Time is of the essence.

Three articles are published in this issue that may lead us, by different paths, to the heart of a successful primary care practice in today's health care environment. In the first article, Fairchild et al. provide data to refute a practice by health plans that excludes academic physicians who practice part time from their networks due to concerns about patient access and continuity of care.1 In “Managed Care, Professional Autonomy, and Income: Effects on Physician Career Satisfaction,” Stoddard et al. aim to pinpoint the reasons why contemporary practicing physicians are so demoralized with managed care.2 Finally, Federman et al.3 report to us why patients leave their primary care physicians in “Intention to Discontinue Care among Primary Care Patients: Influence of Physician Behavior and Process of Care.” While these studies were performed for different purposes, with different methods, and in different populations, their results simultaneously take us to the very core of medicine, our time with patients. In the two-year retrospective cohort study by Fairchild et al., academic physicians with part-time practices were able to see more patients per hour than their colleagues who had full-time clinical practices. The study physicians were contracted by 1 globally capitated HMO plan to practice in the clinical sites of 2 teaching hospitals. The study compared physicians who practiced less than 20 hours per week to their colleagues who practiced more than 20 hours per week using 4 outcomes: patient satisfaction, preventive care, resource utilization, and productivity, measured by work units/bookable clinical hour. Half of the 132 physicians in the study were classified as part-time clinicians; however, most worked full-time (all but 9) by combining their practices with academic, teaching, or research activities. Data for all 4 outcomes were available for only the 57 physicians at 1 of the teaching hospitals, 21 of whom practiced part time. The part-time clinicians produced more work units per bookable hour than the full-time clinicians, while both groups performed similarly on the other 3 outcome measures. These results suggest that the academic physicians who practiced part time were more efficient during office visits than physicians with full-time clinical practices. Stoddard et al. found that managed care diminished physician career satisfaction through negative influences on professional autonomy, in particular by not allowing adequate time with patients during an office visit. This cross-sectional telephone survey of a nationally representative sample of 12,385 physicians had a response rate of 65%. Career satisfaction, physician compensation, and 6 aspects of professional autonomy were also measured. The primary care physicians sampled in the study were demoralized; only 37% of General Internists were very satisfied with their career, compared to 43% of family physicians and 49% of pediatricians. Physicians in academic settings reported higher levels of career satisfaction than physicians in other practice settings. When analyzed separately, both income level relative to peers and participation in managed care were strongly associated with career satisfaction in the expected directions. However, the negative relation between managed care and career satisfaction appeared to be mediated through its effects on professional autonomy, not income. Among the aspects of professional autonomy, an inverse dose-response relationship was noted only for time spent with patients during office visits. As managed care participation increased, these results suggest that physicians more often felt pressured for time during their office visits. The third paper found that duration and quality of the doctor-patient encounter are important to avoid patient dissatisfaction. From the results of a telephone survey of 160 patients in a managed care plan who intended to leave their academic primary care practice in Boston, Federman et al. discovered 3 important points relating to the doctor-patient relationship. Patients who were dissatisfied with their visit duration were 3 times as likely to leave the practice as those who were satisfied with the visit duration. Patients who felt that the physician did not listen to what they had to say were 9 times as likely to leave the practice as were patients who felt their physician listened. Patients who were prescribed medications without an explanation were 5 times as likely to leave the practice as were those patients who reported receiving an explanation. Patients in this study were sensitive to the time pressure felt by their physicians and to their poor communication skills. While no article mentioned a specific quantity of time, time with patients was a central theme in all 3 of these articles. The time a physician spends with patients is key to career satisfaction, patient satisfaction, and productivity.4 As actual time with patients decreases, physicians tend to avoid psychosocial concerns and patient participation, spend less time on prevention and patient education, and increase their use of prescriptions and specialty referrals.5“Quality time with patients” lies in patient-centered interviewing skills: a physician actively listens to the patient to determine the true reasons for the visit, responds empathetically to the patient's concerns, and partners with the patient regarding care. Such skills are essential for the “connection” of patient and physician and for a meaningful therapeutic relationship.6 Accurate diagnoses and fulfillment of patients and physicians are the result. Patient-centered interviewing has also been shown to be more time-efficient than doctor-centered interviewing and better for health care outcomes, resource utilization, and risk of malpractice claims.4 Stoddard et al.'s report poignantly indicates that managed care, through time pressure, invades the doctor-patient relationship. Federman et al.'s work hints that poor doctor-patient relationships in a managed care setting are due to time pressure and a physician's inability to listen to or educate the patient during the interview. It seems that a physician's ability to engage the patient without distraction from other activities is an important determinant in the quality of an encounter with a patient. True access means being psychologically available to conduct interviews that center on the physical, social, and psychological needs of each patient. Time pressure felt by physicians in managed care settings may impair a physician's ability to be “all there” for the patient. Linzer et al. have shown time pressure to be related to lower levels of physician career satisfaction, especially among physicians practicing in HMO settings.7 Through its effect on the doctor-patient relationship, time pressure may diminish the very outcomes that health plans strive to achieve: high quality of care, access, cost-effective resource utilization, and patient satisfaction. If time pressure during the office visit is so important, how were the part-time clinicians in the Fairchild et al. study able to see more patients per hour than their full-time colleagues and still maintain patient satisfaction? One explanation may be that these part-time academic clinicians experienced less time pressure and hence were more accessible to their patients during the interview. Perhaps they felt less time pressure because they had a better balance of career activities. True part-time physicians who balance work activities with other responsibilities outside of medicine have reported increased work control, greater satisfaction with personal time, administration and patient care issues, and decreased work stress compared to full-time physicians (J.E. McMurray, August 2001, unpublished data). One of the few studies to evaluate patient and physician satisfaction simultaneously found that patients of physicians who worked part time were more satisfied with their care than were the patients of physicians who worked full time.8 The work of Fairchild et al. and others9 has shown that the quality of care of part-time physicians has not suffered. On all the important counts, part-time clinical practice is a more successful way than full-time practice to deliver high-quality patient care and to balance clinical responsibilities with other lifetime interests and responsibilities. Stoddard et al.'s results that academic physicians experience increased career satisfaction reinforce this. Health care delivery is frequently adjusted in response to changes in patient satisfaction levels. The needs of patients and physicians are measured using patient and physician satisfaction surveys. To maximize the doctor-patient equation, similar measurements and adjustments should be made to address the physician side of the formula. Interventions to decrease the time pressure during office visits may increase both patient and physician satisfaction. Competent supportive staff in clinical settings can relieve time pressure from administrative tasks in managed care settings. Education to improve physicians' interviewing skills may help with time management during the patient visit. Flexible scheduling can allow visit time to be adjusted to the needs and complexity of each patient. Part-time work and clinical practices also appear to improve both sides of the equation. We need to move toward a profession in which part-time work is embraced not only because it is important for the physician and his or her family and career, but also because of what this balance brings to the patient and health care as a whole. Time is of the essence. —