How long should the average generalist patient visit last? While this certainly varies with the visit reason, we all understand that the visit should last long enough. Most adults require appropriate time to do a variety of tasks. I have read, but cannot find the reference, that the average visit length with an internist is currently around 21-22 minutes. As we ask our generalists to do more each visit, and hold them responsible, can patients possibly receive adequate care?

Imagine a 50 year old woman with Type II diabetes, hypertension, obesity (BMI of 31), and depression. She smokes 1 pack per day for the past 30 years. She says she cannot exercise because of knee pain. We can imagine the agendas at the visit.

First, we must address her diabetes. We review her medications. We then go through the FLECKS (my mneumonic for diabetes care). Check her feet for lesions, and for early peripheral neuropathy. Review her lipid profile (remember to treat hyperlipidemia aggressively in type II diabetes. Consider her eyes by reviewing her record to see if she has visited the opthalmologist. If we have no record then ask her who she saw - and request their consultation report. Ask her about her blood sugar control, and review her HgbA1c value. Again review her labs for evidence of early kidney disease, or check to see how much proteinuria she has on treatment - considering whether to increase her ACE inhibitor or ARB (or add one). Review her shot history - is she uptodate on her immunizations (especially pneumovax and influenza vaccine). Ask her an open ended question about diabetes complications and medication adherence. That handles her diabetes.

We then review her hypertension history, her medications, her blood pressures (especially if she checks them at home or at the fire station or at the pharmacist. Ask her about medication side effects again. Reassess her regimen and adjust as is appropriate.

Review her depression, evaluate any medications for side effects. Ask about sleep, crying, her social situation. Reassess that treatment and try to understand her satisfaction and needs with the management of this problem.

She is 50 so we need to consider prevention. Have we screened her for colon cancer? If not, we take time to discuss her options (this is not usually a quick discussion). We review her breast cancer screening and gynecologic screening history. At 50 we start to check on symptoms of impending menopause.

Now we get to the cigarette smoking. We have counseled her in the past, but we must try again. We try logic, we try emotional appeals, we try anything that we can imagine.

We discuss exercise and diet. She states that she cannot exercise because her knees hurt. This new complaint takes several minutes to assess. While one's initial thought is osteoarthritis secondary to a BMI of 31, one must be thorough - occasionally it is something else.

We finish with an open ended discussion allowing her agenda to come forth. Anything could happen at the end of the visit. We sometimes joke in teaching clinic that we hate hearing (at the end of the visit) the phrase, 'Doc, by the way'. Often that phrase does not occur until you are getting ready to leave the office.

The direct patient encounter has finished (probably 20-25 minutes if one is very efficient), but the true visit time continues. If any prescriptions have expired, or we changed medications we write new prescriptions. We order appropriate laboratory tests, and determine when to see that patient back. One must then dictate the visit. This will probably take around 5 minutes - documentation is important for the next visit, but we must dictate even more to satisfy the bureaucrats and the lawyers. Our notes are longer and include redundant information than is necessary. Nonetheless, in 2002 we must dictate a fairly complete note.

So we can assume 20 minutes with the patient (and that was very efficient), and 5 minutes after the visit dictating. But time continues. The next day or so, our laboratory data returns. We must review the results in the context of the patient. We might decide to alter her medication regimen based on her lipid profile, or change her diabetes medicines because her HgbA1c has increased. Or we find increased proteinuria and consider that regimen. Often we need to talk to the patient on the phone (another 2-3 minutes). I will assume 2 minutes on average for laboratory and test review.

If we dictate our notes, they come back soon, and we need to proof the dictation and sign it (hopefully just 1 minute). Between visits, the patient likely will call the office with an issue (add another minute to answer the question). Have you kept track? I would estimate that the true time of the visit is 30 minutes.

How many hours should a generalist work each day? How many days a week? Should physicians also have a life?

We will assume that one can see 90 such patients each week (hoping for few 'no shows'). If my time assumptions hold, that represents a 45 hour week in the office (with extra time for 'keeping up'). If one restricts the practice to outpatient medicine, we must add time for telephone calls with specialists, hospitalists, emergency rooms and pharmacies. Give me another 5 hours.

What is a fair salary for that physicians? I would argue that $150,000 seems reasonable (remember 4 years of college, 4 years of medical school and 3 years of residency - leaving > $100,000 debt). The physician first generates income at age 30 (if he or she goes straight through schooling and residency). Assume a 50 week year (2 weeks for much need vacation), that comes to $3,000 per week. Divide by 90 patients each week and you need $33 per patient visit after overhead (rent, supplies, nurse salaries, clerical salaries, and malpractice insurance). Overhead generally runs around 50-60% for such a practice. Assume 50% overhead, then the physician would need to charge and receive $66 per patient visit. If you assume that $100,000 is a large enough income, then we could lower our estimates to $45 per visit (assuming we could really decrease overhead costs - a very debatable point).

Many readers are now thinking that I am whining about physician income (damn rich doctors). The problem is that the generalist should be the key to one's ongoing best health. Only the generalist will consider the array of issues that the patient has. Every specialist makes more than the generalist. With current reimbursement, the generalist has difficulty making the $100,000. Medical students and residents know this - and they choose more lucrative fields in medicine. Specialization follow money.

If we assume the $100,000 income (and 2500 hours per year), we get $40 per hour for a highly trained physician to attend to your health. You pay more for car repair, or a plummer, or an electrician. Our health care system has undervalued your generalist. We have a decreasing number of physicians practicing general medicine (either family medicine or general internal medicine). Health care costs will increase because prevention will decrease. Concientious medical care requires time. In our current system, time is not on your side.