Managing consultation duration in primary care: A systematic review with health equity insights

ABSTRACT

Introduction:

In the past, reviews have found high levels of variability in physician consultation times across the globe in general patients attending primary care consultations. The matter remains a pressing public health policy topic, given that some health systems put pressure to decrease time physicians may spend with their patients. Little is presently known about the consultation time needs in specific potentially vulnerable populations including patients with disabilities, multimorbid conditions, older adults, patients from lower socioeconomic status, and patients in need of an interpreter. It is important to undertake a systematic review of the consultation time needs of these populations in order to better understand their needs and to reduce equity issues in accessibility to healthcare.

Methods:

A systematic review of PubMed and Medline, Web of Science, and Google Scholar was undertaken for all relevant studies on consultation time in specific populations including patients with chronic and multimorbid conditions, mental or psychological disorders, disabilities, migrants, and older adults that have been published over the past 20 years from 2002–2022. Studies in patients who did not belong to these specific groups were excluded.

Results:

A total of 65 articles met inclusion criteria and were included in this review. Patients from specific populations have unique consultation time needs. Patients with the greatest time needs from these specific populations in descending order include patients with mental health or psychological disorders as well as patients requiring interpreters, followed by patients with multimorbid conditions, and finally older adults. Patients need adequate time to schedule an interpreter and to allow for communication between the patient, doctor, and interpreter which fosters meaningful discussion. Patients with mental health disorders need much time to discuss their challenges (mean duration from 10.6 up to 60 min). Multimorbid patients have increasing consultation lengths in a dose-dependent manner with rising number of health problems. Older adults spent between 10.6 and 26.7 min with their general practitioners (GPs). Patients with disabilities are understudied but overall raise similar concerns around time constraints. Patients from lower socioeconomic status experience inequities stemming from shorter consultations irrespective of their chronic disease statuses.

Discussion:

Inequities in health accessibility exist in specific populations if sufficient time is not accorded to meet their unique health needs. A fixed appointment time could create disadvantages for these populations. Future research is needed to better understand what the ideal consultation time would be for these populations or whether individually tailored approaches are needed.

Conclusion:

Policymakers should consider flexible appointments for patients from specific populations to prevent accessibility issues to healthcare and subsequent perpetuated health inequities. Future research is also needed to better understand the ideal consultation duration for certain patients based on their unique needs, especially those with disabilities.

Introduction

Background

Physician consultation time is an important and pressing public health and primary care topic that is of public policy concern. In recent years, different countries have implemented policies that restrict the time that physicians may spend with their patients during a consultation.[1] Emerging evidence suggests that shorter consultation time may have some negative effects.[1] The largest systematic review to date (1946–2016) found that most consultations around the world are under 5 min, with the shortest consultation time in Bangladesh lasting 48 s and the longest one in Sweden lasting 22.5 min.[1] Studies have found that primary care physicians do not have enough hours in a day to undertake all necessary care for their patients according to medical guidelines.[2,3] Furthermore, a review found increased hospitalization in diabetic patients who had shorter consultation times.[1]

Certain policies in some countries have placed fixed consultation times for all patients, irrespective of their needs, or have limited the number of health problems they may address during a given consultation with a general practitioner (GP).[4,5] Thus, specific populations or potentially vulnerable groups may suffer from disparities that stem from shorter consultation times during primary care consultation times with GPs and primary care providers (PCPs) which may result from such policies.

For instance, primary care patients with chronic and comorbid or multimorbid conditions may require special attention to their multifaceted needs and a restricted consultation time with their GP may affect accessibility to care. In a systematic review, patients with comorbidities had longer mean consultation times than their counterparts without multimorbidities.[6] However, it was based on only one observational study.[6] Thus, there is a need to undertake a more comprehensive review to better understand this relationship.

In addition to patients with comorbidities and chronic conditions, migrants may also experience accessibility challenges during primary care medical consultations due to language barriers and this has implications for consultation time.[7] Research indicates that lack of interpreter services has a direct effect on quality of care and patient satisfaction and may put patients at risk.[7] Additionally, a review found that most migrants across Switzerland struggle with language and communication barriers during medical consultations.[8] Although interpreters assist with improving the consultations, a review found that this significantly increases the time of the consultation.[8] Better understanding exactly how much time is needed for migrants is needed given the gaps in the prevailing literature.

