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Truth or fallacy? Three hour wait for three minutes with the doctor: Findings from a private clinic in rural Japan

Truth or fallacy? Three hour wait for three minutes with the doctor: Findings from a private... Introduction: While previous reports examine various aspects of Family Medicine in Japan, there is sparse research on consultation lengths. A common phrase permeates throughout Japan, sanjikan machi, sanpun shinsatsu that means, “Three hour wait, three minute visit.” The purpose of this study is to examine consultation length in Japan, and how it is affected by patient variables. Case Description: We conducted a case study of consultation length and how it varies in relation to the demographics, presenting illness, and diagnoses at a rural clinic in central Japan. Data were coded according to the standards of the International Classification of Primary Care. Descriptive statistics were obtained to identify features of the data. Further, regression analysis was performed to characterize and to quantify the association between length of consultation and various subject level characteristics. Discussion and Evaluation: A total of 263 patients aged 0 - 93 years old had consultations during the 8-day study period. The mean consultation duration was 6.12 minutes. Of all consultations, 11.8% lasted 3 minutes or less. The mean (median) consultation time among males was 6.29 (5.2) minutes and among females was 6.03 (5.4) minutes. The duration of visits increased with age. Among different International Classification of Primary Care categories, psychological issues required the most time (mean = 10.75 min, median = 10.9 min) while urological issues required the least (mean = 5.08 min, median = 4.9 min). The majority of cases seen in the clinic were stable, chronic conditions and required shorter consultation times. Conclusions: While the mean and median consultation length in this study extends beyond the anecdotal three minutes, the average length of consultation is still remarkably short. Trends affecting consultation length were similar to other international studies. These data present only one aspect of primary care delivery in Japan. To better understand the significance of consultation length relative to the delivery of primary care, future research should examine issues such as continuity, frequency of consultations over time and comprehensiveness of care. Background Japanese government does not recognize family Japanese people live longer than any other population in medicine as a specialty in Japan, there is a national the world, and neonatal and infant mortality rates are movement to develop family medicine training. Current among the lowest in the world [1]. The population of Japanese private practitioners (kaigyoi) mostly are hybrid Japan has universal coverage either through employee specialty care/primary care providers who trained and insurance or through the National Health Insurance practiced specialty care in a hospital for 5-10 years prior scheme [2-5]. Japan also has a Long Term Care Insur- to going into private practice [8]. There are 277,927 ance (Kaigo Hoken) program that covers disability as a physicians in Japan with 95,213 physicians working in consequence of medical conditions [6,7]. While the ambulatory clinics. Of these 95,213 physicians, 74.8 per- cent own a solo practice and 25.2 percent work in a * Correspondence: mfetters@umich.edu group practice [9]. Since they do not have hospital privi- University of Michigan, Department of Family Medicine, 1018 Fuller St, Ann leges they provide ambulatory-based chronic and acute Arbor, MI 48104-1213, USA care, and often home care [10]. Full list of author information is available at the end of the article © 2010 Wooldridge et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 2 of 8 http://www.apfmj.com/content/9/1/11 Public insurance benefits do not include preventive was approved by the University of Michigan care that private practitioners can bill for unless there is Institutional Review Board, ID HUM00019913, and the a contract or voucher system with the local government. need for written consent for adults and assent for Most private practitioners do not provide women’s children was waived because the research presented no health unless they trained in obstetrics and gynecology. more than minimal risk, assent was not practicable, and Prescribing patterns are a unique feature of Japanese waiver would not impact the rights and welfare of health care. Private practitioners spend much of their subjects. day in short visits prescribing and in some places, dis- pensing medicines. While the legal limits of the duration Setting of most drug prescriptions officially increased from a The setting was Yuge Medical Clinic in the village of maximum of 90 days to more than 90 days in 2002, [11] Ryuo, Japan in June 2008. Ryuo is located about 44 km the vast majority of physicians prescribe about a 14 day east of the major city of Kyoto in central Japan. It is a supply [12]. Recent data suggests the longest mean town of approximately 13,000 people and its local econ- duration of drug dispensing from outpatient offices is 30 omy is predominantly agriculturally based. days with many chronic medications dispensed for less than 20 days [12]. The chronically ill make short clinic Study Population visits every 14-30 days just for medications. All patients presenting to a Japanese physician during Prescribing patterns strongly contribute to the most eight consecutive clinical days in June 2008 served as striking feature of Japanese ambulatory care practice, e. the study population. Like many office-based physi- g., the number of patient consultations in a routine cians in Japan, this physician completed internal medi- workday. Japanese private practitioners often see 60-100 cine training in Japan, but is a self-taught, self- patients a day [13]. This pattern raises questions about declared practitionaer of family/general medicine [8]. what is being conducted differently and the implications His office hours, billing procedures, staffing and mix of how primary care is delivered. A common phrase in of outpatient care and home visits are typical to pri- Japan, sanjikan machi, sanpun shinsatsu,meaning, vate practitioners in rural Japan. The only dissimilarity “three hour wait, three minute visit” alludes to the pub- to other Japanese physicians is that he has sufficient lic’s less than enthusiastic opinion of the system [14]. space in his building to allow a small number of other While a smattering of articles in English address other physicians to practice part-time in his office. Other- aspects of family medicine in Japan, [15,16] there are wise, this practice is very similar to other rural Japa- few reports on the details of clinical practice [17]. The nese clinics. In his clinic, he documents the visit in an most informative cross-national comparative research electronic health record during the patient results can be found in studies led by Okkes and consultation. Yamada [18,19]. The Okkes study collected data from several countries including Japan regarding reasons of Data Collection encounters, diagnoses, and interventions [18]. However, The observer (ANW) positioned himself in a non- it does not provide moment-by-moment details for a obtrusive way in the consultation room. The physician fine-grained understanding of time utilization. Other introducing himself signaled the start time and extend- than studies of geriatric clinics and a small linguistics ing his salutations to the patient marked the end of the study of ten patient-physician interactions [14,15,17] the consultation. The consultation length was recorded literature lacks empirical studies on primary care con- using a small digital timer to avoid disrupting the physi- sultation length in Japan. European research illustrates cian-patient interaction. Although the physician was that consultation length increases if the patient is older, aware that data about his consultation lengths would be if the patient is a female, if the reason for the encounter recorded, he did not know the days that time data is a psychosocial problem, and if the clinic is in an would be collected. Consultations were recorded in sec- urban setting [20]. Given this gap in the literature, the onds, and later converted to minutes. Data on the purpose of this study was to examine duration of visits patients’ age, gender, reason for encounter, and diag- and how these differ by factors such as age and gender noses were recorded. The latter were later coded in Japan. according to the standards of the International Classifi- cation of Primary Care (ICPC). The ICPC is a classifica- Methods tion system useful for primary care encounters as it Design accounts for the reason for encounter, the problems/ We conducted a detailed case study of primary care diagnoses, primary care interventions, and ordering of delivery for all patient visits during 8 days at a Japanese primary care data from an encounter as an episode of family physician’s clinic in rural Japan. This research care [21]. Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 3 of 8 http://www.apfmj.com/content/9/1/11 Data Entry and Analysis Table 1 Patient demographics Data were entered into Microsoft Excel and exported to Females Males All N = 174 N=89 N = 263 Statistical Package for the Social Sciences (SPSS) to cal- Characteristic n % n % n % culate statistics. We examined variation by gender, age, and number of diagnoses. Averages and ranges of con- Age in years sultation times were also determined for each of the 0-12 7 4 8 9 15 6 general ICPC categories by gender. To determine time 13-18 7 4 1 1 8 3 spent according to consultation type - whether acute, 19-49 16 9 11 12 27 10 chronicorpreventive-thereason of the visit andthe 50-64 37 21 25 28 62 24 diagnosis were reviewed and were coded per visit. We 65-74 51 29 23 26 74 28 used the following criteria to categorize the visit types: 75-84 45 26 21 24 66 25 a) acute illness visit is a condition with either a rapid ≥85 11 6 - - 11 4 onset or a short course or both, b) chronic illness visit Number of diagnoses is due to a condition that has a long-lasting course or is recurrent, and c) preventive care visit is one to prevent one 131 75 68 76 199 76 an illness or an injury, rather than to cure it. If a patient two 40 23 18 20 58 22 presented with both acute and chronic issues, he/she three 3 2 3 3 6 2 was categorized as having an acute problem. Regression analysis was performed with log minutes as Mean SD Mean SD P value outcome; the variables sex and diagnosis code as factors Age 62.9 21.3 58.7 22.2 0.13 and age as covariate. Logarithm of consultation time (in minutes) is used as an outcome since the resultant model provided a better fit to the normality assumption. years (Table 1). Patients aged 65 years and older consti- Post-hoc comparisons between the diagnostic codes tuted 57% of the total sample. The 19-64 age range were carried out using Bonferroni adjustment for multi- included 30% of the entire female and 40% of the male ple comparisons. A two-sample t-test was used to iden- populations, respectively. Still, there were proportio- tify any possible differences in mean consulting time nately more females than males in this age group. The between acute and chronic reasons for encounter. majority of patients (76%), received one diagnosis while Further, a logistic regression analysis was carried out to 22% received two diagnoses, and 2% received three diag- identify any difference in the likelihood for acute and noses. There was virtually no difference in the distribu- chronic reasons for encounter by gender and age. tion of the number of diagnoses between male and The data for this study was collected from a rural, female patients. community-based private clinic similar in most respects to other private clinics in Japan. The purpose was to Consultation length by gender and age obtain descriptive summaries of practice patterns. Con- The average consultation length for the entire popula- sequently, the sample size was not targeted to achieve a tion was 6.12 minutes. Males had a longer average con- pre-specified power for subgroup comparisons. How- sultation length (6.29 minutes) than females (6.03 ever, our ultimate sample size of 263 subjects was ade- minutes), although the difference was not statistically quate to provide descriptive summaries with a sufficient significant. Based on the multiple regression model with level of confidence. For example, assuming the standard age, gender and diagnosis code as covariates, there is a deviation of the consultation length to be 3.2 minutes, significant positive association between consultation as estimated from our data, the true mean consultation time and age with every 10 year increase in age corre- length can be estimated to within 0.4 minutes with 95% sponding to a 5% increase in mean consultation time confidence. Similarly, estimates of proportion of catego- (p < 0.001). Among the advancing age categories from 0 rical outcomes can also be obtained with reasonable through ≥74 (0-18, 19-49, 50-74 and ≥74) there are 63, precision. For example, the true proportion of acute 23, and 17 seconds differences between categories, visit types can be assessed to within five percentage respectively. The consultation duration was the longest points with 95% confidence assuming the expected pro- for women in the 19-49 years age group. There is a portion to be around 75%, as estimated from our data. noticeable, although not a fixed increase in consultation time in higher age brackets (Table 2). Results Demographics Consultation Length by ICPC Category The sample includes 263 patients, 174 (66%) females The longest average consultation length among the dif- and 89 (34%) males with their ages ranging from 0 - 93 ferent ICPC categories was 10.75 minutes for Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 4 of 8 http://www.apfmj.com/content/9/1/11 Table 2 Mean Consultation Length in Minutes by Age Table 3 Mean Consultation Length in Minutes by Major and Gender Disease Category and Gender Females Males All Female Male All N = 174 N=89 N = 263 ICPC Category Mean Mean Mean Variable Mean Mean Mean Median Median Median Median Median Median (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) General 5.7 7.4 6.5 Overall 6.0 6.3 6.1 5.6 5.7 5.6 5.4 5.2 5.3 (4,7.4) (4.8,10) (5,7.9) (5.6, 6.5) (5.6,7) (5.7,6.5) Blood/Immune 8.8 *one case 8.2 Age 8.8 6.9 (-37.1, 54.6) (-1.2,17.5) 0-18 years of age 4.6 5.3 4.6 4.5 5.1 4.5 Digestive 5.6 4.1 5.4 (3.3,5.9), (3.8,6.8) (3.3,5.9) 5.7 5.3 5.5 (4.5,6.8) (0.3,8.5) (6.4,5.4) 19-49 years of age 7.2 4.6 7.2 5.4 3.8 5.4 Cardiovascular 5.8 6.2 5.9 (3.9,10.5) (2.5,6.7) (3.9,10.5) 5.3 5.1 5.2 (5.3,6.4) (5.2,7.1) (5.5,6.4) 50-74 years of age 5.7 6.5 5.7 5.1 5.2 5.1 Musculoskeletal 5.4 *one case 5.3 (5.2,6.3) (5.5,7.6) (5.2,6.3) 4 4.2 (2.5,8.3) (2.9,7.6) ≥74 years of age 6.6 6.9 6.6 6.7 5.6 6.7 Neurological 6 4.7 5.7 (6,7.3) (5.4,8.5) (6,7.3) 5.2 4.3 5 (4,8) (2.6,6.8) (4.2,7) Psychological 9.9 13.4 10.8 psychological issues while the shortest average consulta- 8.3 13.6 10.9 tion length was 5.08 minutes for urological problems (4.2,15.5) (8.3,18.5) (6.6, 14.9) (Table 3, Figure 1). Males had longer consultation times Respiratory 5.2 7.3 5.7 5.1 5.5 5.1 in the categories of psychological, urological and respira- (3.9,6.5) (-0.9,15.4) (4.2,7.3) tory issues. There is a significant difference in mean Skin 5.8 4.9 5.5 consultation time across the different diagnosis codes (P 5.4 4.6 4.6 = .003). A post-hoc analysis manifested that the mean (2.4,9.2) (-1.1,10.9) (3.3,7.7) consultation time for psychological diagnosis was signifi- Endocrine 6.5 5.6 6 cantly higher than that for cardiovascular, respiratory /Metabolic 5.9 4.7 5.2 (5.2,7.9) (4.1,7.1) (5,6.9) and endocrine related diagnoses (all P-values <.05). The Urological 3.7 6 5.1 consultation time for psychological diagnoses was also 3.7 6.1 4.9 mildly higher than skin-related diagnoses (P = .053), as (-12,19.3) (-1,13.1) (1.9,8.2) well as digestive and musculoskeletal diagnoses (P = .07 for both). No other pairs of diagnoses differed signifi- Quickest and Longest Consultation Times cantly with regards to average consultation time. Consultation lengths ranged from 1.10 minutes to 26.75 minutes (Figure 1). The three shortest consultations Consultation Length by Acute and Chronic Reasons of were for patients for preventive immunizations, dermati- Encounter tis, and sinusitis, 1.10, 2.02, and 2.40 minutes respec- Overall the mean consultation time did not differ signif- tively (Table 5). The three longest consultations were icantly by visit type The majority of cases at Yuge Clinic for patients with liver disease, diabetes mellitus, and are chronic in nature followed by acute and preventive depressive disorder, 17.92, 18.18, and 26.75 minutes care.Between malesand femalesthere seemstobe respectively. some differences in the 19-49 and the 75-84 age groups, both in cases of acute and chronic diseases (4.05 and Discussion 2.46 minutes and 2.27 and 1.89 minutes in respective As to the truth or fallacy to the common perception that groups (Table 4). Only the last figure (1.89) signifies a consultation time is only three minutes in Japan, [22] in difference in increase for the chronically diseased male this clinic it appears to be both. Among 263 patient con- population of 75-84 years of age. There is no difference sultations of one physician, the mean duration at 6.12 in the likelihood for acute and chronic reasons for minutes is more than double the three-minute mark. For encounter identified by gender and age. Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 5 of 8 http://www.apfmj.com/content/9/1/11 Table 4 Distribution of Acute and Chronic Visit Types with Mean Duration of Consultation in Minutes by Gender Female N = 39 Male N = 27 All N = 66 Visit Type n Mean n Mean n Mean Median Median Median (95% CI) (95% CI) (95% CI) Acute 0-12 2 6.1 2 6.5 4 6.3 6.1 6.5 6.1 (-0.4, 12.7) (-10.3, 23.2) (4.4,8.2) 13-18 2 5.3 0 *no valid cases 2 5.3 5.3 5.3 (-10.8, 21.4) (-10.8, 21.4) 19-49 5 7.6 2 3.5 7 6.4 6.4 3.5 5.2 (2.9,12.2) (-0.2,7.2) (3,9.8) Note: the dots and asterisks in the plot refer to mild and extreme outliers, respectively. 