The Office Visit Ritual

The office visit is repeated in the clinics of millions of practitioners every day across America. In some offices 15 minutes is allotted, in others 20. Doctors who see fifty people a day must schedule about 8 minutes. If anything slows down the process, an elderly person, a talkative person, someone who needs translation or just needs to go to the bathroom the delicate mechanism is smashed as if by the fist of a storm giant. Somehow she must catch up; there are people in the waiting room getting mad and if something isn’t done the physician will face a whole day of angry patients forced to wait too long. No matter how she looks, in her head a little voice is whispering”hurry up hurry up”. Last month she did not meet her RVU target and she is facing a big salary cut.

In the first part of the visit, the caregiver stands outside the door and tries to confirm where she is on the computer schedule to make sure she clicks the right patient. Theoretically she knows him as this is not a “new patient visit”, but if the wrong computer chart is entered it can lead to catastrophic results. The dreaded “what are you talking about, I didn’t have a mammogram”or “Fill my Flexeril prescription? The only medication I take is Synthroid” will cause an icy chill in her spine. Once she is satisfied the door opens and she tries to immediately manage the interaction.

As the door opens, the patient scans her face and forms first impressions. He already has fixed beliefs about her from previous sessions. Strangely he may have already decided that she is “useless” and that he will ignore everything she says. He may be seething with anger at the medical profession in general. He may have deep-seated fears about anything that violates his personal space. He may be ashamed of his alcoholism or his sexual preferences or his obesity. Last time he promised to take his blood pressure medication but he hasn’t. Last time he said he would exercise and get a colonoscopy but there is no way he is going to do this. She reminds him of his very annoying sister who is the one who made him come in the first place. Today she just looks at the computer cradled in her arms not at him. “Looks pissed”,he thinks.

She sits down and launches into his prescriptions. He has not filled the expensive diabetes medication for months and there is no way he hasn’t run out. He insists he is taking it. The cultural tradition is that both accept this and move on. If she tries to argue with him it will waste time which is inexorably moving on like a fine flow of sand cascading down her back. He wants that Percocet from the ER refilled but she kindly refuses as it “is not in his best interest”. When he gets this news his sensory system may shut down, like lowering one of those metal screens in the front of an inner city store at night. He will signal this by grunting all subsequent answers.

She does a “review of systems” theoretically to get him to open up about any new symptoms or problems. Actually if there is a new problem she is forced by time to ask him to schedule another visit to discuss it. He would rather wrestle his mother in law in a sewer during a rainstorm than make an extra visit so he does not volunteer anything. She next performs an examination which probably does not involve getting undressed or putting on a gown. In her heart she knows this is not ideal but the clock is ticking. She launches into her assessment and orders tests including labs and X-Rays. She prints an after visit summary that generally looks like a small book and reads like “Moby Dick”.

At this point he is pointed toward the door. He never got to mention that he wanted some Viagra or that he has got up to urinate six times every night. Unless his sister makes him there is no way he will get that X-Ray.

A study concluded that 55 percent of patients dont trust or have faith in their doctor. This group follows medical advice about 15 percent of the time. The sad fact is that he has chosen a great doctor. She is well-trained and very compassionate by nature. She became a doctor to make a real change in the screwed up American Health Care system. But the office visit has enmeshed her like a spider web. As the years pass, it is the most dedicated and compassionate physicians that “burn out” and leave the office for “Quality Management” or an insurance or pharmaceutical job. Sadly I do not have the solution, but it would be a good idea to put some smart guys in a room and have them work on this.

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