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07/25/2012

Rationing at the Bedside: Dr. Roger Barrow on Ethical Issues in Family Medicine

We are pleased to share with you a guest blog post from Roger Barrow, MD. Dr. Barrow is an Associate Professor of Family Medicine and practices at the Contra Costa Regional Medical Center in Martinez, CA.

“Bedside Rationing” of Clinic Time      

Fairness to each patient in an overly busy Family Medicine clinic is difficult to achieve. I practice in a county facility in the “safety net” treating the indigent as well as increasing numbers of people “disenfranchised” from their former insurance coverage after losing their job. All are in need of health care and most have no other options. The system is chronically underfunded, therefore our county’s human and other resources have not kept pace with the increasing number of patients needing our services. I’ve learned some efficiency tools over my 35 years practicing in this system, but they have been overwhelmed by the sheer number of patients and the complexity of caring for the multiply challenged chronically ill. Each of these complex patients is scheduled for 20 minutes to accomplish what often should take 30-40 minutes. Follow-up appointments are scarce and when a follow-up visit is needed in a near future, patients are frequently overbooked into that full clinic. This results in reducing the time for each patient in that future clinic. Hopefully future additional human resources as well as arrangements such as a “Patient Centered Medical Home” will help solve this dilemma, but for the foreseeable future my patients are left with having their needs met in brief visits in our under-resourced system.

Many of the medical efficiencies (and the joy) of primary care Family Medicine are derived from the relationships with patients that develop over months and years. The patients in our “safety net” clinics commonly bring significant challenges such as a lower educational level as well as language and cultural issues. Developing enduring continuity relationships requires adequate time for sensitive listening, respectful communication and shared decision making. The increased access to medical information via electronic media has increased my comfort level in managing multiple diseases and helps me to avoid the option of referring patients to specialists for the management of each individual medical problem since this often leads to confusion and fragmented care.

As I begin each day in clinic, I have to accept the fact that I will not have enough time with each patient to meet their needs. Many visits are subject to severe time constraints, making the challenge of prioritizing the time spent on each issue an ongoing and rather chaotic process. An unfortunate reality in my primary care practice is that the medical nirvana of being able to give each patient the time they actually need is not possible. “What can I do for you today?” really means, “Let’s prioritize what I can do for you in the brief time that we have to spend.” I am realizing that at the end of the day, I’ve triaged the available time subconsciously and in part based on non medical factors such as the assertiveness of each individual.

For example, Patient A is unhappy about waiting 2 months to be seen and insists on covering all of the items on his agenda, most of which are medically minor but quite important to him.  Patient B speaks only Punjabi and has also been waiting 2 months for her appointment and has medical problems that are more severe than Patient A. Through an interpreter, she expresses awareness that everyone seems rushed and that she “doesn’t want to take up too much time”, even though her medical problems are more complex and potentially life threatening. Is it fair to cut Patient A’s visit short in order to allow more time for Patient B’s more serious medical issues?

My physicians oath and medical ethics principles encourage me to do the best for each person I’m treating, but time is so limited that I usually triage the time distribution subconsciously,  hoping that each patient will get a fair and appropriate allotment of the time available. I’ve been involved as a member of our institution’s clinical ethics committee for 20 years and have a basic understanding distributive justice. I believe that time is a “critical resource” in primary care and that I am de facto “bedside rationing” this resource on a regular basis in our Family Medicine clinics. I believe we should openly acknowledge this practice and strive to use our time as fairly as possible.

Until resources are improved, is it wise or even possible to attempt to distribute the available time more fairly? Are there processes through which we can develop criteria to “ration time”, such as using “medical utility” criteria? Should patients receive information up front that I will need to prioritize the time based on “medical utility” and that because the goal is fairness for all, they may have some of their problems deferred to another day? How can we avoid negative de facto “bedside rationing” based on non-medical factors? I’m uncomfortable with this current medical environment. I hope our medical ethics colleagues can help us understand and address these issues.

 

Roger Barrow MD

Associate Professor of Family Medicine

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