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Is Patients' Perception of Time Spent With the Physician a Determinant of Ambulatory Patient Satisfaction?
Chen-Tan Lin, MD;
Gail A. Albertson, MD;
Lisa M. Schilling, MD;
Elizabeth M. Cyran, MD;
Susan N. Anderson, BS;
Lindsay Ware, BA;
Robert J. Anderson, MD
Arch Intern Med. 2001;161:1437-1442.
ABSTRACT
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Background Time management in ambulatory patient visits is increasingly critical.
Do patients who perceive a longer visit with internists report increased satisfaction?
Methods Prospective survey of 1486 consecutively encountered ambulatory visits
to 16 primary care physicians (PCPs) in an academic primary care clinic. Patients
were queried regarding demographics, health status, perception of time spent
before and after ambulatory visits, whether the physician appeared rushed,
and visit satisfaction. Physicians were queried regarding time spent, estimated
patient satisfaction, and whether they felt rushed.
Results In 69% of 1486 consecutive visits, patient previsit expectation of visit
duration was 20 minutes or less. Patient and PCP postvisit estimates of time
spent significantly exceeded patient previsit time expectation. Patients who
estimated that they spent more time than expected with the PCP were significantly
more satisfied with the visit. When patient postvisit estimate of time spent
was less than the previsit expectation, visit satisfaction was significantly
lower independent of time spent. Patient worry about health and lower self-perceived
health status were significantly associated with patient expectation for longer
visits. Primary care physicians felt rushed in 10% of encounters. Although
PCPs estimated patient satisfaction was significantly lower when they felt
rushed, patient satisfaction was identical when PCPs did and did not feel
rushed. Patients indicated that PCPs appeared rushed in 3% of encounters,
but this perception did not affect patient satisfaction.
Conclusion Perceived ambulatory visit duration and meeting or exceeding patient
expectation of time needed to be spent with the physician are determinants
of patient satisfaction in an ambulatory internal medicine practice.
INTRODUCTION
TIME MANAGEMENT is a key issue in a contemporary ambulatory internal
medicine practice. Increasing administrative duties and emphasis on cost-effectiveness
often act to limit the time physicians spend with patients.1-2
Diminished physician time spent in ambulatory encounters may decrease patient
and physician satisfaction,1-9
reduce preventive care,1-2,5-6,10-11
promote inappropriate prescribing and referring behavior,1-2,12-14
and increase the risk of malpractice claims.15-16
No studies, to our knowledge, have assessed patient expectations for
time needed with the physician in current ambulatory internal medicine practice.
The present study was therefore undertaken to test our hypothesis that increasing
duration of ambulatory visits and meeting patients' expectations for time
needed to be spent with the physician are associated with enhanced visit satisfaction.
Secondary objectives of our study were to assess the characteristics of patients
who perceive a need for more time with the physician and to ascertain the
frequency and impact of physicians' feeling rushed during the ambulatory medical
encounter.
PATIENTS AND METHODS
SETTING
The study was conducted at a community-based, ambulatory internal medicine
clinic affiliated with the University of Colorado Health Sciences Center,
Denver. This clinic is staffed by 16 general internists and provides care
for several managed care plans and for participants in other types of payment
plans. The 16 physicians who saw study patients were aware of a research study
but were unaware of the objectives of the study. All consecutively encountered
patients seen during a 3-month interval in the spring of 1998 were asked to
participate. Aggregate billing data show that about 50% of this patient population
are from 1 of several capitated and noncapitated managed care contracts, 33%
are from non–managed care Medicare, and 17% are from different sources,
including commercial insurance, self-pay, and non–managed care Medicaid.
Patients were not stratified based on insurance type. Insurance information
was not collected directly from patients for this study. More than 95% of
patients who were asked participated in the study. Information on those refusing
to participate was not obtained. Patients were asked to participate and informed
consent was obtained by a professional research assistant in the waiting room
before the visit. Patients were told that their participation required the
completion of brief (2- to 3-minute) previsit and postvisit self-administered
questionnaires. Patients were informed that all responses were confidential.
