Many family physicians are under greater and greater pressure these days —pressure to avoid unnecessary expenditures, pressure to ride an avalanche of paperwork and pressure to see an increasing number of patients per day. As one result of all this pressure, differences in practice styles are becoming a subject of contention among family physicians (See “Turtles and Rabbits: Family Physicians Under Time Pressure,” April 1999). The differences have always been there: The “turtles” believe that slow and steady wins the race, and they feel duty bound to give every patient the time he or she needs. The “rabbits” believe that excellent care doesn't always require spending a lot of time with the patient; they are proud of their efficiency. Now, however, the problem is being exacerbated by the growing tendency of the health care system to favor the approach of the rabbits. Turtles feel themselves on the defensive and under attack.

At the end of the article mentioned above, I invited readers to contribute to the discussion by sending their comments to FPM. The number and the passion of the responses we received indicate the gravity of the issue. While we received far more comments than we have space for here, I read them all carefully, and I was struck by the amount of thought that family physicians across the country have given to this issue. What follows is a selection from the comments readers made. I have grouped the excerpts under four headings, each suggesting one of the four general themes that seemed to come through the messages. Here's what readers had to say.

Turtles play an important role

Many physicians will say that it's fine if the turtles see only 15 patients a day, but they should get paid only half of what the rabbits get paid, since they are so much less productive. If you look only at money on the books, that is true. But if you study the larger picture, there is some evidence that, over the long haul, the turtles may actually be saving the system more money than the rabbits.

Two months ago, I saw a 50-year-old woman with a one-year history of intermittent headaches. I was in a hurry, so I did a quick history and exam and ordered a CT scan that was, of course, normal. I prescribed appropriate headache medication. She will probably take it for a number of years and continue to have headaches. Last month, I saw a similar patient but had time to do a more thorough work-up. I discovered that she had a significant caffeine history, lots of stress in her life, very inadequate nutrition, no exercise and five cats in her house. I discussed these things with her, ordered no tests, and her headaches stopped after she made some changes in her life. All physicians can recount similar stories.

It seems clear that I acted in the first instance as a rabbit and in the second as a turtle. It also seems to me that this type of problem is common in an average family practice. How can we honor both the different types of physicians and the different types of patients? I believe we must allow physicians to practice at the speed at which they want to practice. The task we now have before us is to figure out how to reimburse turtles in a manner that is not based only on the amount of money they put on the books each month. That will not be an easy thing to do.

— Bill Manahan, MD, Mankato, Minn.

A patient with fibromyalgia and chronic pain from “migraine” headaches signed up with our group. The physician she first saw didn't spend a lot of time with her, and she ended up going to the ER weekly for narcotic injections. By spending time with her on a weekly basis, I was able to manage her well enough that she hasn't been to the ER since. This ended up saving the group a lot of money, but it cut into my statistics.

Similarly, patients with complicated medical problems like diabetes and congestive heart failure know when they're getting the bum's rush. They ultimately bounce around until they see someone who will take care of their problems. They won't be satisfied with a “your time's up now” approach. Someone has to care for these patients, in the process cutting the cost of care by decreasing the number of admissions. It's not fair for doctors to “dump” these patients off so they will seek care from someone who will then have to take more time, which might impact that doctor's income. I think living by numbers alone will jeopardize a group's success because of patients like this.

— Gil L. Solomon, MD, West Hills, Calif.

Thank you so much for the chance to discuss this frustrating issue. I am a turtle who's been in practice for seven years in several settings. I went into family practice for the opportunity to work with whole people, and I grieve over the divisive “busyness” of modern medicine. I don't want to be “carried” by speedier doctors, but I insist that there are more ingredients to the equation than simply the number of patients put through the “mill.”

We need studies that track the out-of-office expense that a system favoring rabbits promotes. My referral rate to specialists, laboratories and hospital or outpatient diagnostic centers is considerably lower than that of those who see more patients. I believe that my 10- to 20-minute additional time spent with the patient often lets me uncover an explanation for a problem that can obviate the need for further testing or at least fine-tune the testing required.

With my interests in alternative care, I tend to accumulate the type of patient who is burned out in our present system — those with fibromyalgia, chronic fatigue, depression and environmental illnesses. These patients cannot be dealt with in a 10-minute visit, and I believe their numbers are growing. They respond well to a more turtle-like approach, and we do make progress! Who else will take care of these patients? One day, I believe, failing to address their particular needs in a patient, holistic fashion will prove to be very expensive. Who will reimburse me for the cost savings and allow me to continue the kind of care that I cannot compromise?

