In Italy, a lively debate is currently under way in the health care sector. The hot topic is time spent by physicians and other health care professionals in communicating with patient. As one can imagine, different perspectives are expressed by professionals and policy makers.
Such a debate may have a significant impact on the rehabilitation sector. The questions raised may also be of interest for physiatrists and rehabilitation professionals working in other countries, Therefore, it might be useful to share thougths and opinions on this topic. As a starting point, we present a contribution of the President of the Italian Society of PRM (SIMFER) recently published in italian on a popular online journal on healthcare.
THE VALUE OF “TIME” IN REHABILITATION
Blaise Pascal wrote: “I would have written a shorter letter but did not have the time”. Many physicians could recognize themselves in this sentence, when they meet persons affected by multiple chronic health conditions, and are asked to listen, examine, select between different treatment options and explain everything to the patient in a handful of minutes, partly spent in updating the medical record.
In Italy, such “time issue” became a matter of a lively debate in the last months, when some Regional Health Authorities issued new rules imposing restricted time limits for the medical consultations and diagnostic procedures in the outpatient setting.
The National Federation of the Colleges of Physicians (FNOMCeO) rightly made a stand against such measures, seen as an unreasonable limitation of the professional autonomy, with a potentially strong negative impact on the patient-physician relationship.
The Italian Society of Physical and Rehabilitation Medicine (SIMFER) agreed with the statement of the FNOMCeO, sharing its concern about the consequences of a measure apparently adopted only for economic reasons, without any consideration of other multiple and complex aspects of the care process.
From a general point of view, this episode confirms the persistence of a large cultural gap between professionals and policy makers, with regard to the management of a fundamental, non-renewable resource such as “time”.
The majority of health care professionals rightly believe that a reasonable amount of time is a key factor in establishing a good relationship with the persons served, and increasing the knowledge of their health condition and their cooperation in the care plan. Time spent in listening and talking is also seen as an important factor in reducing the duration (and costs) of the subsequent treatments.
Several “humanistic”, approaches to healthcare that became popular in the last few years, such as the perspectives proposed by the “Narrative” approach in many countries, by “Choosing Wisely” in the USA and by “Slow Medicine” in Italy, emphasize the role and value of an adequate communication with the patient during the whole process of care.
Those who argue against these positions often set up economic reasons; that is, the need of optimizing the productivity of the healthcare processes in response to the increasing shortage of the available resources.
Many data appear to contradict this assertion; an adequate amount of time spent in talking with the patient could increase the quality of care and may be helpful in saving time and money, by avoiding unnecessary subsequent examinations or treatments.
This has been shown in many health conditions , such as, for example, in dialysis, surgery, oncology, multimorbidity and chronic disabling conditions (Kaplan et al., 2016). The conclusion of Haas et al. in a paper published on Dec, 26th, 2014 in “Harvard Business Review” was that “ …attempting to improve a physician’s productivity by placing arbitrary limits on length of appointments …lowers costs at the front end of a care cycle. ..but they incur much higher costs later in the cycle… “
Besides the time spent in talking with the patients and family members, the time of interprofessional communication – if properly used – seems to be another good investiment. A holistic, comprehensive evaluation of healthcare needs, of social-environmental aspects and of patients’ preferences in mutiple chronic conditions, through a mulitprofessional evaluation, resulted in a 21% increase of costs of the initial assessment, but also in a 74% saving in subsequent treatment costs, according to a report from Kaiser Permanente Colorado (cit. in Kaplan et al. ,2016).
These data suggest that the issues of “time of care” and “time of communication in healthcare“ require a much higher level of thinking than a mere conflict between a narrow-minded hyper-efficientism and the – albeit necessary – protection of the professional independence.
We should remind ourselves that one of the reasons of the popularity of the so-called “alternative approaches” in medicine is the –real or presumed to be – higher attention paid to listening and talking with the patient.
Should we leave such a privilege to practices often devoid of a serious scientific basis?
As we know, these issues are crucial in the field of Rehabilitation; the care process in Physical and Rehabilitation Medicine requires an adequate amount of time for a comprehensive assessment of the persons and its environment, according to the bio-psycho-social paradigm which is one of the key features of the discipline.
Time is needed to establish a good relationship with the person served, and to bridge the gap in knowledge and expectations which could prevent the mutual understanding and the shared definition of goals and objectives of the Individual Rehabilitation Plan.
Last, but not least, time is required to circulate information and share opinions and objectives among the members of the rehabilitation team.
Many experiences have shown that minimizing the time spent in communication during the rehabilitation process may result in an increase in diagnostic tests and in duration of treatments, partly caused by the patients’ poorer understanding and compliance with the therapeutic proposals.
For a long time now, the Italian Society of Physical and Rehabilitation Medicine has emphasised the importance of these aspects in the different settings of care delivery: inpatient, outpatient and home-and-community.
The pressure to maximize the number of patients and the constraints of time spent with the single patient is particularly perceived in the outpatient setting, leading to the above-mentioned negative consequences. This may be the result of a vision narrowly focused on the delivery of single, discrete health services, rather than on a comprehensive view of the whole clinical process and the final results of the rehabilitation plan.
From the organizational and economic standpoint, this perspective emphasises the quantitative aspect of care and its efficiency rather than its efficacy/effectiveness, and is supported by the fee-for-service payment/reimboursement system currently adopted in the outpatient rehabilitation setting in our Country.
The proposal of SIMFER is to adopt a different model in care delivery, based on a set of services which should consistently fit into a Individual Rehabilitation Plan, instead of a sum of single diagnostic and therapeutic interventions. A value-based reimboursement model should replace the fee-for-service system. Such a model should adequately consider the time and resources spent in communication, as well as the dimension of continuity of care and the outcomes achieved with regard to the initial goals and objectives.
Under this perspective, many different activities can be recognized under the umbrella term of “physiatric consultation”, each of them having a different dimension and value: clinical, relational, management etc.
This is a crucial step of the care pathway, requiring a reasonable amount of time. The quality and the outcomes of care largely depend on how such initial phase is carried out.
We, as PRM specialists, should be fully aware of the relevance of these aspects, and promote adequate actions to raise such awareness among the other rehabilitation professionals, the policy makers and the community at large.
- Kaplan RS et al: Adding Value by Talking More N Engl J Med 2016; 375:1918-1920
- Haas DA et al.: Delivering higher value care means spending more time with patients. Harvard Business Review. December 26, 2014
Paolo Boldrini – President, Italian Society of Physical and Rehabilitation Medicine