The downside of 'one issue per visit' medicine

When a Brantford, Ont. woman named Christina Gilman took her son to the doctor, she reportedly saw a sign in the waiting room limiting patients to one issue per visit. She posted a photo of the sign on Twitter and got some strong reactions. 

Limiting patients to one health complaint per visit is far from uniform and yet it happens enough to be considered a recognized phenomenon. I haven't seen a study that looks at how widespread the practice is. There are lots of anecdotal examples across Canada of clinics that have a one-issue policy. I suspect a great many more doctors and clinics don't subscribe to the policy but do believe that there should be some sort of limit on what patients can discuss during a visit with the doctor.

There are several reasons why some doctors put limits on what patients can discuss with them during an appointment. Some doctors label patients as 'difficult' if they bring up more issues than can be discussed during a single visit. They say some patients are not adept at sticking to the most urgent problems. They say that other patients are bad at time management. Some doctors complain that patients wait until the last minute of the appointment to pull out a long list of questions to ask the doctor.

Some patients visit the doctor so rarely they make every moment count by asking about every symptom they've had during the long interval since the previous appointment. Some try to cover more issues than they should because they have to wait a long time to get another appointment.

On the other hand, some doctors are habitually late. Perhaps some patients are tempted to make the wait worthwhile by maximizing face time with the doctors. And some doctors waste time with the patient that could be spent getting more accomplished.

There are systemic factors that put pressure on doctors to limit their time with patients. Taking care of patients is getting more challenging. That's because patients are older and have more complicated illnesses than ever. One study found that as many as 78 per cent of patients in the United Kingdom who make appointments to see their family doctor have multiple medical problems like heart disease, kidney problems, arthritis as well as depression and other mental health issues. Any one or two of these could fill an entire appointment.

As well, GPs say they're expected to manage diseases that were once managed by specialists. For instance, the surgical oncologist who used to order diagnostic imaging may now expect the family doctor to have done so before accepting the referral. A colleague told me recently that she's expected to manage patients with epilepsy that (in the past) would have been managed by a neurologist. They have more tests to order to diagnose and screen for diseases. The growth in the number of doctors has not kept up with the demand. That said, not everyone views the doctor supply numbers the same way. 

Nevertheless, these kinds of factors have led most physicians to pack more medicine into shorter appointments.

In the U.K., the 10-minute patient appointment has become the norm. A practice guide for young doctors in Canada , published by the Canadian Medical Association, recommended 10- to 15-minute appointments.

Doctors need to manage their time better

I think there's plenty of potential harm in asking patients to stick to one problem per visit. For one thing, you inconvenience patients with complex needs. Christina Gilman, the woman who tweeted the photo of the one-issue-per-visit sign, is a good example. She told CBC News that she has four children with complex medical problems including autism spectrum disorder, mental health issues and recovering from leukemia. She has more than enough on her plate without having to book additional appointments.

You're also expecting patients to know which single issue is paramount. In my experience, patients often mention something really important to the diagnosis as I'm about to leave the room. Sometimes, what they say at the end of the visit is so crucial it changes completely my diagnosis. Any policy that makes patients reluctant to speak to the doctor could endanger their welfare.

How should this be addressed?

The College of Physicians and Surgeons of British Columbia says it is neither realistic nor acceptable to expect patients to identify the one problem deserving of priority management. It says it would not accept a "one issue only" policy as a defence should a patient complain that they were harmed. A paper posted to the web site of the College of Physicians and Surgeons of Ontario said that just because the patient gives a long list of medical complaints does not mean the doctor is obliged to respond to the entire list at a single visit.

I think this issue is mostly on doctors. They need to manage their time better by delegating things they don't need to do to free up more time for patients. They also need to plan appointments better by asking up front if the patient has a list of things to cover. I also think we should get rid of bottlenecks in the system such as lack of specialists and outpatient clinics that manage patients with complex medical problems. Doing so would free doctors to spend more time with patients.

This problem is solvable with the right attitude.