I recently saw a patient for a second opinion with a consequential missed diagnosis. Understandably, he was frustrated and remarked that his initial opinion was given after less than 10 minutes of face-to-face consultation time. This got me thinking about the various demands on spine clinicians’ attention and if there might be a breaking point when it comes to health care outcomes.

In the ongoing era of hospital system consolidation, many physicians face growing patient panels and increased complexity of visits, while also battling a new normal of administrative burden. While hospital systems push for more completed visits per hour to meet volume and access goals, spine providers may feel compelled to do the same but for different reasons: create space for those patients who need more expeditious care and/or offset reimbursement losses for services provided.

The reasons for increasing patient complexity per visit is a topic for another day, but an interesting one. My question for today: What is the variance in spine consultation time and is there a relationship to outcomes or access?

While this question has been studied for primary care visits, the science is sparce as it relates to spine. A 2006 Cochrane systematic review reported insufficient evidence that increases primary care visit length provides measurable benefits to group mean health outcomes.1 In addition, increasing primary care visit length does not necessarily reduce the visit rate per patient per year.

However, for individual subgroups, especially those with multiple comorbidities or mental health problems, longer visits were associated with more accurate diagnoses, improved patient self-efficacy, and improved quality of life. When instead looking at the effects of reducing visit lengths in primary care, multiple studies report negative consequences: higher physician burnout, worse patient satisfaction, worse patient outcomes, reduced patient self-efficacy, failure to meet guideline directed recommendations for chronic disease management, and inappropriate prescribing of antibiotics (a global marker of quality in outpatient primary care).2-5

For an average primary care patient panel size of 2,500 patients, primary care providers would need 26.7 hours per day to meet the demands of guideline-based acute and chronic disease diagnosis and management.2 It is also concerning that 18 countries covering ~50% of the world’s population have a mean consultation length of 5 minutes or less.5 Obviously, something must give here, and, in some cases, what gives is the quality of the spine referral or the quality of the nonoperative management pursued prior to referral to spine.6,7

I could not find published studies regarding spine surgeon time spent with patients as it relates to outcomes. Specifically, we do not know if shorter visit lengths lead to worse spine surgical outcomes or to better access for patients truly needing spine expertise. Like primary care, visit complexity in spine is rising over time. In spine, this can mean not only addressing structural complexity, but also bone health, psychological health, frailty, other social determinants of health, sifting through information about prior spine care, and careful consideration of medical comorbidities.

I suspect that the increasing complexity of spine consultations combined with shorter visit lengths probably does increase the rates of missed diagnoses and missed opportunities to improve patient self-efficacy. It seems that the minimum length for a spine consultation should be enough time to make an accurate diagnosis and understand the patient’s goals, since an incorrect diagnosis or poorly indicated intervention is unlikely to yield a good outcome, regardless of the total time spent with the patient.

While we lack specific studies on spine consultation time, there are publications describing specific patient education initiatives and their impact on spine surgical outcomes. These programs are typically not delivered by the primary consultant or surgeon. For instance, having a specially trained nurse spend an extra hour with the patient on the nature of the spine surgery and immediate perioperative period does not necessarily reduce length of stay or pain intensity.8

However, structured education or prehabilitation programs with an emphasis on pain education, expectations, physical conditioning, or cognitive-behavioral based interventions have all demonstrated positive outcomes for spine surgical patients, with respect to postoperative pain, disability, self-efficacy, psychological behaviors, and satisfaction with surgery.9 This type of expectation setting, motivational interviewing and patient engagement takes time and is difficult to deliver effectively in a typical outpatient spine consult, due to the growing demands of a given visit within a finite schedule.

So how much of our scarce attention should be devoted to a given patient per visit? I believe the answer is enough time to get the right diagnosis, understand the patient’s goals, answer most questions, and hopefully build some rapport. However, in most templates, the same visit length will be planned for the patient with spinal deformity considering surgery versus palliative options, as the person with an uncomplicated transverse process fracture.

As pressure increases to optimize access, efficiency, room utilization, and revenue, I think there is great opportunity to research enhanced triage, consultation time (with and without ambient AI program use), and structured education programs, and their effects on satisfaction and health outcomes.10  Until then, it may be best to start setting more upfront expectations for patients regarding wait times, consultation time, and team-based care, while we providers work on accepting that good spine care takes the time it takes and should be slow enough to be able to pay attention.2

On that note, I’d like to introduce the March/April issue of SpineLine and highlight just a few of the topics worthy of your limited time. Please take a close look at the President’s Message, where Dr. Mitchell details some of the insidious consequences of expanding hospital employment of physicians. I found the Invited Review by Dr. Anderson and colleagues on Hip-Spine syndrome to be immediately applicable in practice. In Coding, Dr. DiPompeo efficiently deciphers important coding changes for sacroiliac joint fusions. Finally, for some lighter reading, direct your attention to Behind the Mask, one of many ways to get to know our spine community better.