— Lauri E. Nandyal, MD, Columbus, Ohio

I'm very concerned that being more “productive” benefits the HMO, not the patient. Discussing the natural history of a chronic disease, medicine side effects and psychosocial stressors increases patient trust and prescription compliance. It also creates an atmosphere of concern and interpersonal warmth that modern life so often lacks. Make the world a better place: Spend five extra minutes. Give more than the minimum if you expect your patients to actually listen to your advice.

— Courtney Richards, MD, Lahaina, Hawaii

Turtles need a boost

Some suggestions for family physicians who want to become rabbits:

• Get an electronic medical record system: Install a terminal in each examination room and train a medical assistant or RN according to their style of practice;

• Delegate chores like prescriptions, phones, paperwork and patient education;

• Better, get a prescription printer that interfaces with your medical record system;

• Better still, have an assistant in the exam room with you typing notes during the encounter: You can go on to the next patient while your assistant is completing the notes, giving instructions and scheduling the next appointment.

— Henedina Macabalitaw, MD, Gary, Ind.

Your article mentions a number of time-optimizing strategies, all of which might well be effective for some part of our physician population. You did not mention the effective use of the telephone for triage of patients. You also did not discuss the effective use of midlevel providers. I have seen that a rabbit PA can be very effectively matched with a turtle MD or DO to deal with some of these issues.

Another strategy is to use a designated “on call” provider for work-in patients and to use extended hours for acutely ill patients. Yet another strategy is to form an alliance with an extended-hours facility. This can be especially effective for small groups. Often arrangements can be made to have such a facility take telephone call coverage for at least several hours. (I know this because I operate such a facility within a network of similar facilities.) The costs to the patient are usually much less than for an emergency department visit and may be looked upon more favorably by managed care utilization managers.

Another issue can be how physicians are compensated, as noted in your article. Some groups use a salary that is capped at a certain maximum after some years of service, etc. Bonuses can then be production-based or split evenly based on the profitability of the group. This can be very fair to groups that may have disparities in the distribution of patients from various managed care plans with different compensation methods.

— Rolf Naley, MD, Irving, Texas

I have had some success introducing a surrogate “me” into the practice by making very simple (even hokey) videotapes of the little speeches we all know we should be making (such as why viral infections do not respond to antibiotics and the supportive measures that would be appropriate instead, not to mention the antibiotic resistance crisis, etc.). I come to the diagnosis point, put the tape in and leave an instruction sheet in the chart holder on the door. I'm dictated and halfway through the next patient by the time my echo finishes the spiel. Patient needs are better met. Maybe I'll make it home for dinner with the kids. No guilt over shortchanging the patient. Multiply the 10 minutes of tape by five or six times a day, and you've struck a blow for both quality and productivity, if not for the arts.

— Dennis R. Peterson, MD, Bountiful, Utah

Turtles are the problem

I recently retired from over 30 years as a busy family physician in a very good rural family medicine clinic, and I would like to offer four points that I feel are important:

1. All physicians, especially the low producers, should learn to work more efficiently and increase their productivity while maintaining a good-quality medical practice, or accept the alternative of less compensation. This is simply a reality.

2. High productivity does not equal low-quality medicine. It can, but not necessarily. Conversely, low productivity can be a quality problem.

3. The time is coming soon when payers will replace low-producing primary care physicians with midlevel providers because they simply cannot afford the former.

4. Physicians need to understand that, in addition to their role as providers of health care, they are also the “cash engine” that runs their practices. The practice's financial survival depends on their productivity.

— Frank Leak, MD, Clinton, N.C.

The system needs fixing

I am pretty much a turtle, but I have the luxury of being paid hourly rather than per patient or DRG seen. I get patients who complain that a rabbit partner of mine is too hurried, but I lose as many patients to him because they prefer his habit of running on schedule (and obviously note no lack in his medical care).

I recall a fairly poor friend of mine who refuses to return to the county health department for care because “they treat patients like cattle there.” I am unconvinced that doesn't also occur in some HMOs, and in both cases I feel that the patients are getting what they paid for: adequate care provided quickly and brusquely so it can be provided cheaply.

Until patients are actually willing to pay more for doctors who provide the extra time some of them need or want, I am not convinced that the more efficient patients and doctors should subsidize such behavior. I do wish those patients who feel they need more from their doctors had a channel for purchasing that extra privately. I always fantasize that if I were to open a private practice and charge what I wish, accepting no insurance (or balance billing people for my time somehow), some of my patients would follow me there, willing to pay enough above insurance reimbursements to keep my income up despite spending more time than the average doctor for the same bill-able events.

