Physicians have more work than time in the day
Study determines amount of time needed for guideline-based care.
Primary care physicians get 24 hours a day – but would need at least 26.7 to provide guideline-based care to their patients.
The findings were part of “Revisiting the Time Needed to Provide Adult Primary Care,” a study published July 1 in the Journal of General Internal Medicine. Authors Justin Porter, MD, Cynthia Boyd, MD, MPH, M. Reza Skandari, PhD, and Neda Laiteerapong, MD, MS, used 2020 data from the National Health and Nutrition Examination Survey to create model patient panels of 2,500 patients.
Based on the U.S. Preventive Services Task Force guidelines, they calculated how much time physicians would need each day to handle preventive care, chronic disease care, acute care, and documentation and inbox management. Using team-based care, they estimated that amount of primary care physician time could decrease to 9.3 hours per day.
Medical Economics discussed the results with Porter, the lead author and assistant professor of medicine at University of Chicago Medicine. Responses have been edited for length and clarity.
Medical Economics (ME): In your own words, can you explain why it's so important for primary care physicians to spend time with their patients?
Justin Porter (JP): When many people think about what a doctor does, it's diagnosing disease, it's prescribing medications, but more than that, it's about taking patients by the hand and explaining their medical problems to them, and what they need to do to put them in perspective. Patients now are in an increasingly fragmented medical system where they have many different subspecialists talking about many different things that they need to do, but they need someone to take them by the hand and put all these things in perspective. That's, really what the role of the primary care doctor is. And that takes time. That's more than just writing a prescription. It's making patients understand what's going on and understanding their values. It's complicated and it certainly takes time.
ME: Your study examined the time physicians need to provide adult primary care. What did you find?
JP: We took a bottom-up approach to answer this question. We were trying to think, not so much how long does a doctor take to provide primary care to their patient panel, but how long should it take if they follow the guidelines as they were written? We broke down the tasks that a primary care doctor needs to do. All primary care doctors need to provide preventive care services for their patients, chronic disease services for their patients, need to address acute care issues that come up. Then there's documentation, inbox management. We tackled each of these processes individually. Then we thought about applying the guidelines as they are written to a standard patient panel and then adding up the total amount of time. The result that we got was, unfortunately, if a doctor followed the guidelines as they were written for a standard patient panel representative of the adult U.S. population, of 2,500 patients, it would take 26.7 hours per day to provide that care, which is obviously an infeasible amount of time.
ME: Given your own experience, were you surprised at that result?
JP: Unfortunately, I was actually not surprised. When I first started working on this paper, I was a resident, and I noticed the difference between the way we are taught to provide care and the constraints of a clinic workday. And I felt those two things were very much at odds. This is something I think all clinicians feel intuitively. It was actually not a surprise.
ME: Can you explain how you measure the time?
JP: We use the National Health and Nutrition Examination Survey dataset. This was a very useful data set for us to make hypothetical patient panels from, and we created our hypothetical panels of 2,500 patients. Then we looked at the guidelines. For example, there are preventive care guidelines of what should be done for each patient. So, for example, if you had a patient with obesity, there's a United States Preventive Services Task Force (USPSTF) recommendation that patients should get dietary counseling, to prevent comorbidities associated with obesity. For each obese patient in our panel, they would need counseling. And then we thought, well, how long should we spend on those counseling services? If you look at the USPSTF meta-analysis that underlines that recommendation, they found it takes a minimum of 12 visits per year to have a measurable evidence of benefit. It is very different than what clinicians are actually able to do, but it's important to make this calculation to expose the gap between what the guideline suggests we should do and what the limits of a clinical workday are. We worked up a bottom-up approach, and we did that for all the USPSTF Class A and B recommendations. Then we did separate calculations for the chronic diseases that existed in a particular patient, how much time it would take to address each of those chronic diseases. We added that up, then we thought about how long it would take on average to address acute care issues for these patients. And then overall documentation, inbox management for that whole panel.
ME: With electronic health records, what is the role of technology in adding to the work burden for primary care physicians? What is the role of technology to relieve the work burden?
JP: There are challenges and opportunities with greater integration of EHR and the way we provide medical care. Starting with opportunities first, it had the potential for you to connect with your patients much more frequently. There's potential to share information with patients more easily – they can send pictures of rashes over the EHR. That definitely is an opportunity. For challenges, any clinician can attest to a lot of bloat in the amount of paperwork we need to do for patients and that tends to come through the electronic medical record. People now understand that doctors are more accessible than they were, and so adds to the workload. Although you have the opportunity to provide more care, the challenge is, the time requirements have increased.
ME: No physician wants to shortcut their care for patients, but with the workloads, does that force physicians to take shortcuts during the workday to save time?