Besides challenges experienced with migrant patients, a review across six countries in Europe found that older patients and those who required a psychological consultation (patients with psychosocial needs besides physical) had longer mean consultation times as well.[9] It is unclear how much time older adults and patients with psychological disorders need exactly during primary care consultations in order to fully meet their unique and complex needs. It is especially important to understand how much time these patients need within the context of fixed and restrictive consultation time policies applicable for all patients, which may potentially impact equitable accessibility to care for these specific populations.

Finally, adults with disabilities including physical and intellectual ones may be impacted by restrictive policies concerning their consultation time with GPs. Research indicates that disabled adults require longer consultation times due to the complexity of their conditions, needs for accommodation, and slower communication.[10] Past research has found that patients with disabilities do not feel that they are given enough time to comprehensively discuss their health.[11] Thus, rushing consultations with disabled patients may potentially adversely affect their health, wellbeing, and satisfaction with care. However, little is presently known about their specific consultation time needs, necessitating a review to gain further insights.

Thus, there is a need to better understand the consultation time needs and differences in specific population groups to determine if inequities exist under fixed restrictive consultation policies. In other words, should primary care consultation time be personally tailored according to patient needs or should “a one size fits all” approach remain?

A previous systematic review which evaluated the mean consultation time in studies till 2016 did not evaluate consultation duration variations in vulnerable populations who may have accessibility challenges,[1] highlighting the need to evaluate all studies that have been undertaken in the relatively underrepresented vulnerable sector to date. Additionally, there is a need for health equity policy recommendations for special groups who may be potentially disadvantaged by restrictive and fixed consultation times such as immigrants, disabled patients, patients with chronic and comorbid conditions, older adults, and those with psychosocial illness.

Aims

The rational for this study was to evaluate what are the specific consultation time needs for patients who have complex health problems in order to consider whether fixed and restrictive consultation policies may impact their consultation needs and equitable access to primary care.

Thus, this systematic review aimed to better understand consultation duration in specific and potentially vulnerable populations including older adults, patients with chronic and multimorbid conditions, patients with disabilities, and patients requiring an interpreter who may require longer consultation times given the inherent theoretical complexity of their medical needs and potential challenges relative to other patients without complex needs.

To date, there has not been a review to the best of our knowledge that has focused on these specific and potentially vulnerable populations who may require more time. The reason for focusing on this population was to better understand their unique consultation time needs in order to ensure equitable accessibility to healthcare for these patients and to reduce disparities that may exist. This included evaluating patient needs and perspectives when it comes to consultation time and accessibility, differences in consultation time between specific populations and their counterparts, and understanding the average duration. As this is the first review to comprehensively examine consultation duration in vulnerable populations, we aimed to systematically capture the most relevant research to date, focusing on consultation time patterns and their variations over the past 20 years. The rationale for excluding studies older than 20 years was to focus on the most relevant consultation time policies that have impacted patients in this new millennium. We focused on primary care patients with psychological or mental illness, patients with disabilities, immigrant patients, and older adults who attend medical appointments with primary care physicians or GPs. We make recommendations for health policy in relation to promoting equitable consultation time for all patients based on needs.

Methods

A systematic review was undertaken for all relevant studies on consultation time in specific primary care populations across the globe over 20 years from 2002 to 2022. The review followed the Prisma-P guidelines for systematic reviews.[12]

The target population included all primary care patients belonging to one or more specific groups such as older adults, patients with disabilities, patients with psychological health challenges or patients with mental illness, and patients requiring an interpreter whilst attending a primary care appointment. All study designs were included. In order to be included, the articles must have explicitly stated that the studies were undertaken in a primary care setting with primary care patients including consulting with a GP or PCP. The definition of primary care was general care provided to patients in a community setting from a licensed medical general practitioner GP in a general practice office setting, medical doctor primary care provider office setting, or family medicine doctor office setting. Medical specialists were not considered to be PCPs, and thus, any encounter with a specialist was excluded. Patients seen in inpatient hospital settings were also excluded. We included all primary care consultations irrespective of whether they were new patients or repeating consultation with patients. Studies with mixed populations were included if they measured one or more relevant study populations or proxies for chronic disease care. All study designs were included. Studies that did not measure or explicitly describe the consultation time were excluded unless they were qualitative and discussed patient experiences with time. Studies in pediatric populations were excluded. Studies involving specialist care outside of primary care were also excluded.

