Although the usual consultation length in general practice has been studied in many countries, it has not yet been studied in Singapore. This paper reports the consultation length in an established general practice. The mean consultation length as well as the length of time required for acute and chronic conditions are reported. Such measurements are useful for computation purposes on workload and time required in providing care in the general practice setting.

The study was conducted over a period of 20 days from 25 April 1994 to 15 May 1994 at a suburban general practice clinic staffed by four doctors.

The diagnosis or reason for encounter of all consultations was captured by the doctors themselves directly into their computers. The clinic’s customised software displays on the screen both a diagnosis (which the doctor may modify) and the three character codes of ICD 10 for the initial condition that was treated. Where two or more concurrent diagnoses or reasons for encounter existed in the patient, only the main condition was captured.

Cases which had missing diagnosis or reason for encounter, and attendances for ‘repeat medicine’ were excluded. These contributed 10.9% of all consultations studied.

A total of 1667 consultations were recorded in the system over the 20 days. Of this total, the reason for encounter or diagnosis was missing in 65 cases and 116 were attendances for repeat medicine. Of the remaining 1486 cases, 115 were for ‘well’ visits such as health assessment, preventive care, and family planning. The remaining 1371 cases were for ‘sick’ consultations.

The distribution of consultation lengths follows a positively skewed pattern (Fig 1). The mean consultation length was 9.3 minutes, with a median of 6.0 minutes and mode of 3 minutes. Consultation lengths ranged from 1 to 140 minutes.

However, the proportion of chronic conditions seen in this practice - hypertension, diabetes mellitus, and asthma and bronchitis - accounted for 14.9% of cases compared with 10.3% in the MS. The clinic also had relatively more respiratory and dermatological cases and fewer arthritic and diarrhoeal diseases than the MS average for general practitioners. This was contributed by the special interest of the doctors, and a visiting consultant dermatologist who conducted two sessions a week in the clinic.

Acute upper respiratory tract infection

Upper respiratory tract infection accounted for 37.3% of the total consultations. The mean, median and modal consultation lengths for this condition were 7.1, 5.0 and 4 minutes, respectively. The distribution pattern of the consultation lengths for upper respiratory tract infection is shown in Fig 2. On the whole, the variance in consultation lengths for this condition is not high. Of these cases, 56.6% are seen within 5 minutes and 85.6% within 10 minutes.

Essential hypertension

The consultation length for essential hypertension in the clinic had a mode of 4 minutes with a second peak appearing at between 10 and 13 minutes (Fig 3). The median was 5.0 minutes and mean was 7.6 minutes. About half (52.2%) of cases were seen within 5 minutes and 79.1% were seen within 10 minutes. Most of the cases (89.6%) were seen within 15 minutes. The maximum consultation length recorded for hypertension was 35 minutes (Fig 3).

Bronchial asthma

The mean consultation length for bronchial asthma was 9.9 minutes. There were two modes in the distribution, occurring at 4 minutes and 10 minutes (Fig 4). Of these cases, 42.3% were seen within 5 minutes, 73.1% within 10 minutes, and 84.6% within 15 minutes.

Taking the mode of 3 minutes for all consultations into consideration, further analysis showed that there were a total of 426 cases (28.7%) which had consultation lengths that lasted from 2 to 4 minutes. The most common diagnostic conditions for these cases were comparable with those described earlier for all cases (see Table I): acute upper respiratory tract infections (46.0%), essential hypertension (6.1%), acute bronchitis (4.9%), gastroenteritis (2.3%), acute anxiety (1.9%), diabetes mellitus (1.6%), bronchial asthma (1.6%), and other conditions (35.6%).

However, there is a practical limit to how brief a consultation can possibly be. Mechanic observed that doctors were forced to shorten their consultation pace when the patient load increased, a "particularly frustrating and uncongenial" practice which "requires them to practise on an assembly line basis which diminishes the unique satisfaction possible in general practice"(11). Not only is personal job satisfaction diminished, but quality of care may also be compromised with inadequate time for consultations. One study noted that prescriptions were frequently offered instead of advice(12).

(1) review of the patient’s records and summary before calling in the patient;

(2) greeting to put the patient at ease;

(3) allow the patient to present his problem and taking an appropriate history;

(4) carry out appropriate physical examination and opportunistic screening tests such as blood pressure, weight measurements, and urinalysis;

(5) make an assessment and initiate management, including investigations and referrals, where necessary;

(6) advise the patient on the nature of the problem and its prognosis;

(7) check on compliance with previous health advice and reinforce if necessary;

(8) update the clinical notes.

This average duration should suffice for new episodes of minor illnesses and follow-up visits, which do not require the ‘whole process’ of consultation, but rather, focusing usually on one or two specific areas. Consultations for ‘chronic’ conditions likewise may be conducted under separate sessions arranged for the patients by appointment. During each consultation, the doctor may focus on one or several aspects of care for the particular condition, eg., health education, or monitoring for complications in diabetes mellitus.

When representative mean consultation lengths for a typical acute (acute upper respiratory tract infection), chronic (hypertension), and chronic relapsing and remitting condition (bronchial asthma) were compared, similarities were observed between the mode for acute upper respiratory tract infection and the first of the two modes of hypertension and bronchial asthma.

In the bimodal frequency distribution for hypertension, the majority of cases which occur around the first mode of 4 minutes may represent consultations for stabilised hypertensive patients which require fairly few tasks to be performed. As these form the majority of cases, the mean for essential hypertension (7.6 minutes) was fairly similar to those of upper respiratory tract infection (7.1 minutes). The second mode in the distribution for hypertension (10 to 13 minutes) could represent newly diagnosed cases and periodic assessments which require more thorough physical examination, patient education, and investigative procedures.

Bronchial asthma is an example of a chronic relapsing and remitting condition in which the majority of cases would present as chronic stabilised asthma. These routine follow-up visits, represented by the first mode of 4 minutes, would require fewer tasks, including perhaps a quick check-up with the prescription of repeat medication. The remainder of cases which present as acute asthma would require longer consultations as they may need more examination, explanation and reassurance, and management may involve nebulisation and subsequent review. Such cases would account for the second mode of 10 minutes.

Although chronic cases need more time because more tasks are required, this is not so in practice because not all tasks have to be carried out within one visit. Newly diagnosed cases and those requiring acute attention may require longer consultations, but by and large, the tasks required for patients on long-term follow-up may be distributed over the number of visits in a year.

When the distribution of consultation lengths for typical acute and chronic conditions were related to the number and complexity of tasks required, a minimal consultation of at least 5 minutes appears to be reasonable, even for the greater proportion of consultations for chronic conditions, which are for routine follow-up.

Although this study focused on the process rather than the outcome of consultations, linking time spent in consultation with the tasks performed would provide useful indicators on standards of care.