Nguyen Michelle-Linh T, Schotland Samuel V, Howell Joel D
National Clinician Scholars Program, Philip R. Lee Institute for Health Policy Studies, and Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, California (M.T.N.).
School of Medicine, University of Michigan, Ann Arbor, Michigan, and Program in the History of Science and Medicine, Yale University, New Haven, Connecticut (S.V.S.).
Ann Intern Med. 2022 Oct;175(10):1468-1474. doi: 10.7326/M22-1575. Epub 2022 Aug 30.
Many outpatient physicians and patients feel that current scheduling systems do not afford enough time for direct patient-physician interaction, leaving patients feeling unheard and physicians feeling demoralized. This dissatisfaction degrades patients' trust in the health care system and contributes to workforce moral injury and burnout. In the hopes of understanding the roots of this time stress and helping to guide future decisions about how to organize physicians' time, this article describes changes in the organization of U.S. outpatient physicians' time, starting from care at home in the late 19th century. It discusses the origins of the appointment system, which was invented to be highly personalized, with assistants adjusting appointment durations to accommodate clinical activities, specific patient needs, and individual physician proclivities. The article then describes how centralization of appointment scheduling became more common as U.S. medicine became increasingly consolidated into larger and larger groups and health systems. This distanced schedulers from the people and care they were organizing and necessitated standardized appointment durations, which did not accommodate individual patient and physician needs. With the rise of managerialism, schedulers became increasingly accountable to administrators rather than patients and physicians. Whereas early appointment systems depended on personal connection between schedulers and the physicians and patients they supported, today's schedulers have few such interactions. The widespread shift to centralized scheduling and standardized time slots has contributed to misalignment among time allocation, patient care, and health care workforce well-being and is likely exacerbating ongoing tensions among patients, physicians, and administrators.
许多门诊医生和患者认为，当前的排班系统没有提供足够的时间用于医生与患者的直接互动，这让患者感到自己的声音未被倾听，医生也感到士气低落。这种不满降低了患者对医疗系统的信任，并导致医护人员出现道德伤害和职业倦怠。为了理解这种时间压力的根源，并帮助指导未来关于如何安排医生时间的决策，本文描述了美国门诊医生时间安排的变化，从19世纪末在家中提供医疗服务开始。文章讨论了预约系统的起源，该系统最初设计得高度个性化，助手会根据临床活动、患者的具体需求和医生的个人倾向来调整预约时长。接着，文章描述了随着美国医疗越来越多地整合为越来越大的医疗集团和医疗系统，预约排班的集中化是如何变得更加普遍的。这使得排班人员与他们所安排的人员和医疗服务之间的距离变远，从而需要标准化的预约时长，而这无法满足患者和医生的个性化需求。随着管理主义的兴起，排班人员越来越对管理人员负责，而不是对患者和医生负责。早期的预约系统依赖于排班人员与他们所支持的医生和患者之间的个人联系，而如今的排班人员几乎没有这样的互动。向集中排班和标准化时间段的广泛转变导致了时间分配、患者护理和医护人员福祉之间的失调，并且可能正在加剧患者、医生和管理人员之间持续存在的紧张关系。
