The sign in the family doctor's office reads: “One problem per visit please.” Although such notices are not pervasive, they illustrate the need for balance in Canada's primary health care system between productivity, funding capacity and, last but not least, patient and provider satisfaction.
Some people, including doctors and patients, are not keen on this policy for several reasons. They feel it is unprofessional because it violates the duty to care by restricting the patient–physician interaction, potentially hampering communication, which may result in missed diagnoses, poor outcomes or misunderstandings. Some people also feel it is poor public relations for the profession.1
On the other hand, some patients are quite happy with the policy because it keeps waiting times down. They are grateful to have access to a family physician and know that many people are not so fortunate. They have grown to understand the practice challenges their physician faces.
What prompted the doctor to put up the sign in the first place and what conditions would prompt the doctor to take it down or to at least change the message?
Many family doctors see such signs as a necessity for staying in practice. Given the physician shortage and the increasingly unmanageable patient loads, this is one way to establish equity of access. Also of importance are the economic realities of fee-for-service family practice. With little or no control over the setting of provincial fees, which have typically not kept up with rising costs of practice, physicians look to generate more revenue by seeing more patients using the “1 problem per visit” method. Other physicians apply similar policies without posting the sign.
One possible solution to the underlying issues that these signs illustrate is team-based care that is not based on a fee-for-service model. Team-based care purportedly improves productivity, efficiency, cost-effectiveness, as well as access and patient satisfaction. However, when it comes to team-based care, “negotiation of new modes of payment for family physicians has been described as being more of a policy decision than an evidence-based decision.”2 Even if the evidence existed, access to health care teams for all patients and physicians does not exist now. Some physicians must remain in fee-for-service by default or by choice and will choose to use the “1 problem per visit” approach.
Finding mutually satisfying practice configurations for both patients and providers is undoubtedly necessary and will take time, but good communication is basic to any funding model.3
Physicians could consider changing their sign's text from a restrictive message to a message about respect. Posting a sign that encourages patients to respect the time of other patients who are waiting and who also need care creates a patient- centred message. The message could also be educational to create improved understanding of the limits of our health system's capacity by mentioning the physician shortage4,5and expressing that the physician is doing his or her best to provide care to as many patients as possible.
Asking patients to present their concerns at the beginning of the visit is another way to make use of time efficiently, while allowing patients to have their concerns and symptoms heard and allowing the physician to prioritize.
Simple changes to the way patients are asked if they have more concerns that need addressing can also be helpful. The use of the word “something” rather than “anything” in the question “Is there something else you want to address in the visit today?” was shown to decrease patients' unmet concerns by 78% without increasing visit length.6
The reasons behind the “1 problem per visit” signs may take many years to address, encompassing systemic issues such as the physician shortage and difficulties in funding capacity of the health care system. It may be that physicians do not change their policy anytime soon. But good communication is timeless. In the meantime, the message can be improved to provide more satisfaction to patients and providers.
Merrilee Fullerton MD Family physician Kanata, Ont.
Footnotes
With the Editorial-Writing Team (Paul C. Hébert MD MHSc, Rajendra Kale MD, Matthew B. Stanbrook MD PhD, Barbara Sibbald BJ, Ken Flegel MDCM MSc, Noni MacDonald MD MSc and Amir Attaran LLB DPhil)
Competing interests: None declared for Merrilee Fullerton. See www.cmaj.ca/misc/edboard.shtml for the Editorial-Writing Team's statements.
REFERENCES
- 1.Mazurik K. One complaint per visit. Alberta:The College of Physicians and Surgeons of Alberta; 2006. The Messenger. Available: www.cpsa.ab.ca/complaints/attachments/One_complaint_feedback/M126%20One%20complaint%20per%20visit.pdf (accessed 2008 Aug 7).
- 2.Muldoon L, Rowan MS, Geneau R, et al, Models of primary care service delivery in Ontario: Why such diversity? Healthc Manage Forum 2006;19(4):18-23. [DOI] [PubMed]
- 3.Association of Reproductive Health Professionals. Communicating with patients: a quick reference guide for clinicians. Washington: The Association; 2003. Available: www.arhp.org/healthcareproviders/onlinepublications/QRGPACC.cfm (accessed 2008 Jul 30).
- 4.The College of Family Physicians of Canada, the Canadian Medical Association and the Royal College of Physicians and Surgeons of Canada. National Physician Survey. Mississauaga (ON): The College; 2007. Available: www.nationalphysiciansurvey.ca/nps/2007_Survey/2007nps-e.asp (accessed 2008 Aug 9).
- 5.Arnold R. Inside out: slowing down and remining useful: our senior physician workforce. Toronto (ON): The Ontario College of Family Physicians; 2008. Available: www.ocfp.on.ca/local/files/Communications/Ltr2Mbrs/2008 /Inside%20Out%20-%20Number%2048.pdf (accessed 2008 Aug 21).
- 6.Infopoem: Asking “Is there something else?” decreases patients' unmet concerns. J Gen Intern Med 2007;22:1429-33. [DOI] [PMC free article] [PubMed]