— Jennifer S. Marsden, MD, Kempner, Texas

Those who see upwards of 40 to 50 patients a day may need to see the same patient several times to cover the same ground. Is that cost-effective care? Is that good patient care? Or are we only looking at the head count at the end of the day? I agree that we need efficiency. I also agree that we need patient accessibility. I agree that we need cost-effective medicine, but most of all I agree that we need good-quality patient care, with enough time to provide comprehensive preventive medicine. It is reasonable to think that there can be a middle ground that represents efficiency and high-quality care. Will market forces help this model emerge? I don't believe so. Rather, we must help shape our own destiny or it will be done for us.

— J.M. Bylander, MD, St. Cloud, Minn.

Reading “Turtles and Rabbits” makes me realize that the best format in which to practice medicine, optimize production and still be fair to all involved is to return to the old, often laughed at, individual family practice arrangement. If one solo physician is slower than another, then his or her production may be less, and that is fair. Each solo practice gets what it earns, and if the overhead is excessive, then that physician can deal with that problem in his or her own way.

Partnerships and groups do have their advantages, but they bring enough problems that the ideal situation might be a group of physicians sharing a condo-like practice, in which the building and parking, etc., are shared, but the employee and office management are done by each individual physician. In that format, each physician can succeed according to his or her own merits. It is sort of like capitalism, is it not?

— Richard D. Gage, MD, Boise, Idaho

The author's response

To those who wrote about the value of focused, insightful listening as a tool for saving money while maintaining high-quality clinical care, I can only say, “Amen!” The focus in “Turtles and Rabbits” was on visit rates because they are the principal tool used today to measure physician productivity in ambulatory care. As various correspondents indicated, though, they are grossly inadequate for assessing the real value of a doctor's work, and service codes add only limited additional information.

“Productivity” and quality of care appear to be independent variables. Most low-volume physicians are thorough and quality-oriented, but some are simply slow and unfocused. Most high-volume physicians offer more than episodic care, but some just dash from one patient to the next without doing much for any of them. Looking at testing, consultation and hospitalization rates can help, but this approach is controversial: Some observers complain that it promotes cheap, low-quality care. The true value of our work can only be measured in terms of favorable outcomes: faster recovery from curable diseases, reduced suffering from chronic illnesses, and fewer preventable disasters such as strokes and disseminated cancers. We lack practical, cost-effective ways to assess these outcomes in the short term, and further development in this direction is urgently needed.

Here are some approaches that family physicians can take as individuals and as members of physician groups:

• Accept change as an inevitable part of life, one that can be painful but often brings benefits that may be evident only in retrospect. Let nostalgia for the past and distaste for the present turmoil be tempered by cautious optimism that the time-tested American talent for innovation and improvisation will eventually create a better system.

• Examine and fine-tune your personal practice style. Seek ways to use your time more efficiently and to improve your patient-care flow. Make more effective use of your staff in directing patient flow and teaching patients to manage appropriate parts of their health care themselves. (For some appropriate articles from Family Practice Management, see the reading list).

• Re-examine your customary choices of diagnostic studies, drug and other prescriptions, and patient education. Keep up with new evidence-based analyses showing that some of our accepted treatments are wasteful and ineffective. Fine-tune your preventive care and patient education routines to fit them to your patients' needs and their ability to absorb detailed information.

• Support the AAFP and other organizations that are working for constructive change, and share your concerns about these problems with your elected representatives.

• Find ways to do all of this without losing the human touch. Patients rightly expect this of us, and we expect it of ourselves.

In the final analysis, all that has been discussed here will be insufficient to ease the cost pressures on American physicians for two reasons. First, our population is aging, and older people need more medical services per capita than younger ones. Second, ever more expensive medical technological advances are being developed and adopted. Medicine's inexpensive battles were won a long time ago. Today each step forward seems to come at a higher cost than the previous one. At some point our nation will face reality and create a system for prioritizing, allocating or (dare we say the word?) rationing medical services. This is not as reprehensible and inhumane as it may seem. The American non-system already rations health care, but by devious methods. The quality and scope of insurance coverage varies widely by source of payment (have you tried to refer a Medicaid patient to a dermatologist recently?), and one of every six Americans lacks medical insurance altogether.

Experience in other industrialized nations indicates that equity and overall quality of care can be preserved in a system that does not promise to deliver every possible medical service without cost-based limitations. The United States will probably move in that direction eventually, but clearly not soon. For the present, our goal must be to fine-tune what we have and make it more efficient.

All is not lost. In the words of Dennis Peterson, MD, who described himself in a part of his letter not reproduced here as “a turtle trying to move at rabbit speed,” “This is a great time to be practicing medicine. We can prosper, but not without working smarter. We can be a force righting some of the wrongs. We should do it because it's right, not just because our incomes have dropped.”