I recently attended a lunchtime session on the Choosing Wisely initiative. This public and professional awareness endeavor attempts to educate the public and health care providers about procedures that do not benefit patients and that may ultimately cause harm. It was an interesting educational session and while most of the content was not new to me, one of the statements by the expert who presented resonated with me.
She talked about the consequences of unnecessary testing on patients in the oncology context and how so many of our patients spend many hours sitting in waiting rooms, waiting for blood tests that do not change management, or waiting to be seen to be reassured that everything is fine, except when it isn’t. Every day I walk past the waiting room of the various clinics where I work and briefly glance at the patients and their family member who sit patiently, waiting to be seen. Many of them appear anxious, as we know they are, because they are waiting to hear the results of the tests or imaging studies that were done this morning or yesterday or last week. Those results often make the difference for them between hope and despair. And so they wait…
The presenter at the lunch time session talked about how this waiting is often a waste of time for everyone involved in the care of these patients. There is wasted time for the lab technician who may struggle to obtain a blood sample, for the technician who sets up the patient for a scan, and then for the health care provider who has to relay the results of the unnecessary test. But mostly the time wasted is for the patient who has so many better things to do with their limited time.
Time is precious to all of us, especially when time is limited but also because there never seems to be enough of it. Time seems to pass so quickly, especially as we grow older. How much more quickly does it pass for someone who knows that they have a life-threatening illness, even if they are diagnosed at an early stage of the disease and have had successful treatment? All our patients wait for a recurrence, no matter how positive we are in assessing their prognosis. They fear the recurrence of their disease and it is this fear that makes the waiting for test results so all encompassing.
I’ve been thinking about that a lot. I try to see my patients at their allotted time. This means that I book patients according to their need with their first appointment always for an hour because I don’t want to get into the cascade of running late if someone needs more time with me. I start to wrap up the appointment at the 50-minute mark to allow for those final hand-on-the-doorknob questions that frequently arise. Of course I am privileged in being able to allot that much time to each patient. I don’t have managers standing behind me, insisting that I have to see this many patients in that much time. I never double-book patients and I certainly have no pressure to see X amount of patients per hour or per day. I also don’t supervise trainees who need more time to take a patient history or review the patient’s chart. I am a one-woman show and despite the pressure I feel when I have to take a day or so off when ill or when I go away, I also know that the patients I see are not acutely ill and have usually experienced their sexual difficulties for months if not years before asking for or agreeing to a referral to me. The challenges for my oncology colleagues who work with high acuity patients is obviously that much more of an issue.
But these same colleagues are often seeing patients for many years past their treatment where they can quite easily and more effectively be seen by their primary care provider. Someone who had a radical prostatectomy 10 years ago for an organ-confined low-risk prostate cancer does not need to be seen by a specialist to be told that his PSA continues to be fine. That 5-minute appointment, repeated multiple times during the day with similar patients, will add up to more patients early in their diagnostic or treatment phase being seen for longer and/or in a more timely manner. I know that some patients appreciate seeing the specialist who treated them and likewise, seeing a patient with a good outcome for a brief visit is satisfying and a welcome break from the more detailed and challenging newly diagnosed patient.
Time is so important to all of us and, when wasted, is not something that can be recouped. Let’s all try to be more mindful of respecting the time of our patients, who surely have more important things to do than sit on the hard chairs in waiting or examination rooms. It’s about being respectful in so many ways.
Jess Franklin Armor, MD
Nov, 09 2018 9:03 PM
Having been in practice for 15 years, I have a fairly large number of patients who had early stage disease (breast cancer, for example) who still are coming back for annual visits well past 5 years out, despite literature showing that such visits to a specialist are unnecessary, as long as their primary care physician does a breast exam, asks a few pertinent questions, does a physical, and gets annual breast imaging as indicated. Similar for stage II or III colon cancer patients that are 10+ years out now. There are a few patients that are happy to "graduate" from the oncologist office, but many see us as their "life preserver." It is hard to convince someone that coming back to see us once a year will not keep their cancer from recurring. I've tried the survivorship thing in our office, but patients don't seem to absorb the information--and that just wasted more time for me, and for the patients and staff in the office. The enlarging panel of survivors makes it very difficult to schedule newly diagnosed patients, and keeps me up late each night plugging away on the EMR. Is there any good way to (nicely) convince people that it is OK to not have to see me any longer? Sure, I'm honored, but as you say, it's a waste of everyone's time (and the patient/insurance company/Medicare/tax-payers' money) for many of cancer survivors to keep returning unnecessarily. Sure, some of my older partners will point out that people develop 2nd or 3rd malignancies, but how does seeing us every revolution around the Sun prevent such? It doesn't.
One problem is that primary care does not want to take these patients back into their fold, even when I issue recommendations for followup, based on NCCN guidelines, after they're out 5+ years and off all therapies for their cancer. Many times, they send them right back for a "history of breast cancer"....that may be over a decade ago.
Yes, many visits are social visits, some are them griping about their care elsewhere, but regardless, it is a waste of resources for everyone.