PERIPHERALIA

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As a general practitioner, I book two patients every  
45 minutes. Actually, I book patients for two consecutive 
15-minute consultations, and then have a break for  
15 minutes to catch up. I have found that consultations 
over the years have become far more complicated, and the 
peripheral requirements around a consultation, such as 
blood tests, phone calls, referral letters and various forms, 
make the consultations much longer. Even with my present 
schedule, I may need to spend an hour at the end of the day 
clearing my desk.

I am really pleased when I hear the patient say: “I’ve got the 
flu, doc”, because I think I’ll be able to catch up, but then 
at the end, he or she says: “Oh, by the way, doc, while I’m 
here….”. Then we go into phase two, and just before getting 
up to go, I’m asked: “Could you just have a look at…” and we 
enter phase three. 

Consultations with patients whom I know, and whose data 
I have already collected and documented, are quicker. 
However, one does not really know what is coming in the 
door with new patients. Extensive information gathering may 
be needed for a new patient. Thereafter, several enquiries 
may have to be followed-up in order to confirm or obtain 
previous test results and consultation reports. Patients with 
pre-dementia and dementia are also referred to me as I am 
interested in this area of medicine, but the first consultation 
will often take 30–45 minutes.

When a patient presents with a routine illness, one of the 
subjects that we teach is opportunistic care. We have the 
opportunity to check on, among many others, immunisations, 
Pap smears, cholesterol, sugar, smoking habits, urinary stream 
or social behaviour. We all agree that this is an essential part 
of holistic care, but time is also needed for these activities.

Chronic disease care can also be time consuming if one does 
not have a system and help in place. If I am to check all my 
diabetic patients according to the prescribed routines that 
I teach the students, I would probably need to extend my 
consultation time to two patients per hour. There is often a 
marked dissonance between what the students are taught 
they should do, and the time available in modern practice to 
carry out everything that they were taught.

Patient-centred care is another teaching framework in Family 
Medicine. It was found in research that patient-centred 
care did not take any more time than that required using 
a disease-centred approach, and yet there is an epidemic 
of depression, anxiety and stress-related illness in modern 
practice with which patients present, together with the 
routine biomedical and pathological disorders. These all put 
my time schedule out of the window. 

At least the sixth and last element of patient-centred care 
emphasises that one must be realistic, but in a way this 
nullifies the other five elements. I personally don’t like leaving 
things until next time because eventually matters continue 
to get postponed as the subsequent visits are then under 
pressure as well (called the “never-ending consultation”).

I teach the concepts of prioritised health care, brief encounter 
interventions, general practice triage, “chunking” and key 
feature approaches in the time management sessions, but 
these systems don’t seem to work in my practice, although 
they sound good on paper. If you don’t spend the time 
addressing the underlying problems, they don’t go away, and 
you just put them off until another time, when you will still 
not have the time to sort them out. 

When I attend continuing professional development 
lectures, I find that specialists or subspecialists point out the 
specific screening I should be performing for their discipline 
or disease spectrum. As there are now ≥ 40 specialties and 
subspecialties, it amounts to numerous case findings or 
screening over and above the presenting illness.

The US Preventive Services Task Force recommends 
approximately 25 preventative and counselling services for 
each patient. It was found in a contemporary study that it 
would take 7.4 hours per working day for an average general 
practice to fully implement preventative services. This 
leaves very little time for the “worried well” and “Dr Google’s  
Panic Attack”.

In the 21st century, it would seem that in many ways we are 
running out of time.

Chris Ellis 
Family Physician, Pietermaritzburg, KwaZulu-Natal 
e-mail: cristobalellis@gmail.com

The dissonance between  
teaching and practice

“I have measured out my life in coffee spoons”– TS Eliot