The study was approved by the Colorado Multiple Institutional Review Board,
Denver.
STUDY INSTRUMENTS
Two self-administered patient questionnaires were developed, reviewed
by a professional survey consultant, pilot-tested by 20 to 30 patients and
5 to 10 physicians, and further modified for clarity. Before seeing the physician,
patients completed a 1- to 2-minute previsit questionnaire. Patients were
asked to respond to the question "How much time do you expect to spend with
the doctor today?" by checking a box indicating less than 10, 10 to 20, or
more than 20 minutes. These time frames were selected based on recent studies4-5,16-18
conducted in family medicine and general internal medicine settings. For patients
indicating a perceived need for more than a 20-minute visit, we asked them
to indicate if they needed 20 to 39, 40 to 60, or more than 60 minutes. Patients
were asked to rate their overall health as poor, fair, good, very good, or
excellent. Patients were asked to respond to the statement "I am worried about
my overall health" with response options of strongly disagree, disagree, not
sure, agree, or strongly agree. Demographic information on sex and age ( 39,
40-59, or  60 years) was obtained. After seeing the physician, patients
were asked to complete a second questionnaire. They were asked, "How much
time did you spend with the doctor?" (using the same time frames noted previously)
and "Did the doctor appear rushed?" (yes or no). Patients were also asked
to respond to the statement "Overall, I am satisfied with this visit" with
response choices of strongly disagree, disagree, neither agree nor disagree,
agree, or strongly agree.
Physicians completed a self-administered questionnaire after each visit.
Physicians were asked, "How much time did you spend with the patient?" (using
the same time frames as in the patient questionnaire), "Was this a regular
patient of yours?" (no, yes, or new patient), and "Did you feel rushed?" (yes
or no). Physicians were also asked to estimate the patient's satisfaction
with the visit as very unsatisfied, unsatisfied, somewhat satisfied, satisfied,
or very satisfied.
We attempted to ascertain actual patient time spent with the physician
by direct observation by a trained professional research assistant in a random
sample of 174 (11.7%) study encounters. This direct observation was done on
random days for several months by an assistant at a nursing station. Neither
the patient nor physician knew they were being timed. Timing began when the
physician entered the examination room and ended when the physician left the
examination room for the final time. Timing was paused whenever the physician
left the room during the examination and restarted when the physician reentered.
This "paused" time when the physician left the room between initial entrance
and final exit was subtracted to calculate the actual time spent with the
patient. For some of our analyses, "time spent" was converted into the same
categories used for patient and physician estimates to facilitate comparisons.
DATA ANALYSIS
For the patient question related to overall health, a numerical score
was given: 1, poor; 2, fair; 3, good; 4, very good; and 5, excellent. Likewise,
for the patient statement concerning worry about general health, a score was
assigned: 1, strongly disagree; 2, disagree; 3, not sure; 4, agree; and 5,
strongly agree. Scores for the patient question on satisfaction with the visit
were as follows: 1, strongly disagree; 2, disagree; 3, neither agree nor disagree;
4, agree; and 5, strongly agree. For the physician questionnaire regarding
estimated patient satisfaction, possible scores were as follows: 1, very unsatisfied;
2, unsatisfied; 3, somewhat satisfied; 4, satisfied; and 5, very satisfied.
All statistical analyses were performed using commercially available
software (SPSS-PC version 4.2; SPSS Inc, Chicago, Ill). Continuous variables
were tested using analysis of variance. Categorical variables were compared
by means of the  2 tests. Interobserver variability in estimation
of visit duration was assessed using a weighted  statistic.19 Differences were considered statistically significant
at P<.05 (2-tailed). Values are expressed as mean
(± 1 SD).
Because a relatively small number of physicians were studied, we performed
additional statistical analyses. To account for possible clustering by physician,
a mixed linear model was used. These analyses were conducted using an available
statistical software package (PROC Mixed Procedure, SAS version 6.12; SAS
Institute, Cary, NC). The P values in this study
are expressed in terms of the mixed linear model.