50-64 5 5.3 9 6.2 14 5.9 4.6 5.1 4.8 Key to Diagnostic Codes from the International Classification of Primary Care (1.6,9.1) (4.1,8.3) (4.3,7.5) A – General and Unspecified 65-74 11 5.4 65 17 5.3 B – Blood, Blood Forming Organs and Immune Mechanism 4.9 5.1 5.1 (3.9,7) (4.2,5.8) (4.3,6.2) D – Digestive 75-84 13 7.6 8 5.2 21 6.7 K – Cardiovascular 7.2 4.5 6.8 L – Musculoskeletal (6,9.3) (3.3,7) (5.4,8) N – Neurological ≥85 1 ** one case 0 *no valid cases 1 - P – Psychological Chronic R – Respiratory 0-12 5 4.1 6 4.3 11 4.2 S – Skin 4.5 4.1 4.3 (3.1,5.1) (3.2,5.4) (3.6,4.8) T – Endocrine/ Metabolic and Nutritional 13-18 5 4.3 1 **one case 6 5 U – Urological 2.7 3.9 Figure 1 Illness Category and Duration of Consultation in (-0.2,8.7) (1.2,8.9) Minutes Using Boxplot. 19-49 11 7.1 9 4.8 20 6.1 5.1 4.5 4.9 (2.3,11.9) (2.2,7.4) (3.4,8.8) 31 patients (11.8%), however, the consultation actually 50-64 32 6 15 7.2 47 6.4 took 3 minutes or less. If the three-minute rule has valid- 4.9 5.5 4.9 ity, the question would be why the duration in this study (4.8,7.2) (4.5,9.9) (5.2,7.5) wasn’t shorter? One factor could be recent legislative 65-74 39 5.7 14 6.8 53 6 5.4 5.5 5.4 changes implemented by the Ministry of Health, Labour (5,6.4) (4.9,8.7) (5.3,6.7) and Welfare (MHLW). Under this 2008 law, physicians 75-84 31 6.3 13 8.1 44 6.8 can bill for kanri-ryo, a fee twice the repeat consultation 6.3 7 6.4 fee, if the site is a clinic, the patient has a chronic condi- (5.5,7) (5.8,10.5) (5.9,7.7) tion, and the consultation length is at least five minutes ≥85 10 5.8 0 **no valid cases 10 5.8 (written communication, Naoki Ikegami 2/21/2010). 4.8 4.8 (4,7.5) (4,7.5) MHLW financial incentives for extended prescription durations [11] plausibly could have an effect through Acute illness: an acute disease is a disease with either or both of a) rapid onset and b) short course. decreased visits and more time per patient. Current evi- Chronic illness: a chronic disease is a disease that is long lasting or recurrent. dence suggests the duration of prescriptions continues to The term chronic describes the course of the disease, or its rate of onset and be less than 20-30 days for the most common drugs [12]. development. While the three-minute rule is a common colloquial- ism, there are sparse data for comparison within Japan. compared to only 6.19 minutes when age-adjusted in Ishikawa et al found consultation length to average 10.5 the current study [17,23]. A number of reasons could minutes in a Tokyo geriatric clinic and a small linguis- explain this intra-Japan difference, e.g., variations in the tics study of ten physician-patient interactions by Ohtaki patient population with rural patients needing to be et al found consultation lengths to be 8.4 minutes, more healthy to make it to the clinic, more frequent Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 6 of 8 http://www.apfmj.com/content/9/1/11 Table 5 Shortest and Longest Consultation Times by Reason for Encounter and Diagnosis* ICPC Code Reason for Consultation ICPC Code Diagnosis Time (mins) 15 Shortest Consultations A44 Preventive immunizations/Medications A44 Preventive immunizations/Medications 1.10 S06 Rash localized S87 Dermatitis/atopic eczema 2.02 R63 Follow-up R75 Sinusitis acute/chronic 2.40 K63 Follow-up K86 Hypertension uncomplicated 2.43 K63 Follow-up K86 Hypertension 2.43 U36 Follow-up U90 Proteinuria 2.43 T63 Follow-up T93 Lipid disorder 2.48 K63 Follow-up K86 Hypertension uncomplicated 2.62 T63 Follow-up T81 Goiter 2.62 S06 Rash localized S88 Dermatitis contact/allergic 2.65 T27 Fear of endocrine/metabolic disorder T81 Goiter 2.65 K63 Follow-up K86 Hypertension uncomplicated 2.72 A03, R05, R08 Fever, Cough, Nose symptom/complaint R75 Sinusitis 2.73 D12 Constipation D12 Constipation 2.75 R05, R08 Cough, Nose symptom/complaint R74 Upper respiratory infection acute 2.82 15 Longest Consultations B27 Fear blood/lymph disease A97 No disease 12.40 K63, N63 Follow-up K86, N87 Hypertension uncomplicated, Parkinsonism 12.42 A05 Feeling ill Z02 Food/Water Problem 12.52 K63 Follow-up K86 Hypertension uncomplicated 12.52 K63, N63 Follow-up K86, N92 Hypertension uncomplicated, Trigeminal neuralgia 12.73 P63, T63 Follow-up P70, T90 Dementia, Diabetes non-insulin dependent 12.90 P63 Follow-up P76 Depressive disorder 13.03 P63, T63 Follow-up P70, T90 Dementia, Diabetes 13.55 T63 Follow-up T90 Diabetes non-insulin dependent 13.88 R05, R25 Cough, Sputum R81 Pneumonia 14.75 K63, P63 Follow-up K86, P76 Hypertension uncomplicated, Depressive disorder 14.80 P63 Follow-up P76 Depressive disorder 15.33 A05 Feeling ill D97 Liver disease 17.92 T63 Follow-up T90 Diabetes non-insulin dependent 18.18 P63 Follow-up P76 Depressive disorder 26.75 *Table 5 reflects single encounters that had the shortest and longest consultation lengths. visits and shorter consultation by rural patients, more Japan. Access facilitates continuity if the patient sees the financial pressures for productivity in the private rural same physician. office, or more patient demand for visits that would Second, the National Ministry of Health, Labour and result in more time pressures in the rural clinic. Welfare, determines what compensation physicians For an international audience accustomed to much receive for visits and procedures. The government-deter- longer visits, the glaring question is why would consul- mined compensation fee schedule incentivizes physicians tation length be so short? Interestingly, this mean time to seeasmanypatientsaspossiblefor ashort duration is approximately two and half times less than the aver- and on a frequent basis. Although compensation for age U.S. consultation length of 16.3 minutes [24]. While first time visits is approximately three times that of a our study was not designed to assess why physicians can repeat visit, more repeat visits can fit into the schedule see such volumes of patients in Japan, there are several than first time visits. The absence of a refill system, and observations to consider. First, the low patient co-pay the lack of significant financial incentives to give chronic under the National Health Insurance scheme makes medications for more than several weeks results in many access easy and encourages frequent physician visits in visits for chronic medication prescriptions [12]. Since Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 7 of 8 http://www.apfmj.com/content/9/1/11 reimbursement is based on a straightforward point sys- with physicians, and that shorter visits in Japan do not tem, without an option based on time as the billing sys- necessarily mean patients spend substantively less time tem in use in the US, there would be no financial in consultations with the doctor. Whether frequent- incentive to have a longer consultation. Still, frequent short visits, or less frequent-long visits are better for visits mayallowJapanesephysicianstobemoreaware effective delivery of primary care is uncertain. of and manage early minor changes in patients’ chronic This study has limitations. The design did not allow illnesses. us to examine the duration of patient waiting, so we Regarding variation in relative duration for sub- cannot comment on the veracity of the three-hour wait. groups, these findings are consistent for the most part, The geography, season and population served could with Deveugele et al’s work in European countries illus- influence the results. While additional research in other trating that consultation length increases if the patient is settings might provide more definitive estimates of con- older or if the reason for encounter is a psychosocial sultation length, the magnitude probably will not deviate problem [20]. Regarding the longer consultations in much. A physician who sees 60 patients in the 480 min- urban versus rural settings in the Deveugele et al study, utes of an 8-hour day averages 8 minutes per patient, our data from a rural setting compared to the data col- and at 100 patients per day, about 4.8 minutes. The lected in an urban setting by Ishikawa et al [23] are con- medical student’s presence may have altered the physi- sistent with longer consultations in urban versus rural cian’s performance, though we believe the direction of settings. this would be to make the duration longer. We did not In contrast to Deveugele et al’s findings on gender dif- control for first versus follow-up visits, and the latter ferences, we found consultations with men to be longer usually are longer. Finally, our analyses were based on in absolute time, but not at statistical significance, than the practice patterns of one physician. This physician consultations with women [20]. A number of factors was selected due to his local reputation as an excellent could account for this, but it is speculative. As men are practitioner and family physician known to the local more likely to be employed than women, it is possible medical university, willingness to participate, and our that they make fewer visits, and there may be more belief that the selected physician was similar to other ground to cover in a single visit. As a high percentage Japanese physicians. There is good reason to believe that of patients in the study were elderly, and women tend the physician’s examination style would be similar to to be healthier