We also excluded studies that were older than 20 years in order to maintain relevance in relation to current updated restrictive consultation time policies and the contemporary needs of currently living patients who are experiencing complex health needs within the context of the new millennium. To keep an up-to-date record of the most relevant studies for current complex patients in relation to new and evolving consultation time policies, we chose to focus on a large albeit restrictive 20-year window period that the researchers agreed on was most relevant for making future recommendations.

Further details of the inclusion and exclusion criteria are summarized in Table 1.

Table 1.

Inclusion and exclusion criteria

	Inclusion	Exclusion
Population	Specific and potentially vulnerable primary care patients including patients with chronic or multimorbid conditions, older patients 65 years of age or older, patients with disabilities, and migrant patients requiring an interpreter. Patients must have seen a general practitioner or family physician in a primary care setting.	Populations other than those listed from the specific population group definition. Patients who are not primary care patients attending primary care appointments including patients seeing specialists or inpatients.
Outcome measures	Must have measured consultation duration in a specific population. Studies that evaluated satisfaction were only included if they evaluated consultation time in one or more specific populations.	Studies that did not assess consultation time in specific populations. Studies that assessed satisfaction without assessing consultation time in one or more specific populations.
Publication language	English	Non-English languages

Search strategy and databases searched

Databases including PubMed and Medline as well as Web of Science were systematically searched for all relevant articles over a 20-year period with inclusion to December 31, 2022. Google Scholar was also searched for additional results. The references of the included studies and studies that cite them directly as well as past systematic reviews were checked for additional eligibility. Potentially eligible articles from manual hand reference searching were additionally searched and retrieved using the Google Scholar search engine, which was searched for any additional eligible articles. We consulted with a medical librarian who assisted with the search terminology design. The search terms included word variations for “consultation” or “appointment “and “time” or “length” or “duration”, and search terms for additional specific populations included “immigrant”, “disability” or “disabilities”, “co-morbidities” or “chronic disease” or “adult adult*”. The search terminology used for Web of Science included the aforementioned word variations. The full detailed PubMed search strategy example with medical subject headings (MESH) terms is summarized in Table 2.

Table 2.

PubMed Search Strategy Example

(Shorte*[tiab] or lengthen[tiab] or longer[tiab] or interval*[tiab] OR increase*[tiab] OR less[tiab] OR “Refugees”[Mesh] OR “Cultural Diversity”[Mesh] OR “Transients and Migrants”[Mesh] OR “Emigrants and Immigrants”[mesh] OR “Transients and Migrants”[Mesh] OR Transients [tiab] OR migrants [tiab] OR migrant[tiab] OR immigrant* [tiab] OR “ethnic groups” [tiab] OR “minority groups”[tiab] OR immigration [tiab] OR foreign*[tiab] OR refugee*[tiab] OR “asylum seeker*”[tiab] OR “displaced population”[tiab] or minorit*[tiab] OR “culturally and linguistically*”[tiab] or CALD[tiab] OR Cultural Diversity[mesh] OR “Geriatrics”[Mesh] OR “Health Services for the Aged”[Mesh] OR gerontology[tiab] OR geriatric[tiab] OR geriatrics[tiab] OR elderly[tiab] OR elder[tiab] OR elders[tiab] OR “older adult”[tiab] OR “older adults”[tiab] OR “older patient”[tiab] OR “older patients”[tiab] OR senior[ti] OR seniors[ti] OR “aged care”[tiab] OR “Aged”[Mesh] OR “Disabled Persons”[mesh] OR “disabled persons”[tiab] OR “disabled”[tiab] OR “disabilities”[tiab] OR “disability”[tiab] OR “handicap”[tiab] OR “handicapped”[tiab] OR “handicaps”[tiab] OR “hearing disabled persons”[tiab] OR “Hearing Disorders”[mesh] OR “hearing disorders”[tiab] OR “hearing impairments”[tiab] OR “impairment”[tiab] OR “intellectual development disorder”[tiab] OR “Intellectual Disabilities”[tiab] OR “Intellectual Disability”[mesh] OR “Intellectual Disability”[tiab] OR “Korsakoff”[tiab] OR “learning disabilities”[mesh] OR “learning disabilities”[tiab] OR “learning disability”[tiab] OR “learning disorders”[tiab] OR “neurobehavioral manifestations”[tiab] OR “neurocognitive disorder”[tiab] OR “neurocognitive disorders”[mesh] OR “neurocognitive disorders”[tiab] OR “neurodevelopmental disorders”[tiab] OR “hearing impaired”[tiab] OR “people with disabilities”[tiab] OR “physical disabilities”[tiab] OR “physical disability”[tiab] OR “physical disorders”[tiab] OR “physical illness”[tiab] OR “physically disabled”[tiab] OR “physically handicapped”[tiab] OR “speech disorder”[tiab] OR “Speech Disorders”[mesh] OR “speech disorders”[tiab] OR “vision disorders”[mesh] OR “vision, low”[mesh] OR “visual impairment”[tiab] OR “visually impaired”[tiab] OR alzheimer*[tiab] OR dement*[tiab] OR intellectual disabilit*[tiab] OR learning disabilit*[tiab] OR physical disabilit*[tiab] OR “Mental Health”[Mesh] OR “mental disorders “[MeSH] OR “Personal Satisfaction”[Mesh] OR well being[tiab] OR well-being[tiab] OR wellness[tiab] OR health[ti] OR “Health”[Mesh]) AND ((“time”[MAJR] OR “Time Factors”[Mesh] OR time[ti] OR “Time Management”[Mesh]) AND (“referral and consultation”[MeSH Terms] OR consult*[ti] OR “Appointments and Schedules”[Mesh]) OR (“consultation time*”[tiab] or “consultation duration*”[tiab] OR “consultation length”[tiab] OR appointment length[tiab] OR appointment duration[tiab] OR appointment tim*[tiab]) AND (“Patient Satisfaction”[MeSH Terms] OR Patient Satisfaction[tiab] OR satisf*[ti] OR “Patient Preference”[mesh] OR (patient[tiab] AND preference*[tiab]) OR (satisfy*[ti] AND patient*[ti])))

