
Amazing, Thinus – I simply couldn’t cope with that throughput, although perhaps if forced to I’d get somewhat better at it. So many of the things I currently spend my effort on in primary care would have to go out the window.
I guess super-fast throughput medicine is better than nothing, as long as you have a bunch of support staff doing the actual grunge work – the doctor acts more as a consultant to the other workers, rather than the GP consultation being the instrument itself.
LikeLike
If only Justin. I could regale you with tales that would horrify you. And the support was usually a receptionist, no more. And typically you dispensed meds as well.
But it was seriously better than the alternative available in the public system. No Medicare over there
LikeLike
Reblogged this on Genevieve's anthology and commented:
If I could change one thing about working clinically as a GP, it would be time pressure. I find seeing patients every 15 minutes a struggle, especially when instead of “catch up” slots there are “fit in” slots. I cannot imagine being able to feel good about my job if I only had a couple of minutes, or less, with patients. I know the environments and expectations are very different, but I’m not the high throughput type. I like taking my time… https://www.youtube.com/watch?v=zF5gcEQVxL4
LikeLike
I’m a time-taker too, Genevieve. Even when I owned my own practice I was never overly fast.
LikeLike
Interesting discussion at Harvard with an MBA recently – we make our judgements in nanoseconds – every time we are even looking at a patient in the waiting room, already we are gathering socioeconomic information and judging the look on their face. The trick is once you think you’ve made up your mind, are you actively challenging the clinical reasoning by asking ‘what else could it be’/is there anything I could have missed.
LikeLike
Reblogged this on FromSunKissedHands.
LikeLike
With those ridiculously short consultation times, are the patients in a communal area and the doctors move between patients rather than having each patient walking to your consult room? It seems like it’s on the days you run behind that you will invariably have a very slooooow walker and you feel, if they were having 1-minute consults, by the time they arrive, you might be seeing the 5th patient after them…
LikeLike
I don’t believe a true 48 sec consult exists if you consider yourself as a doctor. I don’t trust that study. There is some lack of understanding the way different health care system works. It takes a minute to write a script or patient to be allowed to come to sit in consulting room.
LikeLike
GP’s with ultra-short consults must have a team of nurses to delegate the actual treatment or the data sources were wrong. The Australian data was praised for quality & consistency and suggested as a possible gold standard for length of consult data collection. Please note: the BEACH program was the data source for Australia but the program was unable to attract enough funding in 2016. The BEACH program was forced to stop the continuous data collection late April 2016 and the office was closed later that year. The collected data are still available for reports but it’s a shame that such a reliable data source of general practice activity in Australia has been lost.
LikeLike