The practice of medicine is becoming increasingly challenging. Low insurance reimbursements, a shortage of primary care providers, and high numbers of patients have put a great strain on medical practices, and have caused some to enact internal policies which regulate how many patients a practitioner is supposed to see per hour. Such limitations can have ramifications…as we find in this month’s case.

Dr. P was a 33-year old general practitioner working for a fairly large walk-in family clinic. He had only been at the clinic for a few months, but was finding it greatly different than his previous employment in the office of an aging family practitioner. His previous employer was what some would call “old school” – he knew all his patients by name, always took the time to speak with them, never rushed, answered their phone calls personally, etc. But the physician had retired and sold his practice to the clinic, which offered Dr. P a position.

The clinic was the polar opposite of his experience with the family practitioner. During his orientation, he was told that clinicians (there were several physicians and nurse practitioners) should try to limit patient interactions to 10 minutes. He immediately began to voice his opinion that this wasn’t necessarily long enough, but the administrator went on to explain that the clinicians would be rated by how many patients they treated, and there was a minimum. Dr. P was not happy with the situation, but nevertheless thought he should give the job a fair try.

A few months into his time at the clinic, a teenage girl was brought in by her father. The girl, Miss C, spoke both English and Chinese, but she reported to Dr. P that neither parent spoke English. The father stayed in the waiting room while Dr. P spoke to and examined his patient.

Miss C reported having a stomach virus over the previous few days and still feeling queasy. During their discussion, she mentioned to Dr. P that her parents were getting divorced and that she’d been having trouble sleeping, was feeling sad, and her schoolwork was suffering. She reported that she’d been feeling this way for several weeks. Dr. P nodded, and made a note, all the while monitoring the wall clock hanging over the patient. The physical exam was normal, with the exception of the patient’s nausea.

“Is there someone at school…a counselor or someone…that you could talk to about your situation at home?” the physician asked.

The girl shrugged, morosely. “I don’t know.”

Dr. P was torn. He wanted to take more time to speak to the patient, but he was already running late due to taking too long with some of his earlier patients. He’d been warned once already about not getting his patients in and out promptly enough, and didn’t relish another warning. So he sighed, and wrote out two prescriptions for the patient, one for an anti-nausea medication and one for fluoxetine for depression.

“Your father speaks no English?” Dr. P asked.

“None,” said Miss. C.