Screening and data extraction

Titles were screened for relevance to the research question followed by abstract and full text retrieval of eligible studies meeting inclusion criteria. A second reviewer YE independently screened the abstracts and full texts against inclusion and exclusion criteria to ensure there was agreement. Rayaan AI software was used to screen the articles along with Endnote between the two reviewers. Where there was disagreement, the reviewers met to discuss the papers. Articles meeting the full inclusion criteria at the full text stage were included in the review. Data were extracted and summarized in tabular format including study characteristics, measures, outcome, and study details. Data from subgroups were extracted and analyzed (special populations). Extracted data included population type, study design, location, year, patient health problems, measures, and outcomes in health and satisfaction. A narrative synthesis was undertaken. Due to the heterogeneity between studies, a meta-analysis was not undertaken.

Results

Specific patient populations and consultation time

Overview

A total of 65 studies were included in this review, which evaluated consultation duration in relation to one or more specific populations including older adults, patients with comorbidities and chronic conditions, patients with mental and psychological disorders, patients with disabilities, non-native speaking patients with a translator, female patients, and patients from lower socioeconomic status (SES) and minority groups.[3,9,10,11,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73]

The search is summarized in Figure 1 flow chart. There were only two interventional studies. The studies were undertaken across the world including Australia, Bangladesh, Belgium, Canada, Cambodia China, Croatia, Denmark, Estonia, Ireland, Iran, Germany, Japan, Malaysia, the Netherlands, Poland, Scotland, Spain, Slovenia, Sweden, Switzerland, the USA, the UK, and Taiwan.

Figure 1.

Prisma flow chart

Mean consultation duration

The results are summarized in Table 3. The mean consultation duration for patients with psychological or mental health disorders ranged from 10.6[45] to 60 min.[13] Consultations with interpreters had a reported duration of 13 min to 28 min.[21] The mean appointment duration in patients with either chronic and/or multimorbid conditions ranged from 11.2[32] to 19 min,[30] with longer duration with increasing number of conditions in a dose-dependent manner. The range for three or more conditions was up to 30 min.[44] Older adults spent from 10.6[45] to 26.7 min[36] with their physicians. Figure 2 illustrates the estimated maximum and minimum mean consultation time values across the studies (difference = range).

Table 3.

Study Characteristics

Figure 2.

