More On Physician Work
There have been two recent articles providing data on the changing nature of physician work. The first is a survey conducted by Swensen and Shanafelt. The survey was conducted among people who have volunteered to participate in the Insight Council for the NEJM Catalyst program, so it is not a random selection. However, 96% of the respondents agreed that physician burnout was a problem. Perception of the severity of the problem tended to be higher in the northeastern states, compared to the rest of the country, and physicians tended to rate the problem as more severe than did health care executives. Further, physicians cited decreased quality of care (63%) more often as the reason to address the problem than did administrators, (57%), although the margin was small.
When looking for explanations for the problem, two major factors emerged: increased clerical burden (62%), and increased productivity requirements, (51%). While other factors were also mentioned, these seemed to be the consensus items. When asked what their organizations were doing to address the issues, most said “not much.”
The second study was by Sinsky and colleagues who did direct observation time and motion studies during office hours in four specialties in four different states. A total of 57 physicians were studied. Their conclusion:
“For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on HER and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.”
In my 40+ years, there has always been paper work to be done, and I suspect a study done back then would have shown that for every hour of face time, the office doctor had to spend another hour doing paper work, but clearly the ratio is skewed.
If we assume physicians were accustomed to spending six hours of their day in face time, an estimate based on observation in my own multispecialty group, then they would now be working 14 hours/day, a pace that is not sustainable. So, in fact, since most want to work 40-50 hours/week, it is difficult for primary care doctors to see patients for more than four hours/day with today’s clerical workload. So at the same time as we have more need for primary care physicians, we have less time available. And the documentation burdens are only predicted to go up. So what to do?
Many have suggested strategies for unburdening the physician such as the use of scribes. But scribes cost money and there is no reimbursement for the documentation as such. In fact, the documentation burden began to go up at the same time as the RBRVS system was installed by CMS. Suddenly, instead of charging the patient based on time or effort, you had to be able to count “bullet points.” One of my colleagues, who typically spends at least an hour with new patients dealing with life-threatening diseases, was audited because he charged most of his patients at the highest level for office consultations. Despite the fact that time and complexity were on his side, they wanted money back because he did not always have 14 bullet points in his review of systems. (He had only mentioned the ones relevant to his diagnostic thought process.)
Electronic health records certainly make it possible to load the chart with bullet points, but unless you are going to take your chances, you do need to spend at least a little time reviewing them. And I really wonder if the physical exams being recorded are realistic, particularly when patients complain the doctor did not even use his stethoscope.
The article by Sinsky and colleagues was accompanied by an editorial by Hingle calling for action on improving electronic health records. While that is appropriate, I really think the root of the problem is the “bullet-point” approach to creating a billing document out of something that was once a communication between clinicians about the care of a patient. I am not optimistic we can get the accountants out of the chart, and unless we do, I don’t see the problem getting better.
In fact, with the growing burden imposed by MACRA and other initiatives, I suspect many primary care physicians who do not want to quit practicing medicine will decide to opt out altogether. Since demand for their services is high, it might make more sense for them to just go back to cash payments for services—particularly given the growth of high-deductible plans in the commercial arena. Expenses would be less, so charges would be less, so doctors could improve both patient satisfaction and their own satisfaction. Government policy is clearly based on the assumption doctors will do whatever is needed to get paid. But what if they did whatever is needed to get their patients needs met in a way that was personally satisfying instead?
15 December 2016
 Swensen S, Shanafelt T. Leadership Survey: Why Physician Burnout is Endemic and How Health Care Must Respond. 8 December 2016. http://catalyst.nejm.org/physician-burnout-endemic-healthcare-respond/.
 Sinsky C, Colligan L, Li L, et. al. Allocation of Physician Time In Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med 2016;165-753-760. doi. 10.7326/M16-0961.
 Hingle S. Electronic Health Records: An Unfulfilled Promise and a Call to Action. Ann Intern Med 2016;165:818-819. doi. 10.7326/M16-1757.
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