JP: Our paper showed there's this growing gap between the care that patients should receive if we all work according to the guidelines, and the limits of the clinic workday. We have to think about, how is this gap bridged in practice? There are really a few options to think about. One is that physicians are not doing the guidelines or not providing all the guideline-based care recommendations for a patient panel. And there's certainly evidence to back this up, there have been studies that primary care providers only provide approximately 50% of the guideline-based care recommendations to their patients. There's definitely evidence for that. The other option is that providers are providing these guideline-based care recommendations but they're not doing them according to the guidelines. So, for example, if we were to turn today to dietary counseling for obesity, again, providers may be spending a couple of minutes a year counseling patients for dietary counseling, even though the guidelines show that it requires a much more time-intensive process to actually promote behavioral change and actually get results. The third option is that primary care providers are spending additional time outside of the standard clinic workday, writing paperwork, calling patients back, and there's certainly evidence for that as well. So a combination of all of these three things are happening.
ME: The paper suggested how team-based care could relieve some of the workload on primary care physicians. Who should be the team members and what should they be doing?
JP: There are many health care professionals who are specialized to provide care that's distinct from the physician and they all have their own area of specialty. Think about a dietitian, for example, providing counseling services. If you compare a dietitian to a primary care provider, like myself, I may have gotten a couple of lectures in medical school on dietary counseling. But a dietitian, that is their focus. I like to think that I provide decent dietary counseling, but a dietitian may provide better counseling than I would. If they were able to take that task and do it, I would have more time to do other things that I have been specifically trained for, like the diagnosis and treatment of disease. A lot of these these preventive care tasks don't require a medical degree to perform. Giving routine vaccinations, that is something that could certainly be done by the nurse. The nurse could contact the patient independently from the physician, give the vaccination and record it in the chart. I think it's worth asking: Can this task be done partially or completely by another health care team member? And if that's the case, maybe it should be done that way. That was the premise behind our calculation of how much primary care provider time could be saved in an idealized, perfectly functioning team-based care model. Nurses, NA’s, pharmacists, dietitians, mental health counselors, social workers could potentially be considered part of the healthcare team. Each of them could potentially do tasks that might save primary care providers time.
ME: Within the healthcare sector, it's recognized that workload, the amount of time that physicians spend at work, and difficulty maintaining work-life balance, are contributors to burnout. What needs to take place to integrate more team-based concepts, especially to relieve the physician workload?
JP: To address the first part of your question, I certainly do believe this gap between what the guidelines suggest a physician should do in the clinical workday, and the limits in the workday, are driving burnout. If you ask physicians, it's a common feeling that they have, as to what to do about it. That's the million-dollar question. In some sense, it's much easier to identify the problem than to propose the solutions. However, one solution, or at least a partial solution, is to adjust the funding mechanisms that support the delivery of primary care. If you think about a primary care clinic that works under a fee-for-service system, there is no incentive to hire a lot of these additional team members to provide care. Currently, for example, Medicare only pays dietitians to provide counseling if the patient has specific diagnoses, such as diabetes, or renal disease. If you broaden that definition to include things like obesity, it might allow dietitians to bill for services independently of the primary care physician. In that context, there will be more incentive for the primary care physician to incorporate these other team members in delivering care. Allowing these other members to bill for services independently of the primary care physician could go a long way to supporting team-based care models. Additionally, with the move toward value-based care models, this might incentivize team-based care. If you think about models that are not fee-for-service, but where you provide funding on a per patient basis, per unit of time, and incentivizing quality, that would incentivize more of a team-based care approach as well.
ME: Our main audience is primary care physicians. What would you like to say to them? Or what would you like them to know about this issue?
JP: I am a primary care physician myself. A lot of the reason that we did this paper was based about my personal experience and my coauthors’ personal experience. This is definitely an issue that feels very tangible and real to us. In speaking with other primary care physicians, this study really is not news to them, in a sense. I think they all intuitively feel this. This may just be providing numbers and data to support what they intuitively feel. This validates the feelings that primary care physicians have.
ME: When we're talking about physician time, that includes the doctor-patient relationship. As a physician, what would you like patients to know about this topic?
JP: The doctor-patient relationship is fundamental to many aspects of medicine, but it's certainly even more fundamental to the primary care physician and patient relationship. Because as I mentioned earlier, it's the role of primary care physician to help patients navigate a complicated, complex medical system and that requires a close personal relationship. It's important for patients to know that doctors do understand this and they really prioritize this. However, if you look at the guidelines, there's nothing in primary care or preventive care guidelines that mentions the doctor-patient relationship. There's nothing in guidelines to providing chronic disease care, that mentions the doctor-patient relationship. And in my paper, there is no line item for each of the patients to build the doctor-patient relationship. The challenge becomes that we work in a system that has time constraints and we work in a system that pays for particular services to be delivered. Unfortunately, building the doctor-patient relationship isn't prioritized in that context. I think there's a challenge that although doctors, on an individual level, absolutely prioritize the doctor-patient relationship, sometimes it becomes left behind because of the larger structural factors that work against it.