Approximate mean consultation time differences according to maximum and minimum reported values[13,21,30,32,36,45] across the included studies for specific population types[3,9,10,11,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73]

Mean telehealth consultation time

A couple of the included studies also evaluated consultation time during the pandemic when telehealth was widely implemented.[51,61] A study in USA found that the mean video consultation length was 37.3 min (SD = 10) and was significantly longer than phone consultations which lasted 7.1 min (P value < 0.01).[51] Additionally, in Croatia, phone consultations were shorter than face-to-face appointments.[61]

Patients with chronic conditions and comorbidities

Several studies that investigated the association between chronic and multimorbid patients and consultation duration found a significantly longer consultation time in these specific population groups.[3,9,14,16,17,22,24,31,32,37,39,44,49,50,52,53,58,61,66,72]. A study in Slovenia[72] had significant findings that supported a positive linear relationship between increasing number of health problems and a longer consultation time. They found that patients with three health problems had a mean consultation time of 6.9 min (95% CI 2.0–14.5), while patients with three and five or more health problems had consultation times of 10.6 and 15.5 min (95% CI = 5.0–31.5), respectively. Additionally, a study in Estonia found that patients with one health problem had a mean consultation time of 8 min on average (SD = 4.2), while patients with two or more health problems had an average consultation duration of 11.6 min (SD = 5.1) (P value < 0.01).[58] Similarly, a study in Iran found that patients with multimorbid conditions had mean consultations that were significantly longer than their non-multimorbid counterparts, which lasted 11.2 (SD = 2.0) min on average versus 5.4 min (SD = 1.5) (P value < 0.01).[32] In addition to this, a study in Switzerland found that patients without multimorbid conditions were 91% less likely to have long consultations relative to their multimorbid counterparts.[22]

Mental health and psychological disorders

Several studies evaluated the association between physician consultation duration and mental health as well as psychological disorders, finding that consultations were increased overall in these patient populations.[3,9,13,14,16,17,24,28,31,45,58,65,66] For example, a study in Estonia found that patients with psychological disorders had the longest consultation duration of 11 min (SD = 5) when comparing it with the mean consultation time for all patients of 9 min (SD = 4.9), with a significant 2 min difference between groups (P value < 0.05).[58] A UK-based study found that the mean consultation time for patients with multimorbid mental health disorders was 5 min longer on average.[24] Likewise, a study in Japan found that patients with psychological disorders had a mean consultation time of 10.75 min, while the average consultation duration for all patient was 6.12 min.[65] Furthermore, a study in Malaysia found that psychiatric patients had 60 min consultations relative to other patients whose mean consultation time was 18.2 min (P value < 0.01).[13]

In addition to this, a study in the UK found that patients with psychological disorders spent 10.6 (SD = 5.4) min with their doctors on average, while patients without psychological disorders spent 8.35 (SD = 3.87) min on average (P value < 0.01).[45] Additionally, a study in the Netherlands found that the longest consultations were in patients with psychological disorders (mean = 12.6 min), followed by patients with somatic complaints who had a history of psychological issues (mean = 11.8 min), and the shortest consultation time was noted in patients with a strict somatic medical history (mean = 9.0 min), with significant between group differences (P value < 0.01).[66] Figure 3 illustrates some examples of consultation time differences in patients with psychological or mental health complaints relative to those without across a few countries.

Figure 3.

Mean consultation time differences according to patient type (psychological or MH vs nonpsychological or MH complaints (somatic)) and country adapted from[13,45,58,65,66]

Migrant patients with language barriers needing an interpreter

Several studies evaluated the association between consultation duration and provision of interpretation services for migrant patients.[21,27,30,46,51,55,67] The studies identified challenges relating to consultation time as well as communication and accessibility issues for migrants. For example, one study in USA found that migrants with language barriers required a consultation that was 28 min on average when compared with nonmigrant patients whose mean consultation lasted 3.42 min on average, with significant between group differences (P value < 0.01).[21] They also found that Spanish patients had mean consultation times of 12.2 min longer, while consultation times in Russia patients were 7.1 min longer when compared with native English speakers.[21] Phone consultations were also significantly longer in migrant populations.[21] Although a study in the UK did not find that there were significant differences in consultation times between migrants requiring a translator and native speakers, they did find significant differences in the quality of communication and information provided.[55] Consultations seemed less personable, with fewer words depicting humor and motivation. Medical doctors also provided less advice on modifying health behaviors and chronic disease management including diabetes. There was significantly less discussion around blood tests, medication, blood pressure, food, and weight.[55]