and live longer than men, it is also possi- other physicians in Japan since he trained in Japan. He ble that the visits with men were more complex than is a private practitioner and faces the same productivity the women. Furthermore, it is possible that gender dif- pressures of other private practice physicians. Although ferences are such that male patients may feel more com- the observed physician hires others to work part-time in fortable at asking questions or challenging physician his office, the times observed likely would not be sub- requests than women, or yet that communication pat- stantively different from those of a solo practice since ternswithmalepatientstakelonger. Furtherworkto he is responsible for his own patients and productivity. examine this issue is needed. Future work in additional settings and different times These stark differences in consultation length also of year could provide more robust estimates of doctor- raise questions about whether and, if so, how primary patient consultations in Japan. Specific comparisons of care works differently in Japan? While it is tempting to Japan with other systems that have comprehensive say that longer visits are better, this is debatable. health care coverage would help discern more the Patients’ perceptions of consultation length can be dis- potential pay-for-service environment of the US. Of torted–they may perceive it as shorter than actually, equal interest are the implications of these shorter but [25] or longer than actually [26]. Quality of time appears more frequent visits on the doctor-patient relationship, to be as important as the quantity of time for improving as well as the implications for training Japan’s future the doctor-patient relationship [27]. The three-minute family physicians. colloquialism supports the perception that patients have little time with doctors per visit, but it may be little dif- Conclusions ferent per year than the US. Assuming patients with The mean consultation length of 6.12 minutes is longer chronic medical problems see the doctor once per than the anecdotal reports of three-minute consultation month, in Japan, and the average time is ten minutes, lengths and is affected by variables similar to other physician-patient, face-to-face time totals 120 minutes international studies except that males have slightly annually. A patient in the US with a chronic illness longer consultation times than females. Still, 11% of vis- seen every six weeks (eight visits per year) for 15 min- its in this study took 3 minutes or less. Although this utes a visit, would be seen for about 120 minutes. This study helps to define consultation lengths and how vari- illustrates patients have significant face-to-face time ables affect these times in a rural Japanese practice, Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 8 of 8 http://www.apfmj.com/content/9/1/11 10. Fetters MD: Health policy shortage, not a doctor shortage/Point of View/ there are more aspects of Japanese primary care that Michael D. Fetters. Asahi Shimbun Weekly 2010. need to be investigated. To better understand the signif- 11. Ministry of Health Labour and Welfare: Heisei Year 14 Social Insurance icance of such short consultation lengths, future Medical Examination and Treatment Compensation Revised Summary. Japanese Title: Heisei 14 Nendo Shakai Hoken Shinryou Houshu nadono Kaitei research should explore consultation length in relation Gaiyou 2002 [http://www.mhlw.go.jp/topics/2002/02/tp0222-1a.html], to continuity of care, frequency of visits, and compre- [February 8, 2010]. hensiveness of care and compare these results with 12. Kimura S: “Long-term prescriptions are increasing” Is it true? Nikkei Medical Online 2009, 1-2. other systems with nationalized healthcare. 13. Takemura Y: Family medicine: What does it mean? Asia Pac Fam Med 2003, 2:188-92. 14. Campbell R: The three-minute cure: Doctors and elderly patients in Acknowledgements Japan. In Containing health care cost in Japan. Edited by: Ikegami N, This study was possible in part through funding from the Japan Business Campbell JC. USA: The University of Michigan Press; 1996:226-33. Society of Detroit Foundation. Dr. Fetters’ participation was made possible 15. Ishibashi Y: Why is family medicine needed in Japan. J Fam Pract 1987, through the generous support of the Jitsukoukai Foundation. The authors 25(1):83-6. also gratefully acknowledge Professor Kenichi Mitsunami MD, PhD who 16. Smith BW, Demers R, Garcia-Shelton L: Family medicine in Japan. Arch hosted Adam Wooldridge for a medical student research elective at Shiga Fam Med 1997, 6(1):59-62. University Medical Science. The authors also acknowledge Naoki Ikegami, 17. Ohtaki S, Ohtaki T, Fetters MD: Doctor-patient communication: A MD and John Campbell, PhD for their thoughtful critiques. comparison of the USA and Japan. Fam Pract 2003, 20(3):276-82. 18. Okkes IM, Polderman GO, Fryer GE, Yamada T, Bujak M, Oskam SK, et al: The Author details role of family practice in different health care systems: A comparison of The Ohio State University, College of Medicine, 370 West 9th Avenue, reasons for encounter, diagnoses, and interventions in primary care Columbus, OH 43210, USA. University of Michigan, Department of Family populations in the Netherlands, Japan, Poland, and the United States. Medicine, 1018 Fuller St, Ann Arbor, MI 48104-1213, USA. Yuge Medical J Fam Pract 2002, 51(1):72-3. Clinic, 1825 Yuge, Ryuou-cho, Gamou-gun, Shiga-ken, Japan 520-250. 19. Yamada T, Yoshimra M, Nago N, Inoue Y, Asai Y, Koga Y, et al: A study on the outcomes of health problems (the concept of “Episode of Care”) Authors’ contributions based on clinical statistics using the international classification of ANW and MDF conceived and designed the study. ANW collected data primary care (ICPC). Jap J Prim Care 2000, 23:213-23. while NA, AS, and MDF contributed to data analysis and interpretation. ANW 20. Deveugele M, Derese A, van den Brink-Muinen A, Bensing J, De and MDF drafted the manuscript while all authors critically revised and Maeseneer J: Consultation length in general practice: Cross sectional approved the final manuscript. study in six European countries. BMJ 2002, 325(7362):472. 21. Okkes I, Jamoulle M, Lamberts H, Bentzen N: ICPC-2-E: the electronic Authors’ information version of ICPC-2. Differences from the printed version and the ANW studies medicine at The Ohio State University College of Medicine: consequences. Fam Pract 2000, 17(2):101-7. NA serves as Data Manager, Department of Family Medicine, University of 22. Otaki J: Considering primary care in Japan. Acad Med 1998, 73(6):662-8. Michigan: AS serves as Biostatistician, Department of Family Medicine, 23. Ishikawa H, Hashimoto H, Roter DL, Yamazaki Y, Takayama T, Yano E: University of Michigan: MA serves as Director, Amenomori Family Clinic, Patient contribution to the medical dialogue and perceived patient- Shiga, Japan: MDF serves as Associate Professor, Department of Family centeredness. An observational study in Japanese geriatric Medicine at the University of Michigan and Director, Japanese Family Health consultations. J Gen Intern Med 2005, 20(10):906-10. Program at Dominos Farms Family Medicine. 24. Blumenthal D, Causino N, Chang YC, Culpepper L, Marder W, Saglam D, et al: The duration of ambulatory visits to physicians. J Fam Pract 1999, Competing interests 48(4):264-71. The authors declare that they have no competing interests. 25. Ogden J, Bavalia K, Bull M, Frankum S, Goldie C, Gosslau M, et al: “I want more time with my doctor": A quantitative study of time and the Received: 16 June 2010 Accepted: 23 November 2010 consultation. Fam Pract 2004, 21(5):479-83. Published: 23 November 2010 26. Cape J: Consultation length, patient-estimated consultation length, and satisfaction with the consultation. Br J Gen Pract 2002, 52(485):1004-6. References 27. Braddock CH, Snyder L: The doctor will see you shortly. The ethical 1. World Health Organization: The world health report 2008: Primary health significance of time for the patient-physician relationship. J Gen Intern care now more than ever. Geneva 2008. Med 2005, 20(11):1057-62. 2. Containing health care costs in Japan. Edited by: Ikegami N, Campbell JC. Ann Arbor, MI: University of Michigan; 1996:. doi:10.1186/1447-056X-9-11 3. Campbell JC, Ikegami N: The Art of Balance in Health Policy: Maintaining Cite this article as: Wooldridge et al.: Truth or fallacy? Three hour wait for three minutes with the doctor: Findings from a private clinic in rural Japan’s Low-Cost, Egalitarian System. Cambridge, United Kingdom: Japan. Asia Pacific Family Medicine 2010 9:11. Cambridge University Press; 1998. 4. Ikegami N, Campbell JC: Japan’s health care system: Containing costs and attempting reform. Health Aff (Millwood) 2004, 23(3):26-36. 5. Ikegami N: Japanese healthcare system: Lessons to be learned. Expert Rev Pharmacoecon Outcomes Res 2009, 9(3):201-4. 6. Campbell JC, Ikegami N: Long-term care insurance comes to Japan. Health Aff (Millwood) 2000, 19(3):26-39. 7. Campbell JC, Ikegami N: Japan’s radical reform of long-term care. Social Policy and Administration 2003, 37(1):21-34. 8. Saigal P, Takemura Y, Nishiue T, Fetters MD: Factors considered by medical students when formulating their specialty preferences in Japan: Findings from a qualitative study. BMC Med Educ 2007, 7(1):31. 9. Ministry of Health Labour and Welfare: Heisei Year 18 Physician, Dentist, and Pharmacist Survey; Heisei 18 Ishi, Shikaishi, Yakuzaishi, Chousanogaikyou. 2006 [http://www.mhlw.go.jp/toukei/saikin/hw/ishi/06/ kekka1-1.html]. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Truth or fallacy? Three hour wait for three minutes with the doctor: Findings from a private clinic in rural Japan

