One problem per visit?

What defines “one issue”?

Perhaps the slipperiest part of a one-issue-per-visit policy involves how you define “one issue.” For instance, if a patient is concerned about his right knee pain, that may be a single, distinct concern. But what about a diabetes visit? When I see these patients, I am managing their blood sugar, blood pressure, obesity, cholesterol, kidney function, foot care, and possibly smoking cessation all at once. Is this one issue, or seven?

And if a patient comes in for a complex concern such as leg swelling, should they be restricted from asking an additional simple question like, “should I be taking Vitamin D?” My point is, how you define a single issue can be subjective and difficult to apply categorically.

Doctors are small business owners

As physicians, our offices are also small businesses. We have overhead expenses. We employ staff, and we must also generate a profit so as to provide a reasonable income for ourselves, and to remunerate for our extensive years of training and expertise.

Traditionally, the most common way that doctors bill and generate revenue for their services is a “fee for service” model, in which a doctor is paid a specific amount of money for a specific type of visit or service. In Ontario, for instance, the specifics can be found in the OHIP Schedule of Benefits and Fees.

Generally speaking, fee-for-service models only allow a doctor to bill for one issue per patient per day. This means that if a patient comes in with multiple concerns (say, back pain, blood pressure, a rash, and a sore finger), the doctor will only receive payment for one of the concerns — likely $33.70 if practicing in Ontario.

From a business — and fairness — perspective, it makes little sense, for doctors to spend their time and expertise on multiple issues per visit if they are not getting paid for anything more than the first issue.

On the other hand, there are payment models that pay doctors based on a “capitated model” (flat rate per patient), like Family Health Organizations (FHO) in Ontario. This model incentivizes doctors to address multiple issues each visit because it can cost the doctor more money in overhead and administrative costs to recall a patient multiple times.

Staying on schedule

How often do we hear people complain and criticize our profession for never running on time? It is not that doctors are lazy or slow. Quite the opposite. The problem is that every single patient encounter seems to take an unexpected twist.

For instance, say a patient schedules a visit to see me for her sore back and to renew her blood pressure medication. My secretary thus books her in for a standard 20-mintue appointment. I see her and address these matters in the allotted time, but then the patient reveals she also has a skin spot, a sore throat, and that she is stressed because her husband just lost his job. If I am to take the time to properly and thoroughly discuss these other concerns, that will surely take another 15 or 20 minutes, at least. If I do so at this visit, I will be late for my next patient and rushed, which is not fair to that patient, nor the patients who are scheduled later that day.

One way to respect all of our patients’ time is to limit the number of issues that can be discussed in a single visit. In my practice, when a patient brings up extra issues for which I do not have enough time, I will sometimes advise the patient, “This concern deserves proper attention, without being rushed and glazing over it. Please return to see me for another visit so that we can focus on it properly.” I find this is well received and respectful of everyone’s interests.

Cognitive fatigue

An interesting, but less-discussed aspect of the debate is our cognitive capacity. It works like this: Imagine you are assessing a complex patient for a nebulous symptom such as dizziness, an issue that may require a great deal of mental effort to fully explore all the different possible causes. This will likely be followed by a lengthy discussion with the patient to explain the plan for investigations and next steps. And then your patient pulls out a thick brown envelope and asks if you can go over the paperwork for her disability claims related to her chronic back pain.

I think we can all relate to the feeling of unfocused mental exhaustion and indecisiveness that follows. It has a name: “cognitive fatigue” (a.k.a. “ego depletion”). After an intellectually intensive exercise, if your brain is then loaded with subsequent cognitive tasks, your mind will perform less and less effectively.

We know, too, that patients may only retain a small percentage of the advice and information they are given on a single visit. So it may not even make sense to overload a patient with multiple pieces of complex advice during a single discussion. One could make the case that it’s a potential patient safety concern for a physician to try to address too many issues within a single visit.

“It Depends”

I don’t think there is a clear-cut answer to the one-issue-per-visit question. Each visit is different. Each day is different. The first 10 patients one morning may each have five different issues, but they may be quick and easy to address. The next morning, the first few patients may each arrive with intensive single-issue presentations, such that you already feel overwhelmed and are running 40 minutes late.

It is unpredictable.

Should doctors restrict patients to just one issue per visit? I leave it to you to decide what may work for you and your practice.