Older adults

Several studies evaluated patient age and consultation time, finding that older adults require a longer consultation with their physicians.[9,16,17,32,34,44,45,51,56,57,58,60,63,65,72] Longer consultation time was described as a statistically significantly longer time needed by older adults relative to younger age groups. Longer consultation times often entailed sufficient time for preventive care, adequate knowledge of geriatric needs, and special attention care.[63] Research from qualitative studies indicates that older adults desire sufficient time for communication that will meet their special needs to ensure accessibility.[56,63] One study found that older adult patients with dementia spent 26.7 min with their physicians on average.[36] However, one study in Japan did not find that age was significantly associated with consultation duration.[31] Additionally, one study in dementia patients did not find that longer consultation times enabled greater patient shared decision making.[36]

Patients with disabilities

There were only a couple of studies that explored consultation time in patients with disabilities which were qualitative.[10,11,43] A qualitative study in the Netherlands found that time is a barrier for patients with disabilities as sufficient time is critical for accessibility, adequate knowledge transfer (including through caregivers), and quality of continuity of care.[11] A qualitative study in Canada found that some physicians double their consultation time to properly accommodate disabled patients during appointments. They also found that physicians felt that disabled patients faced inequities when it came to preventive care during consultations.[10] Furthermore, a cross-sectional study found that consultation time was shorter in patients with intellectual disabilities specifically.

The social determinants of health: SES, minority patients, and education

Several studies also found a relationship between SES, education, and consultation duration.[16,17,39,40,41,51,72] This was particularly the case and problematic in patients with chronic multimorbid conditions.[16,17,23,39,40,41,51] For example, one study found that although multimorbid patients had longer consultation times, this was not the pattern for patients from disadvantaged neighborhoods who had shorter consultation times irrespective of their morbidity status.[24] In addition to having less time, one study in Scotland found that physicians had less empathy toward patients in deprived neighborhoods during consultations, while patients in more affluent neighborhoods with multimorbid conditions received greater attentiveness around their care during their appointments (P values < 0.01).[39]

Patient satisfaction

A few studies explored patient satisfaction in relation to consultation length. The study by Miyakoshi et al.[42] in Japan found that psychiatric patients were much more satisfied with longer consultation. The study by Kong et al.[33] in USA also found that elderly patients were most satisfied when the consultations lasted longer. However, other studies did not find that length predicted patient satisfaction.[31,45]

Discussion

The overarching primary aim of this review was to better understand the relationship between primary care appointments and the consultation time needs in potentially vulnerable populations. We aimed to gain greater insight into the consultation times in patients with disabilities, older adults, patients with chronic diseases, patients with psychological disorders or mental illness, and patients requiring an interpreter during primary care consultations with general practitioners. We found that a one size fit all approach cannot be applied to all patients by prescribing fixed consultation times as it creates accessibility issues for specific patient groups. We found that there was a wide range in consultation times across these patient groups and for the most part, they required a longer consultation time than regular patients. Past reviews have focused on the mean consultation time in all general patients, not taking into account that certain vulnerable groups of patients may experience disparities during the medical consultation as they require more time. This is the first review to the best of our knowledge that comprehensively examined consultation time needs in diverse patients including patients with disabilities, older adults, immigrants, patients with chronic diseases, and patients with mental or psychological disorders who may be vulnerable and unrepresented. We found that average fixed appointments that are restricted to a certain time frame for all patients may not be sufficiently long for vulnerable populations during primary care encounters. Therefore, physicians should be mindful that they may need to spend more time on average with vulnerable patients than the average time applied to consultations with their general patients. We will discuss the implications below.

First, this review found that patients with mental health disorders need more time to discuss their issues which cannot be summarized within a short window period of 5–10 min all the time. Research in patients with psychological disorders found that empathy and the ability to express their disorders in a safe supportive environment is important for the doctor–patient relationship built on trust,[74] something which may be hindered during rushed appointments and may potentially impact building a therapeutic alliance founded on the quality of the bond between the provider and patient.[75] They also felt they needed to be listened to by their doctors,[74] which may take more discussion time for patients to fully express themselves. Thus, some potential reasons for longer consultation needs stem from the nature of these psychological and mental disorders which involve lengthier discussion time and fostering an environment which enables this.[74] While the study found that doctors could easily and swiftly prescribe medications such as an antidepressant for their patients, a consideration must also be placed on the importance of building a therapeutic rapport with the GP and the central role patient communication plays as part of their therapy rather than just providing a simple and quick script to solve the problem. A recent study in Denmark found that it was feasible to implement a 45-min extended consultation among patients with mental health disorders in five primary care practices, allowing for a more patient centered approach where they could express their concerns and values.[76] Thus, it seems that having sufficient time is important to allow patients to adequately discuss their psychological and mental health challenges during psychosocial consultations.

