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.