RESULTS
The study assessed 1486 patient visits. Seventy-two percent of the visits
were with the patient's usual physician, 18% were episodic visits with a physician
other than the patient's usual physician, and 10% were new patient visits.
Sixty-five percent of the patients were women. Fifty-one percent of the patients
were aged 40 to 59 years, while 24% were younger than 40 years and 25% were
60 years or older. Most patients self-rated their health as good (42%) or
either very good or excellent (36%), while fewer rated their health as either
fair or poor (22%). Most patients (51%) disagreed or strongly disagreed with
the statement that they were worried about their overall health, while 22%
were not sure and 27% agreed or strongly agreed that they were worried about
their overall health.
Initially, we compared patient estimate of time expected to be spent
with the physician (previsit questionnaire) with patient estimate of actual
time spent with the physician (postvisit questionnaire). As seen in Figure 1, most patients (69%) before the
visit anticipated spending 20 minutes or less with the physician. However,
after the visit, 48% of patients estimated that they actually spent 20 minutes
or less, and most (52%) believed that they spent 20 minutes or longer (postvisit
vs previsit estimate, P<.001). Thus, patients
estimated that they spent more time with the physician than they had anticipated
needing before the visit.
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Figure 1. Most patients anticipate needing
less than 20 minutes with the physician. After the visit, most patients estimate
that the visit lasted longer than 20 minutes (P<.05).
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We next ascertained whether an association existed between patient perception
of time spent with the physician and overall visit satisfaction. We compared
the mean Likert scores in response to the statement "Overall, I am satisfied
with this visit" as a function of postvisit patient estimate of time spent
with the physician. These scores (mean ± SD) were 4.42 ± 0.90
(n = 85) when patients indicated they had spent less than 10 minutes; 4.50
± 0.70 (n = 597), 10 to 20 minutes; and 4.61 ± 0.70 (n = 604),
more than 20 minutes (P = .02). Thus, visit duration
did not correlate with satisfaction scores when analyzed in this way, possibly
because of a "ceiling effect," in that most patients are satisfied with their
clinic visit and that discerning a significant difference between groups may
be problematic.
To address this, we then compared only the most satisfied patients in
each time group. To do this, we studied only the responses in which patients
noted that they strongly agreed with the statement "Overall, I am satisfied
with this visit" as a function of their postvisit estimate of time spent with
the physician (<10, 10-20, or >20 minutes). As seen in Figure 2, there was a modest, stepwise increase in the percentage
of patients rating overall satisfaction with the visit at the highest level
(score of 5) as a function of increasing estimate of time spent with the physician
(P = .005).
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Figure 2. Increasing postvisit patient estimate
of time spent with the physician is associated with higher patient satisfaction
(P = .005).
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Meeting or exceeding patient expectations has been found to be a determinant
of overall patient satisfaction.20 We therefore
examined patient satisfaction when the previsit time expectations were met.
As is apparent in Figure 3, significantly
more patients rated their overall visit satisfaction at the highest level
when their postvisit estimate of time spent with the physician met or exceeded
their previsit estimate of time needed (P = .005).
The mean Likert score for overall satisfaction with the visit when patient
postvisit estimate of time spent with the physician met or exceeded the previsit
estimate of time needed (4.56 ± 0.90, n = 1104) was higher than the
score when the previsit estimate was greater than the postvisit estimate (4.42
± 0.70, n = 142; P = .06).
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Figure 3. Patients are more satisfied when
their previsit estimate of time needed with the physician is met or exceeded
(P<.05).
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We next assessed whether there were differences in 6 demographic and
health status variables when patients who expected a longer visit were compared
with those who expected a shorter visit. In this analysis, we compared the
frequency of the following variables in patients who did and did not expect
to spend more than 20 minutes with the physician: self-rating of poor or fair
health, agreement or strong agreement with the statement that the patient
is worried about his or her health, self-perceived need for specialist referral,
whether the patient was seeing his or her usual physician, sex, and age. As
seen in Table 1, worry about health,
self-perceived poor or fair health status, and seeing one's usual physician
were significantly more common in patients expecting to spend more time with
the physician. Not noted in the table is the absence of a significant sex
distribution difference in those expecting a longer vs a shorter visit (P = .59). Also not depicted in the table is the complex
association we found between age and anticipated visit duration. In this regard,
patients younger than 40 years and 60 years or older were slightly more likely
(33% in both age groups) than patients aged 40 to 59 years (29%) to expect
to spend more than 20 minutes with the physician (P
= .04). We attempted a multivariate analysis of these variables to ascertain
whether 1 or more were independently associated with expectation of longer
visits. However, because of the colinearity of many of these variables, we
were unable to develop a satisfactory model.