Second, based on the findings in this review, it seems that migrant patients with language barriers require longer consultation times to enable equitable health communication, which includes integrating advice on preventive medicine and follow-up questions. Not all interpreters are readily available, and this influences scheduling.[27] Since we found that communication around preventive medicine and follow-up questions are already restrained in medical consultations involving interpreters, the lack of their ready availability further increases the inequities and accessibility gap. Research in Switzerland also indicates that many migrants do not bring professional translators to appointments and replace them with family members who lack professional skills, and 66% of physicians do not have access to any interpreter which creates greater communication issues.[8] It is important to provide migrants with equitable access to interpreters who may be readily available, with sufficient time allocated to meet all their health needs. Thus, future interventions for migrants should involve prescheduling appointments with interpreters and providing additional time for these interpretation services. Policies should also support the ready availability of more medical interpreters in places where there are insufficient interpreters.[8,77]

Third, patients with increasing number of chronic health problems require increasingly longer consultation times. Patients with chronic diseases were more likely to have longer appointments than patients without chronic health problems. Thus, there should not be a short time cap on a fixed appointment duration for these specific population groups. Additionally, future research could consider evaluating what the ideal mean consultation time should be according to the type of chronic condition (e.g. diabetes) and number of comorbidities. This way, an estimation could be made on how much time will be needed for patients depending on the number of chronic health problems they have.

Fourth, older senior patients require longer consultation times than younger patients. Our review found that senior patients desire physicians who are attentive and experienced with geriatric medicine. Communication was viewed as critical especially around preventive care, and time was seen as a barrier. The prevailing literature in geriatric medicine indicates that older adults have special needs, which may potentially explain why they need more time.[78,79,80] For example, older adults are more likely to have chronic health problems, as well as functional disabilities and cognitive impairments,[78,79,80] which have especially been linked with longer time needed with doctors in this review. Furthermore, older adults are at risk of polypharmacy[81] and may require a GP who will allocate sufficient time to explain how to take their medication. Older adults are also at risk of injuries from falls.[82] Preventive medicine and discussions on lifestyle-based interventions (e.g. dietary calcium,[83] balance and falls prevention exercises,[84] anti-slip matts[85]) should be integrated into primary care consultation, and this takes up time. Thus, older adults may face complex health challenges and multiple challenges which may change as they continue to age, requiring attention and a dynamic physician–patient relationship. While it is not clear why older adults did not need more time to build a therapeutic relationship in one study, some reasons may have to do with the limitations around being able to fully build this type of relationship in patients with cognitive limitations in dementia specifically.[36]

Fifth, patients with disabilities are a relatively understudied group when it comes to evaluating their appointment duration with medical doctors. More research is needed to better understand how much time is needed for a medical consultation in patients with physical and intellectual disabilities. Research indicates that disabled patients with mobility impairments in wheelchairs are at greater risk of chronic health problems including heart disease and diabetes.[86,87] As research indicates that patients with disabilities find it more challenging at times to schedule and attend medical appointments and experience accessibility barriers with the physical built environment when attending consultations,[88] it is especially prudent to make the most of the time during allocated the appointment window. There are clear gaps in quantitative research in patients with disabilities, necessitating more research to better understand how much time they specifically need to meet their needs according to different types of disabilities.