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Copyright © 2010 by Wooldridge et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Introduction: While previous reports examine various aspects of Family Medicine in Japan, there is sparse research on consultation lengths. A common phrase permeates throughout Japan, sanjikan machi, sanpun shinsatsu that means, “Three hour wait, three minute visit.” The purpose of this study is to examine consultation length in Japan, and how it is affected by patient variables. Case Description: We conducted a case study of consultation length and how it varies in relation to the demographics, presenting illness, and diagnoses at a rural clinic in central Japan. Data were coded according to the standards of the International Classification of Primary Care. Descriptive statistics were obtained to identify features of the data. Further, regression analysis was performed to characterize and to quantify the association between length of consultation and various subject level characteristics. Discussion and Evaluation: A total of 263 patients aged 0 - 93 years old had consultations during the 8-day study period. The mean consultation duration was 6.12 minutes. Of all consultations, 11.8% lasted 3 minutes or less. The mean (median) consultation time among males was 6.29 (5.2) minutes and among females was 6.03 (5.4) minutes. The duration of visits increased with age. Among different International Classification of Primary Care categories, psychological issues required the most time (mean = 10.75 min, median = 10.9 min) while urological issues required the least (mean = 5.08 min, median = 4.9 min). The majority of cases seen in the clinic were stable, chronic conditions and required shorter consultation times. Conclusions: While the mean and median consultation length in this study extends beyond the anecdotal three minutes, the average length of consultation is still remarkably short. Trends affecting consultation length were similar to other international studies. These data present only one aspect of primary care delivery in Japan. To better understand the significance of consultation length relative to the delivery of primary care, future research should examine issues such as continuity, frequency of consultations over time and comprehensiveness of care. Background Japanese government does not recognize family Japanese people live longer than any other population in medicine as a specialty in Japan, there is a national the world, and neonatal and infant mortality rates are movement to develop family medicine training. Current among the lowest in the world [1]. The population of Japanese private practitioners (kaigyoi) mostly are hybrid Japan has universal coverage either through employee specialty care/primary care providers who trained and insurance or through the National Health Insurance practiced specialty care in a hospital for 5-10 years prior scheme [2-5]. Japan also has a Long Term Care Insur- to going into private practice [8]. There are 277,927 ance (Kaigo Hoken) program that covers disability as a physicians in Japan with 95,213 physicians working in consequence of medical conditions [6,7]. While the ambulatory clinics. Of these 95,213 physicians, 74.8 per- cent own a solo practice and 25.2 percent work in a * Correspondence: mfetters@umich.edu group practice [9]. Since they do not have hospital privi- University of Michigan, Department of Family Medicine, 1018 Fuller St, Ann leges they provide ambulatory-based chronic and acute Arbor, MI 48104-1213, USA care, and often home care [10]. Full list of author information is available at the end of the article © 2010 Wooldridge et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 2 of 8 http://www.apfmj.com/content/9/1/11 Public insurance benefits do not include preventive was approved by the University of Michigan care that private practitioners can bill for unless there is Institutional Review Board, ID HUM00019913, and the a contract or voucher system with the local government. need for written consent for adults and assent for Most private practitioners do not provide women’s children was waived because the research presented no health unless they trained in obstetrics and gynecology. more than minimal risk, assent was not practicable, and Prescribing patterns are a unique feature of Japanese waiver would not impact the rights and welfare of health care. Private practitioners spend much of their subjects. day in short visits prescribing and in some places, dis- pensing medicines. While the legal limits of the duration Setting of most drug prescriptions officially increased from a The setting was Yuge Medical Clinic in the village of maximum of 90 days to more than 90 days in 2002, [11] Ryuo, Japan in June 2008. Ryuo is located about 44 km the vast majority of physicians prescribe about a 14 day east of the major city of Kyoto in central Japan. It is a supply [12]. Recent data suggests the longest mean town of approximately 13,000 people and its local econ- duration of drug dispensing from outpatient offices is 30 omy is predominantly agriculturally based. days with many chronic medications dispensed for less than 20 days [12]. The chronically ill make short clinic Study Population visits every 14-30 days just for medications. All patients presenting to a Japanese physician during Prescribing patterns strongly contribute to the most eight consecutive clinical days in June 2008 served as striking feature of Japanese ambulatory care practice, e. the study population. Like many office-based physi- g., the number of patient consultations in a routine cians in Japan, this physician completed internal medi- workday. Japanese private practitioners often see 60-100 cine training in Japan, but is a self-taught, self- patients a day [13]. This pattern raises questions about declared practitionaer of family/general medicine [8]. what is being conducted differently and the implications His office hours, billing procedures, staffing and mix of how primary care is delivered. A common phrase in of outpatient care and home visits are typical to pri- Japan, sanjikan machi, sanpun shinsatsu,meaning, vate practitioners in rural Japan. The only dissimilarity “three hour wait, three minute visit” alludes to the pub- to other Japanese physicians is that he has sufficient lic’s less than enthusiastic opinion of the system [14]. space in his building to allow a small number of other While a smattering of articles in English address other physicians to practice part-time in his office. Other- aspects of family medicine in Japan, [15,16] there are wise, this practice is very similar to other rural Japa- few reports on the details of clinical practice [17]. The nese clinics. In his clinic, he documents the visit in an most informative cross-national comparative research electronic health record during the patient results can be found in studies led by Okkes and consultation. Yamada [18,19]. The Okkes study collected data from several countries including Japan regarding reasons of Data Collection encounters, diagnoses, and interventions [18]. However, The observer (ANW) positioned himself in a non- it does not provide moment-by-moment details for a obtrusive way in the consultation room. The physician fine-grained understanding of time utilization. Other introducing himself signaled the start time and extend- than studies of geriatric clinics and a small linguistics ing his salutations to the patient marked the end of the study of ten patient-physician interactions [14,15,17] the consultation. The consultation length was recorded literature lacks empirical studies on primary care con- using a small digital timer to avoid disrupting the physi- sultation length in Japan. European research illustrates cian-patient interaction. Although the physician was that consultation length increases if the patient is older, aware that data about his consultation lengths would be if the patient is a female, if the reason for the encounter recorded, he did not know the days that time data is a psychosocial problem, and if the clinic is in an would be collected. Consultations were recorded in sec- urban setting [20]. Given this gap in the literature, the onds, and later converted to minutes. Data on the purpose of this study was to examine duration of visits patients’ age, gender, reason for encounter, and diag- and how these differ by factors such as age and gender noses were recorded. The latter were later coded in Japan. according to the standards of the International Classifi- cation of Primary Care (ICPC). The ICPC is a classifica- Methods tion system useful for primary care encounters as it Design accounts for the reason for encounter, the problems/ We conducted a detailed case study of primary care diagnoses, primary care interventions, and ordering of delivery for all patient visits during 8 days at a Japanese primary care data from an encounter as an episode of family physician’s clinic in rural Japan. This research care [21]. Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 3 of 8 http://www.apfmj.com/content/9/1/11 Data Entry and Analysis Table 1 Patient demographics Data were entered into Microsoft Excel and exported to Females Males All N = 174 N=89 N = 263 Statistical Package for the Social Sciences (SPSS) to cal- Characteristic n % n % n % culate statistics. We examined variation by gender, age, and number of diagnoses. Averages and ranges of con- Age in years sultation times were also determined for each of the 0-12 7 4 8 9 15 6 general ICPC categories by gender. To determine time 13-18 7 4 1 1 8 3 spent according to consultation type - whether acute, 19-49 16 9 11 12 27 10 chronicorpreventive-thereason of the visit andthe 50-64 37 21 25 28 62 24 diagnosis were reviewed and were coded per visit. We 65-74 51 29 23 26 74 28 used the following criteria to categorize the visit types: 75-84 45 26 21 24 66 25 a) acute illness visit is a condition with either a rapid ≥85 11 6 - - 11 4 onset or a short course or both, b) chronic illness visit Number of diagnoses is due to a condition that has a long-lasting course or is recurrent, and c) preventive care visit is one to prevent one 131 75 68 76 199 76 an illness or an injury, rather than to cure it. If a patient two 40 23 18 20 58 22 presented with both acute and chronic issues, he/she three 3 2 3 3 6 2 was categorized as having an acute problem. Regression analysis was performed with log minutes as Mean SD Mean SD P value outcome; the variables sex and diagnosis code as factors Age 62.9 21.3 58.7 22.2 0.13 and age as covariate. Logarithm of consultation time (in minutes) is used as an outcome since the resultant model provided a better fit to the normality assumption. years (Table 1). Patients aged 65 years and older consti- Post-hoc comparisons between the diagnostic codes tuted 57% of the total sample. The 19-64 age range were carried out using Bonferroni adjustment for multi- included 30% of the entire female and 40% of the male ple comparisons. A two-sample t-test was used to iden- populations, respectively. Still, there were proportio- tify any possible differences in mean consulting time nately more females than males in this age group. The between acute and chronic reasons for encounter. majority of patients (76%), received one diagnosis while Further, a logistic regression analysis was carried out to 22% received two diagnoses, and 2% received three diag- identify any difference in the likelihood for acute and noses. There was virtually no difference in the distribu- chronic reasons for encounter by gender and age. tion of the number of diagnoses between male and The data for this study was collected from a rural, female patients. community-based private clinic similar in most respects to other private clinics in Japan. The purpose was to Consultation length by gender and age obtain descriptive summaries of practice patterns. Con- The average consultation length for the entire popula- sequently, the sample size was not targeted to achieve a tion was 6.12 minutes. Males had a longer average con- pre-specified power for subgroup comparisons. How- sultation length (6.29 minutes) than females (6.03 ever, our ultimate sample size of 263 subjects was ade- minutes), although the difference was not statistically quate to provide descriptive summaries with a sufficient significant. Based on the multiple regression model with level of confidence. For example, assuming the standard age, gender and diagnosis code as covariates, there is a deviation of the consultation length to be 3.2 minutes, significant positive association between consultation as estimated from our data, the true mean consultation time and age with every 10 year increase in age corre- length can be estimated to within 0.4 minutes with 95% sponding to a 5% increase in mean consultation time confidence. Similarly, estimates of proportion of catego- (p < 0.001). Among the advancing age categories from 0 rical outcomes can also be obtained with reasonable through ≥74 (0-18, 19-49, 50-74 and ≥74) there are 63, precision. For example, the true proportion of acute 23, and 17 seconds differences between categories, visit types can be assessed to within five percentage respectively. The consultation duration was the longest points with 95% confidence assuming the expected pro- for women in the 19-49 years age group. There is a portion to be around 75%, as estimated from our data. noticeable, although not a fixed increase in consultation time in higher age brackets (Table 2). Results Demographics Consultation Length by ICPC Category The sample includes 263 patients, 174 (66%) females The longest average consultation length among the dif- and 89 (34%) males with their ages ranging from 0 - 93 ferent ICPC categories was 10.75 minutes for Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 4 of 8 http://www.apfmj.com/content/9/1/11 Table 2 Mean Consultation Length in Minutes by Age Table 3 Mean Consultation Length in Minutes by Major and Gender Disease Category and Gender Females Males All Female Male All N = 174 N=89 N = 263 ICPC Category Mean Mean Mean Variable Mean Mean Mean Median Median Median Median Median Median (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) General 5.7 7.4 6.5 Overall 6.0 6.3 6.1 5.6 5.7 5.6 5.4 5.2 5.3 (4,7.4) (4.8,10) (5,7.9) (5.6, 6.5) (5.6,7) (5.7,6.5) Blood/Immune 8.8 *one case 8.2 Age 8.8 6.9 (-37.1, 54.6) (-1.2,17.5) 0-18 years of age 4.6 5.3 4.6 4.5 5.1 4.5 Digestive 5.6 4.1 5.4 (3.3,5.9), (3.8,6.8) (3.3,5.9) 5.7 5.3 5.5 (4.5,6.8) (0.3,8.5) (6.4,5.4) 19-49 years of age 7.2 4.6 7.2 5.4 3.8 5.4 Cardiovascular 5.8 6.2 5.9 (3.9,10.5) (2.5,6.7) (3.9,10.5) 5.3 5.1 5.2 (5.3,6.4) (5.2,7.1) (5.5,6.4) 50-74 years of age 5.7 6.5 5.7 5.1 5.2 5.1 Musculoskeletal 5.4 *one case 5.3 (5.2,6.3) (5.5,7.6) (5.2,6.3) 4 4.2 (2.5,8.3) (2.9,7.6) ≥74 years of age 6.6 6.9 6.6 6.7 5.6 6.7 Neurological 6 4.7 5.7 (6,7.3) (5.4,8.5) (6,7.3) 5.2 4.3 5 (4,8) (2.6,6.8) (4.2,7) Psychological 9.9 13.4 10.8 psychological issues while the shortest average consulta- 8.3 13.6 10.9 tion length was 5.08 minutes for urological problems (4.2,15.5) (8.3,18.5) (6.6, 14.9) (Table 3, Figure 1). Males had longer consultation times Respiratory 5.2 7.3 5.7 5.1 5.5 5.1 in the categories of psychological, urological and respira- (3.9,6.5) (-0.9,15.4) (4.2,7.3) tory issues. There is a significant difference in mean Skin 5.8 4.9 5.5 consultation time across the different diagnosis codes (P 5.4 4.6 4.6 = .003). A post-hoc analysis manifested that the mean (2.4,9.2) (-1.1,10.9) (3.3,7.7) consultation time for psychological diagnosis was signifi- Endocrine 6.5 5.6 6 cantly higher than that for cardiovascular, respiratory /Metabolic 5.9 4.7 5.2 (5.2,7.9) (4.1,7.1) (5,6.9) and endocrine related diagnoses (all P-values <.05). The Urological 3.7 6 5.1 consultation time for psychological diagnoses was also 3.7 6.1 4.9 mildly higher than skin-related diagnoses (P = .053), as (-12,19.3) (-1,13.1) (1.9,8.2) well as digestive and musculoskeletal diagnoses (P = .07 for both). No other pairs of diagnoses differed signifi- Quickest and Longest Consultation Times cantly with regards to average consultation time. Consultation lengths ranged from 1.10 minutes to 26.75 minutes (Figure 1). The three shortest consultations Consultation Length by Acute and Chronic Reasons of were for patients for preventive immunizations, dermati- Encounter tis, and sinusitis, 1.10, 2.02, and 2.40 minutes respec- Overall the mean consultation time did not differ signif- tively (Table 5). The three longest consultations were icantly by visit type The majority of cases at Yuge Clinic for patients with liver disease, diabetes mellitus, and are chronic in nature followed by acute and preventive depressive disorder, 17.92, 18.18, and 26.75 minutes care.Between malesand femalesthere seemstobe respectively. some differences in the 19-49 and the 75-84 age groups, both in cases of acute and chronic diseases (4.05 and Discussion 2.46 minutes and 2.27 and 1.89 minutes in respective As to the truth or fallacy to the common perception that groups (Table 4). Only the last figure (1.89) signifies a consultation time is only three minutes in Japan, [22] in difference in increase for the chronically diseased male this clinic it appears to be both. Among 263 patient con- population of 75-84 years of age. There is no difference sultations of one physician, the mean duration at 6.12 in the likelihood for acute and chronic reasons for minutes is more than double the three-minute mark. For encounter identified by gender and age. Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 5 of 8 http://www.apfmj.com/content/9/1/11 Table 4 Distribution of Acute and Chronic Visit Types with Mean Duration of Consultation in Minutes by Gender Female N = 39 Male N = 27 All N = 66 Visit Type n Mean n Mean n Mean Median Median Median (95% CI) (95% CI) (95% CI) Acute 0-12 2 6.1 2 6.5 4 6.3 6.1 6.5 6.1 (-0.4, 12.7) (-10.3, 23.2) (4.4,8.2) 13-18 2 5.3 0 *no valid cases 2 5.3 5.3 5.3 (-10.8, 21.4) (-10.8, 21.4) 19-49 5 7.6 2 3.5 7 6.4 6.4 3.5 5.2 (2.9,12.2) (-0.2,7.2) (3,9.8) Note: the dots and asterisks in the plot refer to mild and extreme outliers, respectively. 50-64 5 5.3 9 6.2 14 5.9 4.6 5.1 4.8 Key to Diagnostic Codes from the International Classification of Primary Care (1.6,9.1) (4.1,8.3) (4.3,7.5) A – General and Unspecified 65-74 11 5.4 65 17 5.3 B – Blood, Blood Forming Organs and Immune Mechanism 4.9 5.1 5.1 (3.9,7) (4.2,5.8) (4.3,6.2) D – Digestive 75-84 13 7.6 8 5.2 21 6.7 K – Cardiovascular 7.2 4.5 6.8 L – Musculoskeletal (6,9.3) (3.3,7) (5.4,8) N – Neurological ≥85 1 ** one case 0 *no valid cases 1 - P – Psychological Chronic R – Respiratory 0-12 5 4.1 6 4.3 11 4.2 S – Skin 4.5 4.1 4.3 (3.1,5.1) (3.2,5.4) (3.6,4.8) T – Endocrine/ Metabolic and Nutritional 13-18 5 4.3 1 **one case 6 5 U – Urological 2.7 3.9 Figure 1 Illness Category and Duration of Consultation in (-0.2,8.7) (1.2,8.9) Minutes Using Boxplot. 19-49 11 7.1 9 4.8 20 6.1 5.1 4.5 4.9 (2.3,11.9) (2.2,7.4) (3.4,8.8) 31 patients (11.8%), however, the consultation actually 50-64 32 6 15 7.2 47 6.4 took 3 minutes or less. If the three-minute rule has valid- 4.9 5.5 4.9 ity, the question would be why the duration in this study (4.8,7.2) (4.5,9.9) (5.2,7.5) wasn’t shorter? One factor could be recent legislative 65-74 39 5.7 14 6.8 53 6 5.4 5.5 5.4 changes implemented by the Ministry of Health, Labour (5,6.4) (4.9,8.7) (5.3,6.7) and Welfare (MHLW). Under this 2008 law, physicians 75-84 31 6.3 13 8.1 44 6.8 can bill for kanri-ryo, a fee twice the repeat consultation 6.3 7 6.4 fee, if the site is a clinic, the patient has a chronic condi- (5.5,7) (5.8,10.5) (5.9,7.7) tion, and the consultation length is at least five minutes ≥85 10 5.8 0 **no valid cases 10 5.8 (written communication, Naoki Ikegami 2/21/2010). 4.8 4.8 (4,7.5) (4,7.5) MHLW financial incentives for extended prescription durations [11] plausibly could have an effect through Acute illness: an acute disease is a disease with either or both of a) rapid onset and b) short course. decreased visits and more time per patient. Current evi- Chronic illness: a chronic disease is a disease that is long lasting or recurrent. dence suggests the duration of prescriptions continues to The term chronic describes the course of the disease, or its rate of onset and be less than 20-30 days for the most common drugs [12]. development. While the three-minute rule is a common colloquial- ism, there are sparse data for comparison within Japan. compared to only 6.19 minutes when age-adjusted in Ishikawa et al found consultation length to average 10.5 the current study [17,23]. A number of reasons could minutes in a Tokyo geriatric clinic and a small linguis- explain this intra-Japan difference, e.g., variations in the tics study of ten physician-patient interactions by Ohtaki patient population with rural patients needing to be et al found consultation lengths to be 8.4 minutes, more healthy to make it to the clinic, more frequent Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 6 of 8 http://www.apfmj.com/content/9/1/11 Table 5 Shortest and Longest Consultation Times by Reason for Encounter and Diagnosis* ICPC Code Reason for Consultation ICPC Code Diagnosis Time (mins) 15 Shortest Consultations A44 Preventive immunizations/Medications A44 Preventive immunizations/Medications 1.10 S06 Rash localized S87 Dermatitis/atopic eczema 2.02 R63 Follow-up R75 Sinusitis acute/chronic 2.40 K63 Follow-up K86 Hypertension uncomplicated 2.43 K63 Follow-up K86 Hypertension 2.43 U36 Follow-up U90 Proteinuria 2.43 T63 Follow-up T93 Lipid disorder 2.48 K63 Follow-up K86 Hypertension uncomplicated 2.62 T63 Follow-up T81 Goiter 2.62 S06 Rash localized S88 Dermatitis contact/allergic 2.65 T27 Fear of endocrine/metabolic disorder T81 Goiter 2.65 K63 Follow-up K86 Hypertension uncomplicated 2.72 A03, R05, R08 Fever, Cough, Nose symptom/complaint R75 Sinusitis 2.73 D12 Constipation D12 Constipation 2.75 R05, R08 Cough, Nose symptom/complaint R74 Upper respiratory infection acute 2.82 15 Longest Consultations B27 Fear blood/lymph disease A97 No disease 12.40 K63, N63 Follow-up K86, N87 Hypertension uncomplicated, Parkinsonism 12.42 A05 Feeling ill Z02 Food/Water Problem 12.52 K63 Follow-up K86 Hypertension uncomplicated 12.52 K63, N63 Follow-up K86, N92 Hypertension uncomplicated, Trigeminal neuralgia 12.73 P63, T63 Follow-up P70, T90 Dementia, Diabetes non-insulin dependent 12.90 P63 Follow-up P76 Depressive disorder 13.03 P63, T63 Follow-up P70, T90 Dementia, Diabetes 13.55 T63 Follow-up T90 Diabetes non-insulin dependent 13.88 R05, R25 Cough, Sputum R81 Pneumonia 14.75 K63, P63 Follow-up K86, P76 Hypertension uncomplicated, Depressive disorder 14.80 P63 Follow-up P76 Depressive disorder 15.33 A05 Feeling ill D97 Liver disease 17.92 T63 Follow-up T90 Diabetes non-insulin dependent 18.18 P63 Follow-up P76 Depressive disorder 26.75 *Table 5 reflects single encounters that had the shortest and longest consultation lengths. visits and shorter consultation by rural patients, more Japan. Access facilitates continuity if the patient sees the financial pressures for productivity in the private rural same physician. office, or more patient demand for visits that would Second, the National Ministry of Health, Labour and result in more time pressures in the rural clinic. Welfare, determines what compensation physicians For an international audience accustomed to much receive for visits and procedures. The government-deter- longer visits, the glaring question is why would consul- mined compensation fee schedule incentivizes physicians tation length be so short? Interestingly, this mean time to seeasmanypatientsaspossiblefor ashort duration is approximately two and half times less than the aver- and on a frequent basis. Although compensation for age U.S. consultation length of 16.3 minutes [24]. While first time visits is approximately three times that of a our study was not designed to assess why physicians can repeat visit, more repeat visits can fit into the schedule see such volumes of patients in Japan, there are several than first time visits. The absence of a refill system, and observations to consider. First, the low patient co-pay the lack of significant financial incentives to give chronic under the National Health Insurance scheme makes medications for more than several weeks results in many access easy and encourages frequent physician visits in visits for chronic medication prescriptions [12]. Since Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 7 of 8 http://www.apfmj.com/content/9/1/11 reimbursement is based on a straightforward point sys- with physicians, and that shorter visits in Japan do not tem, without an option based on time as the billing sys- necessarily mean patients spend substantively less time tem in use in the US, there would be no financial in consultations with the doctor. Whether frequent- incentive to have a longer consultation. Still, frequent short visits, or less frequent-long visits are better for visits mayallowJapanesephysicianstobemoreaware effective delivery of primary care is uncertain. of and manage early minor changes in patients’ chronic This study has limitations. The design did not allow illnesses. us to examine the duration of patient waiting, so we Regarding variation in relative duration for sub- cannot comment on the veracity of the three-hour wait. groups, these findings are consistent for the most part, The geography, season and population served could with Deveugele et al’s work in European countries illus- influence the results. While additional research in other trating that consultation length increases if the patient is settings might provide more definitive estimates of con- older or if the reason for encounter is a psychosocial sultation length, the magnitude probably will not deviate problem [20]. Regarding the longer consultations in much. A physician who sees 60 patients in the 480 min- urban versus rural settings in the Deveugele et al study, utes of an 8-hour day averages 8 minutes per patient, our data from a rural setting compared to the data col- and at 100 patients per day, about 4.8 minutes. The lected in an urban setting by Ishikawa et al [23] are con- medical student’s presence may have altered the physi- sistent with longer consultations in urban versus rural cian’s performance, though we believe the direction of settings. this would be to make the duration longer. We did not In contrast to Deveugele et al’s findings on gender dif- control for first versus follow-up visits, and the latter ferences, we found consultations with men to be longer usually are longer. Finally, our analyses were based on in absolute time, but not at statistical significance, than the practice patterns of one physician. This physician consultations with women [20]. A number of factors was selected due to his local reputation as an excellent could account for this, but it is speculative. As men are practitioner and family physician known to the local more likely to be employed than