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Selected Variables in 1009 Patients Estimating Needing 20 Minutes or
Less and 477 Patients Estimating Needing More Than 20 Minutes With the Physician*
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There were no correlations between physician age and time spent with
patients in our sample. It would be unlikely that there would be a difference
in time spent, given a standard patient schedule (20-minute visits) for all
physicians in this clinic. We also performed additional statistical analysis
(mixed linear model) to ascertain that there was no clustering effect by physician.
We also analyzed patient expectation of time needed as a function of
physician classification of the type of visit (new patient visit, continuity
visit, or other). Patients classified as "new" estimated a need for more than
20 minutes in 59% of cases and a need for less than 10 minutes in 2% of cases.
Among those classified as continuity patients, 50% estimated a need to spend
more than 20 minutes and 7%, less than 10 minutes. Patients classified as
"other" likely represented patients with urgent concerns who were unable to
see their usual primary care physician because of scheduling constraints.
This group of patients had the lowest (P<.001)
estimated need for more than 20 minutes (20%) and highest (P<.02) estimated need for less than 10 minutes (18%).
Patient perception of the physician's being rushed may be associated
with adverse consequences.15 We therefore ascertained
how often the patients perceived the physicians to be rushed and how often
the physicians perceived themselves to be rushed. We found that patients perceived
physicians to be rushed in 3% (43/1310) of visits, while physicians felt rushed
in 10% (146/1483) of visits. When visits in which patients perceived the physician
was rushed were compared with those in which the patient thought the physician
did not appear rushed, there were no significant differences in overall patient
satisfaction with the visit (4.3 ± 1.0 rushed vs 4.6 ± 0.8 not
rushed; P = .67). Physicians perceived themselves
to be rushed in 8.2% of visits when the patient did not feel the physician
appeared to be rushed and in 18.6% of visits when patients noted the physician
appeared rushed (P = .09). Patient perception of
time spent did not differ significantly when patients did or did not perceive
that the physician was rushed. When physicians felt rushed, they ranked patient
satisfaction lower (3.9 ± 0.6 rushed vs 4.2 ± 0.4 not rushed; P<.001), while patient self-ranking of satisfaction
was comparable when physicians did and did not feel rushed (4.5 ± 0.8
rushed vs 4.5 ± 0.9 not rushed; P = .62).
When physicians felt rushed, physician (P = .007)
and patient (P.001) postvisit estimates of time
spent were significantly greater than they were when physicians did not feel
rushed. Patients perceived the physician appeared to be rushed in 3% of visits
in which physicians did not perceive themselves to be rushed and in 7% of
visits in which physicians did perceive themselves to be rushed (P = .02).
One hundred seventy-four (11.7%) of 1486 visits were directly timed
by a trained professional research assistant. Patient and physician postvisit
estimation differed from time actually spent in 38.5% and 40.8% of encounters,
respectively. The differences were usually modest in degree. Patients (58%
of differences) and physicians (52% of differences) alike underestimated actual
time spent. The weighted statistic applied to actual vs patient postvisit
estimates was 0.41, and the test for symmetry was not significant (P = .76). The weighted statistic when applied to actual vs
physician postvisit estimates was 0.43, with a nonsignificant test of symmetry
(P = .85). When physician postvisit estimates of
time spent were compared, the weighted statistic was 0.38. The test
of symmetry was statistically significant (P<.05),
indicating that the patient's postvisit estimate of time spent was typically
less than the physician's estimate (45 [70%] of the 64 differences).
