So Much to Do, So Little Time

Productivity, proficiency, and volume performance.” These are watchwords we hear with increasing frequency as more and more primary care is delivered through prepaid insurance plans and discounted, fee-for-service arrangements. Because the value of primary care is increasingly recognized by patients, payers, and our subspecialist colleagues, it is critical that we continuously evaluate the marginal value of our interventions in promoting the health of our patients. Fortunately, quality, access, and patient satisfaction are also watchwords of these evolving health care delivery models.

In this issue of JGIM, Wenrich and colleagues describe an excellent observational study documenting the frequency and comprehensiveness with which practicing primary care physicians question standardized patients about common HIV risk behaviors during episodic office encounters for common complaints.¹ Their study analyzes clinical encounters by 134 volunteer primary care physicians with nine standardized patients trained to offer at least one significant risk behavior for HIV infection, if questioned, or to exhibit a physical finding consistent with advanced HIV infection. The primary care physicians included at least one question about HIV risk behavior in 59% of all encounters, and in 49% of encounters their questions elicited the specific behavior for HIV risk. The authors concluded that their findings “. . . document the need for improvement in HIV risk screening by primary care providers.”

When HIV infection may be related to the presenting complaint, it is clear that better efforts are needed to assess risk behaviors for HIV infection. More problematic, however, is the question whether to pursue HIV case finding and counseling about risk reduction during office visits when the presenting complaint is not likely to be related to HIV infection. The episodic office visit is an opportunity to promote health maintenance and screen for occult disease, especially in otherwise healthy young people who may come for care only when they think they are sick.

The time required to elicit a sexual history and a substance-abuse history, to counsel the patient about HIV risk reduction, and to provide counseling before HIV testing is nontrivial and must be considered a part of the cost of case finding. For example, the time required might prevent full consideration of the patient's presenting problem, adequate counseling about other health maintenance activities, and complete screening for occult disease. The time required should not be dismissed, as time is the most important resource of the primary care provider and must be apportioned carefully to deliver adequate care. A primary care physician could easily exhaust the entire office visit on the presenting complaint and on HIV issues, especially if only 15 minutes are scheduled. Further, it is important to remember that patients expect their presenting symptom to receive foremost attention. Health promotion and disease prevention, even for such important issues as HIV infection, are likely secondary in their minds to the presenting problem.

So, what is the right approach? Should counseling about smoking cessation, asking about physical abuse, updating immunizations, and screening for alcoholism, drug abuse, depression, occult cancer, and sexually transmitted diseases all be pursued during every episodic office visit? Clearly, the principles of evidence-based medicine should apply. The limited time available must be utilized to produce the best health outcome. Primary care physicians should consider this question in much the same way as they approach other technologies. For example, baseline population prevalence, specific patient factors, the positive and negative predictive values of screening maneuvers, and the likelihood of improvement all need to be considered. It is unlikely we will ever have consensus opinion, but these issues are so important that more effort should be devoted to understanding them, using these principles to drive decision making.

While a 15-minute appointment may allow barely enough time for evaluating an episodic complaint, explaining the diagnostic or treatment plan, and writing or dictating a note in the chart, it is appropriate to use this type of encounter to promote health maintenance and provide appropriate screening. The use of patient questionnaires, educational materials, and even interactive computer programs, may increase efficiency and help physicians identify risk factors that will direct health maintenance and screening activity. It is unlikely, however, that the future will permit us to spend more time on each encounter or to encounter patients more frequently. Therefore, it is imperative that interventions with the greatest marginal value be considered ahead of those with less benefit. Patient expectations should also be considered, because patient satisfaction is an important outcome.