The missing fifteen minutes

Russia’s health minister, Mikhail Murashko, recently described a rigid fifteen-minute appointment standard as “meaningless”. He proposed asking patients questions in advance so that the length of each consultation could be determined when they book.

His remarks prompted a wave of criticism from frontline healthcare workers in professional online forums. Doctors and nurses in Russia’s public outpatient clinics have endured excessive workloads for years, while official working-time standards are often ignored. Against that background, talk of abandoning a rigid appointment standard sounds detached from reality at best. At worst, it signals another reform that will intensify the pressure.

In practice, the fifteen-minute standard set by a Health Ministry order for initial consultations with district primary-care doctors and certain specialists is already largely absent from clinic schedules. At best, clinics use an average twelve-minute slot covering both initial and follow-up visits. Some schedule patients every eight to ten minutes, or allow twelve minutes for an initial visit and eight for a follow-up. Doctors must work at a punishing pace while spending much of their time on paperwork, at the expense of direct patient care.

Yet research and surveys of doctors indicate that district primary-care physicians and paediatricians need at least twenty minutes for a good-quality initial consultation, and sometimes much longer. Private clinics commonly schedule thirty-minute appointments. The chance to care for patients properly, without an exhausting rush, is frequently cited as a reason for leaving public institutions for private practice.

How doctors made the state account for their time

For a long time, Russian healthcare had no regulatory framework governing the time allowed per patient. Doctors were pushed to speed up consultations, especially when illness rates rose, spending five to seven minutes on a patient, sometimes only three.

This eventually led to two prominent protest campaigns coordinated by the healthcare workers’ union Deystviye (“Action”): a work-to-rule action by district paediatricians in Izhevsk in April 2013, and a similar action by doctors in Moscow’s public clinics in spring 2015. In both cases, doctors refused to rush consultations or stay beyond the end of their contracted shifts.

After the Moscow work-to-rule action, the Health Ministry issued its first sector-wide standards for consultation times on 2 June 2015. Order No. 290n chiefly covered the specialties involved in the protests: district paediatricians, district primary-care physicians, general practitioners and obstetrician-gynaecologists. Two further orders later established time standards for other specialties.

Order No. 290n allowed fifteen minutes for an initial consultation with a district doctor, eighteen minutes with a general practitioner or family doctor, and twenty-two minutes with an obstetrician-gynaecologist. Follow-up visits were to take 70–80% of the initial consultation time, and preventive appointments 60–70%. These orders brought some temporary improvement. The most extreme seven- or eight-minute slots were eliminated, and electronic booking systems adopted average intervals of twelve minutes for district doctors and, for example, fifteen for obstetrician-gynaecologists.

Staff shortages and the limits of what doctors can do

But clinics continued to enlarge the populations assigned to district doctors or make them cover several districts whose posts were vacant. With staff shortages unresolved, management tried to compensate by extending the part of the working day devoted to consultations. Time previously reserved for other duties was reassigned to seeing patients in the consulting room.

That changes the question of how many minutes each patient receives. Three or four hours of intensive consultations followed by home visits, reviewing records or other duties is one thing. Six or seven hours of almost continuous consultations, seeing a new patient every ten to twelve minutes, is another. Even the thirty-minute lunch break is often swallowed up by appointments running late or unfinished paperwork.

Outpatient consultations are among the most intensive forms of medical work: a continuous sequence of clinical decisions made under severe time pressure and with considerable responsibility. Appointment length therefore has to be considered alongside the overall organisation of working time.

How the right to a shorter working day was eroded

Soviet working-time standards recognised the need to limit continuous outpatient consultations, including their intense mental and physical demands. Specialists seeing outpatients were assigned a shorter working day of five and a half hours across a six-day week. Moving to a five-day week increased the daily allowance to six hours and thirty-six minutes, preserving the same thirty-three-hour week.

Russia’s Labour Code established a shorter working week for healthcare workers, capped at thirty-nine hours. A government decree of 14 February 2003 retained a special thirty-three-hour week for doctors whose work consists exclusively of outpatient consultations.

For district primary-care doctors, however, no binding limit was set on the consultation portion of the working day. For years, a common arrangement allocated four hours to adult primary-care consultations, or three hours to paediatric consultations, two hours to home visits, and 1.8 hours — one hour and forty-eight minutes — to other duties. A four-hour clinic session has increasingly become the exception. It is extended to five or six hours, and when home visits are transferred to an urgent-care unit, consultations can occupy the entire working day: 7.3 or 7.8 hours, meaning seven hours and eighteen or forty-eight minutes.