COMMENT
Time spent with the physician in the ambulatory primary care setting
has important cost and quality-of-care implications. Recent studies4-5,16-17 indicate
that ambulatory visits to family medicine physicians average 9 to 18 minutes,
while ambulatory visits to internal medicine physicians average 15 to 24 minutes.
A preliminary report by Watanabe et al,18 based
on data from the National Ambulatory Medical Care Survey, indicates that the
mean duration of new patient visits to internists declined from 29 to 17 minutes
from 1980 to 1996, while return visit duration decreased from 19 to 16 minutes
during the same interval. In other countries, even remarkably shorter intervals
(5 to 10 minutes) are the norm in general practice.7-8
In our study of ambulatory internal medicine clinic patients, we found that
most patients perceived a need to spend 20 minutes or less with the physician.
However, nearly 30% felt a need to spend more than 20 minutes with the physician.
Moreover, patients' postvisit estimate of time actually spent with the physician
significantly exceeded the previsit estimate.
We found that several elements were significantly related to anticipated
need for longer visits, including patient worry about his or her health, self-rated
lower overall health, seeing one's regular physician, and the first visit
of a patient to the physician. These factors are not surprising inasmuch as
patients with lower health status may have more concerns to discuss with the
physician. Anticipated need for longer visits with their regular physician
may relate to the comfort level patients feel in discussing their concerns
in an established relationship. We also found a tendency for patients with
concern about a referral to anticipate a need for greater time with the physician.
Such an association may reflect the patient's desire to fully discuss such
a concern and to justify the referral with the physician. Other studies21-22 demonstrate additional factors, such
as advancing age and interaction with non–English-speaking patients,
that contribute to increased duration of ambulatory visits. Physician characteristics
and medical practice organizational issues (support staff, number of examination
rooms, schedule, and number of patients to be seen), which were not analyzed
in our study, also contribute to duration of patient visits with physicians.
Longer ambulatory visits have been directly related to increased patient
satisfaction in family medicine ambulatory settings.3-8
We also found an association between longer patient-estimated duration of
the time spent with the physician and higher overall patient satisfaction.
A unique finding of the present study is that patients were significantly
less satisfied with their visit when their postvisit estimate of time spent
was less than their previsit estimate of time needed. This observation is
consonant with the findings of another study,20
indicating the importance of meeting patient expectations in optimizing ambulatory
care visit satisfaction. Not only patient satisfaction but also several other
aspects of quality of medical care that were not addressed in the present
study, such as attention to preventive services, addressing substance abuse
and psychosocial issues, careful prescribing of medication, risk of malpractice
claims, and appropriate use of referrals, may be adversely affected by shorter
time spent with the physician.1-16
Although patient perception of time spent is one determinant of satisfaction,
there are many other determinants, the most important of which is the physician-patient
relationship.23 This is based on communication
skills, such as engaging the patient and developing empathy with the patient.
In fact, physicians who underwent training in communication skills were rated
by standardized patients as better able to handle emotion and more proficient
overall.24
Our study also assessed the frequency and impact of physicians' feeling
rushed and patients' perceiving their physician was rushed. A previous study15 found that obstetricians who had more malpractice
claims were more commonly perceived as rushed than were obstetricians without
such claims. In our study, although physicians felt rushed in about 10% of
visits, patients perceived physicians to be rushed in only 3% of visits, and
neither patient nor physician perception of being rushed had major impact,
according to our observations. We are unsure what contributes to a physician's
sense of being rushed. It appears that this internal sense is not often communicated
to the patient, as is evidenced by the lack of correlation in the patient's
perception of the physician's being rushed. On the other hand, it is curious
that patients will sometimes perceive that a physician is rushed when the
physician does not note this. It is possible that nonverbal behaviors may
communicate an unintended message. We are reassured that only 3% of patients
in our study expressed this misperception. These are areas deserving of further
study.
Several caveats are important in interpreting our results. Our study
was conducted at only a single site, and thus our results may not be generalizable
in other settings. The number of visits that were actually timed was small,
and thus a substantial proportion of our data is based on patient and physician
perceptions of time spent. However, such perceptions rather than actual time
are relevant to the practice setting.