women, it is possible medical university, willingness to participate, and our that they make fewer visits, and there may be more belief that the selected physician was similar to other ground to cover in a single visit. As a high percentage Japanese physicians. There is good reason to believe that of patients in the study were elderly, and women tend the physician’s examination style would be similar to to be healthier and live longer than men, it is also possi- other physicians in Japan since he trained in Japan. He ble that the visits with men were more complex than is a private practitioner and faces the same productivity the women. Furthermore, it is possible that gender dif- pressures of other private practice physicians. Although ferences are such that male patients may feel more com- the observed physician hires others to work part-time in fortable at asking questions or challenging physician his office, the times observed likely would not be sub- requests than women, or yet that communication pat- stantively different from those of a solo practice since ternswithmalepatientstakelonger. Furtherworkto he is responsible for his own patients and productivity. examine this issue is needed. Future work in additional settings and different times These stark differences in consultation length also of year could provide more robust estimates of doctor- raise questions about whether and, if so, how primary patient consultations in Japan. Specific comparisons of care works differently in Japan? While it is tempting to Japan with other systems that have comprehensive say that longer visits are better, this is debatable. health care coverage would help discern more the Patients’ perceptions of consultation length can be dis- potential pay-for-service environment of the US. Of torted–they may perceive it as shorter than actually, equal interest are the implications of these shorter but [25] or longer than actually [26]. Quality of time appears more frequent visits on the doctor-patient relationship, to be as important as the quantity of time for improving as well as the implications for training Japan’s future the doctor-patient relationship [27]. The three-minute family physicians. colloquialism supports the perception that patients have little time with doctors per visit, but it may be little dif- Conclusions ferent per year than the US. Assuming patients with The mean consultation length of 6.12 minutes is longer chronic medical problems see the doctor once per than the anecdotal reports of three-minute consultation month, in Japan, and the average time is ten minutes, lengths and is affected by variables similar to other physician-patient, face-to-face time totals 120 minutes international studies except that males have slightly annually. A patient in the US with a chronic illness longer consultation times than females. Still, 11% of vis- seen every six weeks (eight visits per year) for 15 min- its in this study took 3 minutes or less. Although this utes a visit, would be seen for about 120 minutes. This study helps to define consultation lengths and how vari- illustrates patients have significant face-to-face time ables affect these times in a rural Japanese practice, Wooldridge et al. Asia Pacific Family Medicine 2010, 9:11 Page 8 of 8 http://www.apfmj.com/content/9/1/11 10. Fetters MD: Health policy shortage, not a doctor shortage/Point of View/ there are more aspects of Japanese primary care that Michael D. Fetters. Asahi Shimbun Weekly 2010. need to be investigated. To better understand the signif- 11. Ministry of Health Labour and Welfare: Heisei Year 14 Social Insurance icance of such short consultation lengths, future Medical Examination and Treatment Compensation Revised Summary. Japanese Title: Heisei 14 Nendo Shakai Hoken Shinryou Houshu nadono Kaitei research should explore consultation length in relation Gaiyou 2002 [http://www.mhlw.go.jp/topics/2002/02/tp0222-1a.html], to continuity of care, frequency of visits, and compre- [February 8, 2010]. hensiveness of care and compare these results with 12. Kimura S: “Long-term prescriptions are increasing” Is it true? Nikkei Medical Online 2009, 1-2. other systems with nationalized healthcare. 13. Takemura Y: Family medicine: What does it mean? Asia Pac Fam Med 2003, 2:188-92. 14. Campbell R: The three-minute cure: Doctors and elderly patients in Acknowledgements Japan. In Containing health care cost in Japan. Edited by: Ikegami N, This study was possible in part through funding from the Japan Business Campbell JC. USA: The University of Michigan Press; 1996:226-33. Society of Detroit Foundation. Dr. Fetters’ participation was made possible 15. Ishibashi Y: Why is family medicine needed in Japan. J Fam Pract 1987, through the generous support of the Jitsukoukai Foundation. The authors 25(1):83-6. also gratefully acknowledge Professor Kenichi Mitsunami MD, PhD who 16. Smith BW, Demers R, Garcia-Shelton L: Family medicine in Japan. Arch hosted Adam Wooldridge for a medical student research elective at Shiga Fam Med 1997, 6(1):59-62. University Medical Science. The authors also acknowledge Naoki Ikegami, 17. Ohtaki S, Ohtaki T, Fetters MD: Doctor-patient communication: A MD and John Campbell, PhD for their thoughtful critiques. comparison of the USA and Japan. Fam Pract 2003, 20(3):276-82. 18. Okkes IM, Polderman GO, Fryer GE, Yamada T, Bujak M, Oskam SK, et al: The Author details role of family practice in different health care systems: A comparison of The Ohio State University, College of Medicine, 370 West 9th Avenue, reasons for encounter, diagnoses, and interventions in primary care Columbus, OH 43210, USA. University of Michigan, Department of Family populations in the Netherlands, Japan, Poland, and the United States. Medicine, 1018 Fuller St, Ann Arbor, MI 48104-1213, USA. Yuge Medical J Fam Pract 2002, 51(1):72-3. Clinic, 1825 Yuge, Ryuou-cho, Gamou-gun, Shiga-ken, Japan 520-250. 19. Yamada T, Yoshimra M, Nago N, Inoue Y, Asai Y, Koga Y, et al: A study on the outcomes of health problems (the concept of “Episode of Care”) Authors’ contributions based on clinical statistics using the international classification of ANW and MDF conceived and designed the study. ANW collected data primary care (ICPC). Jap J Prim Care 2000, 23:213-23. while NA, AS, and MDF contributed to data analysis and interpretation. ANW 20. Deveugele M, Derese A, van den Brink-Muinen A, Bensing J, De and MDF drafted the manuscript while all authors critically revised and Maeseneer J: Consultation length in general practice: Cross sectional approved the final manuscript. study in six European countries. BMJ 2002, 325(7362):472. 21. Okkes I, Jamoulle M, Lamberts H, Bentzen N: ICPC-2-E: the electronic Authors’ information version of ICPC-2. Differences from the printed version and the ANW studies medicine at The Ohio State University College of Medicine: consequences. Fam Pract 2000, 17(2):101-7. NA serves as Data Manager, Department of Family Medicine, University of 22. Otaki J: Considering primary care in Japan. Acad Med 1998, 73(6):662-8. Michigan: AS serves as Biostatistician, Department of Family Medicine, 23. Ishikawa H, Hashimoto H, Roter DL, Yamazaki Y, Takayama T, Yano E: University of Michigan: MA serves as Director, Amenomori Family Clinic, Patient contribution to the medical dialogue and perceived patient- Shiga, Japan: MDF serves as Associate Professor, Department of Family centeredness. An observational study in Japanese geriatric Medicine at the University of Michigan and Director, Japanese Family Health consultations. J Gen Intern Med 2005, 20(10):906-10. Program at Dominos Farms Family Medicine. 24. Blumenthal D, Causino N, Chang YC, Culpepper L, Marder W, Saglam D, et al: The duration of ambulatory visits to physicians. J Fam Pract 1999, Competing interests 48(4):264-71. The authors declare that they have no competing interests. 25. Ogden J, Bavalia K, Bull M, Frankum S, Goldie C, Gosslau M, et al: “I want more time with my doctor": A quantitative study of time and the Received: 16 June 2010 Accepted: 23 November 2010 consultation. Fam Pract 2004, 21(5):479-83. 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Ikegami N, Campbell JC: Japan’s health care system: Containing costs and attempting reform. Health Aff (Millwood) 2004, 23(3):26-36. 5. Ikegami N: Japanese healthcare system: Lessons to be learned. Expert Rev Pharmacoecon Outcomes Res 2009, 9(3):201-4. 6. Campbell JC, Ikegami N: Long-term care insurance comes to Japan. Health Aff (Millwood) 2000, 19(3):26-39. 7. Campbell JC, Ikegami N: Japan’s radical reform of long-term care. Social Policy and Administration 2003, 37(1):21-34. 8. Saigal P, Takemura Y, Nishiue T, Fetters MD: Factors considered by medical students when formulating their specialty preferences in Japan: Findings from a qualitative study. BMC Med Educ 2007, 7(1):31. 9. Ministry of Health Labour and Welfare: Heisei Year 18 Physician, Dentist, and Pharmacist Survey; Heisei 18 Ishi, Shikaishi, Yakuzaishi, Chousanogaikyou. 2006 [http://www.mhlw.go.jp/toukei/saikin/hw/ishi/06/ kekka1-1.html].

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Asia Pacific Family MedicineSpringer Journals

Published: Nov 23, 2010

References