Our work describes the current states of doctor–patient communication in oncological follow-up clinics in China’s public hospitals. The fast pace of outpatient operations manifests in the flow of large numbers of cancer patients and a heavy workload on oncologists in these hospitals. As a result, patients tend to have a singular need for each clinic visit, particularly those attending follow-up appointments after discharge. Regarding the content of the clinic visit, physicians spent as much time addressing reimbursement issues as they did on routine medical care. Without the clinicians’ attention, patients seldom reported symptom distress from the patients during the visit. This observation suggests an inadequate focus on patients’ status, which can potentially reflect the progress of disease or alarm adverse effects from cancer treatment.
In this study, the median visit duration for the established patients were 4 minutes, shorter than time spent by the newly diagnosed patients and that in other countries, which ranged from 6 to 15 minutes,[18–21] Outpatient visits in tertiary hospitals in China can easily exceed 20,000 per day making it common for a single clinic to accommodate over 100 outpatient appointments. Oncologists have to see around 20–60 patients during a half-day shift.[22] Physicians are required to multitask during outpatient visits, due to extreme time constraints. Their tasks include documenting patient history and coordinating with other departments. This heavy workload necessitates prioritizing tasks for greater efficiency.[23] In other words, physicians face a dilemma between fulfilling outpatient tasks and establishing a deep connection with their patients.[24]
We analyzed the characteristics associated with visit duration. Patient education had an impact on the visit length and it has been reported that patients with a higher level of education tend to receive more time with their physicians,[21] which provides more opportunities to understand their disease and grasp related more comprehensively.[25] The present of family members accompanying patients is also related to the duration of the visit.. More individuals equate to more demands for expression, undoubtedly complicating the outpatient environment with their presence.[23] However, the involvement of families in medical decision-making is an crucial elements in achieving patient-centered medicine.[26] Establishing a balance between the advantage and disadvantages of family participation in the care of cancer patients will require further development of specific, standardized strategies, such as the shared decision-making tools,[27] to ensure efficient outpatient management for patients with cancer.
Notably, it took doctors 5 minutes to process medical insurance reimbursement. The reimbursement procedure places serious time demands on clinicians, because their time is devoted in completing paperwork as opposed to on direct patient care.[28] In most cities in China, additional reimbursement (outpatient chronic disease reimbursement policy) is available for outpatient services involving serious illnesses such as cancer or uremia.[29] Reimbursement policies and rates vary by province and city, and the process to obtain reimbursement also varies widely.[3, 30] Regarding this policy, outpatient oncologists are required to: (1) fill out an application form based on cancer information, and (2) inform and provide medical evidence related to cancer for audits. This usually includes cancer-associated medical histories and tests.[31] Oncologists usually work alone in outpatient clinics and must handle all procedures themselves. A study in Slovenia showed that the mean duration of administrative visits (for prescriptions and other administrative visits), which accounted for 25.5% of all the visits, was 3.7 minutes.[21] Study of outpatient doctors' workload in China found that 38.04% of the doctors' service time of each patient in a 4-minute outpatient visit was spent on paperwork (such as taking medical records, writing prescriptions, etc.).[32] We observed that the reimbursement process, while bringing convenience to outpatients with cancer, also sacrifices the physicians’ time that should be devoted to medical care.
Accordingly, we found that only 22 of the 488 established patients visited the oncologist for symptom control, with each visit lasting approximately 7 minutes. The most reported symptoms were pain, loss of appetite, fatigue, and diarrhea, suggesting that symptoms are common in patients with cancer during treatment.[33, 34] A study by the Eastern Cooperative Oncology Group showed that over 35% of patients receiving anti-cancer therapy reported at least three moderate-to-severe symptoms.[35] Patients who actively received anti-cancer treatment had a greater burden of symptoms, particularly physical symptoms. Luana et al.[36] categorized the outpatient oncology services into eight categories, one of which is symptom management. While there is no universal guideline for discussions between oncologist and patients during follow-up visit,[37] we demonstrated that most established patients were undergoing standardized outpatient follow-ups. Due to the substantial outpatient traffic, the interaction between patients and doctors is driven by the primary needs. Since diagnosed patients often visit the clinic multiple times, they clearly outline their concerns for each visit when entering the consultation room. This practice streamlines the process, allowing doctors to address each patient’s primary concerns more efficiently. In our study, considering nearly two-thirds of established patients were under active cancer treatment, this low proportion of symptom consultations may indicates a significant unmet need for patients in China’s public hospitals.[38] We analyzed possible reasons for the low percentage of patients reporting symptoms in this study. First, because of the cross-sectional design of this study, there is no guarantee that the established cancer would have reported their symptoms or other adverse effects to their physicians at previous outpatient visits. Second, studies focusing on symptom reporting behaviors of outpatients with rectal cancer have reported that chronic, nonspecific, and mild symptoms were less discussed by patients than more acute, specific, and severe symptoms.[39] We are concerned about this reason that selective reporting of symptoms to outpatient physicians may put patients at risk. Third, symptomatic patients may seek care in other departments, such as emergency departments, to manage their symptoms. One study reported that cancer survivors presented to the emergency department more frequently than to an oncologist's clinic, even during an oncologist’s working hours.[40] The emergency department currently functions as a crucial location for triaging symptomatic cancer patients. This trend might be attributed to the psychological insecurities of the patients. They would prefer to see a doctor immediately and avoid the difficulties associated with making appointments at the oncology clinic.[41] Patients may be placed at risk by clinicians who fail to recognize their needs promptly, underestimate these needs, or do not adequately document or manage their symptoms.[42] Untreated or underestimated symptoms have downstream effects, including excessive emergency department visits, treatment interruptions, and increased mortality.[43] Managing the specific medical needs, symptom control, of cancer patients poses a challenge. Electronic technique-based outpatient symptom management[15] or outpatient assistance by qualified medical assistants[10] is worth exploring.
Several limitations of this study need to be addressed. First, observer bias is inevitable. The possibility that patients and doctors might change their consciousness and behavior in the face of the observers was not considered in this study. For observers, excessive attention to symptom content may lead to the loss of other important information. We did not consider coexisting conditions that may have contributed to the development of symptoms, namely chronic diseases such as osteoporosis, hypertension, or coronary heart disease. Second, we relied on data from a tertiary hospital in Southwestern China; therefore, generalizing our results to all oncology clinics may be biased. Third, for the analysis of the influencing factors of visit duration, we included quantitative variables that could be collected as much as possible, and qualitative variables were not analyzed due to acquisition difficulties.
In conclusion, by measuring the time spent on various primary complaints during routine follow-up visits for outpatients with cancer in a busy clinic, we underscored the necessity to reallocate personnel resources, particularly for the most time-consuming issue: insurance reimbursement documentation. Additionally, the insufficient focus on symptoms related to cancer treatments highlights a need for a more efficient management strategy in outpatient clinics within China’s public hospitals.