The time frames that we used were ordinal, not continuous, and fairly
broad in range. These ranges were chosen because they represented reported
ranges for duration of the visit4-5,16-18
and because we believed that neither patients nor physicians could accurately
estimate less than 10-minute intervals. We analyzed only the duration of visits
and not the actual content of the visit.
There is difficulty in measuring differences in patient satisfaction
because of a ceiling effect, in that most patients in this study noted they
were either satisfied4 or very satisfied.5 It is difficult to state the clinical significance
of our analysis, but showing a significant increase in most satisfied patients
seems relevant. Without analyzing a larger population of patients, it would
be unrealistic to expect significant statistical differences when analyzing
the entire Likert satisfaction spectrum.
Also, although it would have been interesting to analyze time spent
with older patients (a particularly challenging population) as a subgroup,
we did not assess the time spent in enough of these visits to be able to conduct
this analysis.
Our physicians knew that a study was being performed and that we were
inquiring about the amount of time they spent with individual patients. Because
we do not have observed visit-duration data available in a nonstudy setting,
it is possible that the amount of time that we measured physicians' spending
with their patients was not representative of usual practice.
Our results with regard to rushed visits should be viewed with caution
because the numbers were small. Patient satisfaction is undoubtedly multifactorial,
and our overall patient satisfaction was high. We were, however, able to find
further increments in patient satisfaction as a function of visit length.
Furthermore, because of brevity considerations, we used a nonstandard measure
of patient satisfaction despite the existence of standard measures. Unfortunately,
we did not assess physician visit satisfaction as a function of visit duration.
Finally, although patients were not informed as to the scheduled duration
of their visit, this information was available and, in many cases, known to
physicians. This information, in addition to data on the number of patients
scheduled in a given clinic, could have influenced physicians in agenda setting
and duration of the visit.25
Cost-containment pressures in the current ambulatory care environment
may contribute to the reduction in the amount of time physicians spend with
patients.1-2 Our findings and
those of others document that time spent with the physician is a major factor
in patient satisfaction and in quality of medical care. Sicker and more worried
patients and those seeking specialist referrals tend to anticipate needing
more time with the physician. Visits during which physicians felt rushed were
not significantly associated with decreased patient satisfaction in our study.
AUTHOR INFORMATION
Accepted for publication October 3, 2000.
This study was funded in part by a grant from the University Hospital
Board of Directors, Denver, Colo.
John Steiner, MD, MPH, provided valuable input regarding statistical
analyses and data interpretation. Mary Miller provided expert secretarial
assistance.
Corresponding author and reprints: Chen-Tan Lin, MD, Division of
General Internal Medicine, Department of Medicine, University of Colorado
Health Sciences Center, 4200 E Ninth Ave, Box B-180, Denver, CO 80262 (e-mail: ct.lin{at}UCHSC.edu).
From the Division of General Internal Medicine, Department of Medicine,
University of Colorado Health Sciences Center, Denver.
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JAOA: Journal of the American Osteopathic Association 2005;105:13-18.
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Patient Characteristics and Experiences Associated With Trust in Specialist Physicians
Keating et al.
Arch Intern Med 2004;164:1015-1020.
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Primary Care Clinic Size and Patient Satisfaction in a Military Setting
Mandel et al.
American Journal of Medical Quality 2003;18:251-255.
ABSTRACT
Quality Dimensions That Most Concern People With Physical and Sensory Disabilities
Iezzoni et al.
Arch Intern Med 2003;163:2085-2092.
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Zen and the Art of Physician Autonomy Maintenance
Reinertsen
ANN INTERN MED 2003;138:992-995.
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The Association between Three Different Measures of Health Status and Satisfaction among Patients with Diabetes
Kerr et al.
Med Care Res Rev 2003;60:158-177.
ABSTRACT
Physician Time and Patient Satisfaction
JWatch Gastroenterology 2001;2001:13-13.
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Physician Time and Patient Satisfaction
Journal Watch Dermatology 2001;2001:8-8.
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Physician Time and Patient Satisfaction
JWatch General 2001;2001:2-2.
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