District doctors have unsuccessfully tried to limit consultation hours by invoking the thirty-three-hour standard for specialists as a comparison. Employers and officials disregard the purpose of that limit: protecting the health and quality of work of doctors expected to work at an assembly-line pace.

Even specialists’ access to the thirty-three-hour week has increasingly become the exception. Citing Health Ministry guidance, employers argue that doctors whose formal duties include health education, preventive care or other tasks cannot be considered to work exclusively in outpatient consultations. They are therefore assigned a thirty-nine-hour week. This formalistic interpretation has also found support in court decisions.

As a result, specialists’ entire working day, calculated on a thirty-nine-hour week, can become a continuous succession of consultations every twelve or fifteen minutes. Some administrative work is then finished after their shift ends.

Low pay and staff shortages also push doctors and nurses to take additional posts alongside their main jobs. In practice, that can extend the working day to nine to eleven hours.

One endoscopist at a Moscow clinic approached Deystviye for advice after she was effectively assigned a twelve-hour day, supposedly to provide evening appointments. No separate contract for an additional post was signed, and she was not asked to consent to overtime. She says management simply changed her schedule and opened extra hours in the electronic booking system.

Such workloads are far from exceptional. Health Ministry data put the average ratio of posts held to staff at 1.3 across healthcare in 2024. Rosstat’s figures for 2023 ranged from 1 to 1.8 across regions. A workload study by the Healthcare Workers’ Union of the Russian Federation found that, in some institutions, each specialist covered up to two full-time posts.

Russian rules also make a special exception to the usual limits on additional employment for healthcare workers. Under a Labour Ministry resolution of 30 June 2003, doctors and nursing and other mid-level clinical staff in areas with shortages may work up to a full monthly working-time allowance in an additional job. In other words, regulation allows employers to compensate for missing staff by almost doubling the working time of those already employed.

The electronic schedule as a medical assembly line

The labour movement demanded an eight-hour day as early as the mid-nineteenth century, but the issue became especially pressing with mass production. Moving production lines imposed a rigid external pace on workers. Ford’s assembly line, introduced in 1913, is the classic example. In 1914, the company cut its working day from nine hours to eight; in 1919, the eight-hour principle was enshrined in the International Labour Organization’s first convention. The logic is straightforward: the more intensive the work, the more important limits on its duration and time for recovery become.

The parallel is particularly apt in today’s outpatient clinic. An electronic booking system sets the pace instead of a moving belt, and a new patient enters the room every ten to fifteen minutes in place of another component arriving on the line.

Unlike a worker repeating an operation on a conventional assembly line, a doctor must carry out many different tasks within each slot: hear the patient’s symptoms, take a medical history, examine them, assess the risk of serious conditions, make a diagnosis, order tests, prescribe treatment, complete records and give advice.

Every consultation demands close attention and professional responsibility. A diagnostic error can have immediate consequences for a patient’s health and life.

But sustained concentration has physiological limits. Long periods of demanding, decision-intensive work cause cognitive fatigue: attention deteriorates, information becomes harder to process, decisions slow down and the risk of error rises.

Outpatient staff must constantly switch between different clinical situations, with almost no scheduled breaks to recover their concentration.

Emotional pressure adds to the burden. Clinic doctors and nurses see many patients each day, with different ages, emotional states and expectations. Limited consultation time, queues, delays in seeing specialists, sick-leave certification, tests and access to medicines all create potential for conflict.

Who pays for speeding up the medical assembly line?

Flexible appointment lengths alone cannot solve this problem. Continuous patient-facing work must be limited, recovery breaks made mandatory, and doctors given protected time for records and other duties. But even those measures will be hollow without more staff, less administrative work and limits on using additional posts and longer working days to cover vacancies.

In discussing the quality of care within fifteen-minute appointments, Murashko sidesteps this structural problem. More flexible scheduling creates no additional doctor-hours. Extra time for one patient can only come from fewer appointments, a different allocation of working time or more staff. If patient numbers and staffing stay unchanged, it must be taken from another patient — or once again from a doctor’s breaks, lunch or personal time.

Electronic booking can shift minutes between slots, but it cannot replace missing specialists or override the limits of human attention. A doctor is not a component of a production line, and a patient is not another part to be processed within a fixed interval.

The debate over fifteen minutes is therefore about more than adjusting schedules. It concerns who bears the consequences of chronic understaffing. While the state shifts that burden onto healthcare workers, making them work faster and longer, both staff and patients pay the price. Speeding up the line further knowingly increases the risks of burnout and medical error, and undermines the possibility of good-quality care.

Andrey Konoval is co-chair of Deystviye, the healthcare workers’ union in Russia.