If they followed national recommendation guidelines for preventive care, chronic disease care and acute care, it would take a primary care physician 26.7 hours per day to see an average number of patients, a new study finds.
“There is this sort of disconnect between the care we’ve been trained to give and the constraints of a clinic workday,” said Justin Porter, lead author of the paper and an assistant professor of medicine at the University of Chicago. “We have an ever-increasing set of guidelines, but clinic slots have not increased proportionately.”
This study builds on others that have found a discrepancy between guidelines and a physician’s time. And it has real consequences for the delivery of health care; the researchers said that time pressure helps explain why improvements in outcomes have not kept pace with advances made in the field.
Time pressure plays a role in inequities in health care, with vulnerable populations typically receiving care at overburdened clinics. It also has an impact on patient satisfaction.
“If you do surveys with patients about what frustrates them about their medical care, you’ll frequently hear, ‘My doctor doesn’t spend time with me’ or ‘My doctor doesn’t follow up,’” said Porter. “I think a lot of times this is interpreted as a lack of empathy, or a lack of willingness to care for a patient. But the reality—for the majority of doctors—is simply a lack of time.”
According to the researchers, time constraints are also a key factor in physician burnout, one of the drivers pushing medical students from the field.
The new research—conducted by the University of Chicago, Johns Hopkins University and Imperial College London—used a simulation study to compute time per patient based on data from the National Health and Nutrition Examination Survey.
It built on previous studies by including all types of care a primary care physician provides—preventive, acute, and chronic—as well as administrative tasks, and accounted for changes to the guidelines that have occurred since earlier studies were published. It also used a different methodology, employing real patient data from an annual national survey to calculate its results. The earlier studies used hypothetical patient populations based on the U.S. population.
“When you’re dealing with real people, you have more complexity to the data. A person may have multi-morbidity, or several chronic diseases at once,” said Porter. “That patient would be treated differently than a hypothetical average patient. This leads to more comprehensive and precise calculations.”
For an average number of patients, the simulation study broke down recommended requirements to 14.1 hours/day for preventive care, 7.2 hours/day for chronic disease care, 2.2 hours/day for acute care, and 3.2 hours/day for documentation and inbox management—far outpacing the hours available in any given day.
The authors suggested a partial solution in the form of a model called “team-based care,” where nurses, physician assistants, counselors and others help to deliver recommended care.
Their study found that team-based care reduced the time a physician needed to deliver care from 26.7 hours/day to just 9.3 hours/day. The reduced workload breaks into 2.0 hours/day for preventive care, 3.6 hours/day for chronic disease care, 1.1 hours/day for acute care, and 2.6 hours/day for documentation and inbox management.
“Team-based care is a movement that has been around in medicine for a while and has gathered steam more recently,” said Porter. “Doctors do not give care in a vacuum. There are other extremely important members of the healthcare team that are working together and often independently to provide care for patients. This is a huge opportunity and partial solution to the time constraints currently faced in medical care.”
The researchers used the Comprehensive Primary Care Plus (CPC+) model to develop the estimates for team-based care. The model allows physicians to focus on advanced care and brings in specialized medical professionals to take over other areas. Dietitians, for instance, would handle nutritional counseling for patients with diabetes or obesity, a time-intensive task. Overall, the researchers determined that 65% of primary care services could be handled by other team members.
Moving to a team-care model would require systemic changes to the way Americans pay for care. Currently, payment for many counseling services depends on patients having a qualifying disease. Yet the benefits of team-based care make the effort worth it, the researchers said.
Additional authors include Neda Laiteerapong with the University of Chicago; Cynthia Boyd of the Johns Hopkins School of Medicine; and M. Reza Skandari of the Imperial College Business School, London.
Citation: “Revisiting the Time Needed to Provide Adult Primary Care.” Porter et al., Journal of General Internal Medicine, July 1, 2022.
—Adapted from an article first published by University of Chicago Medicine.