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Bmj Usa: Editor's Choice Editor's choice

The pressure of time

BMJ 2005; 331 doi: (Published 15 September 2005) Cite this as: BMJ 2005;331:E375
  1. Douglas Kamerow, editor

    Primary care is a busy place. We don't limit what our patients can talk about. We don't have the luxury of saying this or that part of the body or disease is not our business. We don't just deal with prevention or diagnosis or treatment. Anything's fair game. This takes a lot of time.

    Most primary care doctors are paid by the visit. More visits and more complex visits mean more income. Time is limited. Everyone wants to be a member of the “good doctor club,” doing the right thing for our patients at the right time, but time is often a barrier—to taking a complete history, performing a complete physical, providing needed counseling. How much health care is enough? How much is too much? These are crucial questions in all of medicine.

    Should we take the time to check the fundi of all our patients with hypertension? We were all taught to do this in medical school. The guidelines say so. But a systematic review by Bert-Jan van den Born and colleagues (p 411) finds that there isn't much evidence that funduscopy provides additional value in the management of hypertensive patients.

    Should we counsel our older patients about the risks and benefits of prophylactic aspirin, recommending it for those without contraindications? Peter Elwood and colleagues (p 423) say yes, that the possibility of benefits (protection from cardiovascular events and maybe cancer and dementia as well) outweighs the risk of bleeding. Colin Baigent (p 425) disagrees, finding the evidence not persuasive that this intervention makes sense on a population basis.

    Should we make time to screen our patients for increased intraocular pressure to prevent decreased vision from glaucoma? A systematic review by Philip Maier et al (p 389), finding that lowering intraocular pressure reduces visual field loss, seems to support such screening. But Russell Harris, a member of the US Preventive Services Task Force, argues (p 381) that the case for screening in primary care is far from settled. It may be that investing the time to do this screening will not pay off in clinical benefit.

    Everyone agrees that we shouldn't waste time on unproven tests, treatments, and preventive maneuvers. There isn't enough time in the day or money in anyone's budget to do everything. One purpose of a medical journal is to publish papers and editorials like these to help us sort things out. If we abandon the unproven, maybe that will leave us just enough time to do things that really make a difference.

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