Finally, it is important to emphasize that gender, income, education, and ethnic minority status are all social determinants of health.[89] Low income and SES, disadvantaged neighborhoods, lower education, and ethnic minority groups experience health inequalities.[90] Poverty is linked with a higher prevalence of chronic diseases and disabilities such as mental health disorders,[91] cardiovascular disease,[92] and obesity.[93] This is concerning as it further perpetuates the health inequality gap between advantaged and disadvantaged populations. Physicians should be mindful of this problem and treat patients equally by ensuring that patients in deprived neighborhoods have sufficiently long consultation times according to their chronic health needs. This could involve evaluating potential resource deprivations (e.g. systemic barriers due to reduced staffing) and addressing this through policies that increase the availability of physicians in deprived areas as a past review found a high turnover of physicians in disadvantaged neighborhoods.[94]

Policy and recommendations

Current government policies pressure medical doctors to reduce their consultation time or have caps on the number of problems that can be addressed in a given consultation.[4,5] It is also worth noting that the systematic review by Irving et al.[1] found a relationship between the duration of a medical consultation and the amount spent on health care (per capita). The researchers suggest that it is a useful proxy for assessing poverty within regions including developed countries. Furthermore, shorter consultation length could also be associated with inappropriate prescribing.[95] Based on the findings in this review, our policy recommendations are to reduce the consultation time inequality gap in in patients with chronic comorbidities, mental or psychological problems, older adults, disabled patients, and migrants including those in deprived neighborhoods. We also recommend limitations on restrictive policies that set limits and caps on GP consultation time, as well as based on fixed amount, and allow flexibility or apply evidence-informed extended consultation duration for specific populations. While one review found that the country with the longest consultation duration of 22.5 min is Sweden,[1] whose length may potentially offset some problems due to short consultations, we have not identified any countries to the best of our knowledge that have implemented tailored or flexible consultation duration policies for the specific populations we have examined here.

Some strategies for consultation times could include setting a fixed time for standard consultations, while allowing for an increased limit for patients with special needs and complex health problems or a flexible appointment length for these populations. This could also involve recording that a given patient is complex in the electronic medical record with a special note that the consultation time will need to be extended for an additional amount of time without negative consequences for the physician and scheduling appointments accordingly. Doctors could also discuss consultation time needs and tailor them to underrepresented patients such as patients with disabilities.

Limitations

There are some limitations to this review. First, there was a wide range of consultations across different countries, with some consultation times being particularly short in more developing countries. It makes it challenging to compare between country consultation time differences for special populations as the policies are highly variable between countries. There was heterogeneity between the studies, and we could not undertake a meta-analysis. Moreover, since medical policies vary between countries and the amount of consultation time allocated, this introduces some bias to our analysis. Nevertheless, this review provides a snapshot of the overall needs of patients from specific populations when it comes to consultation times irrespective of location. While policies vary, we make broad general recommendations that physicians and policymakers can be mindful of when considering primary care encounters with these specific populations.

Additionally, we broadly included all primary care consultations, but there may be great variability between first encounters and follow-ups, something which was out of the scope of this review given that most studies focused on general duration in specific populations without comparing changes over time. Future research could focus on how allocated time changes in these patients during follow-up periods relative to the first consultation. Finally, while we included a few databases, we did not include all databases that were not freely available or available through the institutional subscription, which could limit all the studies that were included. However, we undertook a preliminary search analysis and agreed that we had obtained many papers using the existing databases and further databases likely would not have significantly impacted the results. We also excluded studies older than 20 years, which may have limited long-term trends. The studies on patients with disabilities were also limited as they were mostly qualitative, highlighting that more quantitative research is needed.

Significance

This review is significant because it comprehensively assessed the relationship between consultation time and outcomes in special populations. It is novel as past reviews have not focused on populations who may be disadvantaged by shorter consultation times including older adults, patients with disabilities, patients with comorbidities, and immigrants with language barriers. A past review identified one study on chronic conditions and consultation length,[6] while we identified approximately 20 studies. Additionally, past reviews have not explored consultation length comprehensively in older adults, disabled patients, and immigrant patients to the best of our knowledge. This review policy has important global policy implications for primary care medicine practice for special populations. We included global data in this comprehensive review across time and populations which enhances the generalizability of the findings. We have also provided actionable recommendations for policymakers.

Conclusion

In summary, we sought to evaluate the association between specific population groups and consultation time. Older adults, disabled patients, patients with chronic health problems and comorbidities, patients with psychological and mental health disorders, patients with disabilities, and migrant patients with language barriers require a longer consultation time than regular patients. To reduce inequalities in healthcare accessibility, physicians and policy makers should strive to ensure that these patient populations receive adequately long consultation times to meet their medical needs. There is a strong call to action for further research on the unique time needs of these patients and greater policy efforts to address these health inequities to accessing adequate consultation needs for these patients. There is also a need to focus on underrepresented patients including disabled patients to determine how much time they need according to different types of disabilities.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.