EPtalk by Dr. Jayne 9/1/22

There’s an often-cited study in the primary care literature that looks at the number of hours a physician would need to spend each day to perform the recommended care for a standard panel of patients. The problem was that it hadn’t been updated in years. Earlier this month, a study was published in the Journal of General Internal Medicine that updates the info and confirms that the situation hasn’t gotten any better.

Researchers from the University of Chicago, Johns Hopkins University, and Imperial College London found that primary care physicians would need to spend nearly 27 hours each day in order to provide all the guideline-based care needed for a hypothetical panel of 2,500 patients. The breakdown includes 14.1 hours for prevention, 7.2 hours for chronic diseases, 2.2 hours for acute care, and 3.2 hours for documentation and wrangling the inbox.

The authors used data from the 2017-18 National Health and Nutrition Examination Survey (NHANES) and the 2020 care recommendations to develop the projections. The statistics seem grim, so what’s the answer? Most agree that team-based care needs to be the norm and not the exception. The authors took the same requirements to see how they could be delivered by a team. That approach would reduce the physician component to 9.3 hours per day, with most of the savings occurring in the areas of preventive care and chronic disease care.

In this model, counseling might be delivered by a dietician, nurse, or other member of the support staff. The authors noted, however, that many practices are already using teams to deliver a variety of pre-visit screenings and counseling, so the ability to improve this might be variable. They went further to conclude that even with team-based care, the requirements would be “excessive.”

Another potential solution would be for physicians to have fewer patients on their panels, although this wouldn’t do much to ease the primary care shortage. Overall, fewer patients generate fewer appointment requests and fewer phone calls. The reality is that many of the organizations that employ physicians won’t let them close their panels to new patients without a lot of weeping, wailing, and gnashing of teeth. I once did a consulting engagement with a group that forced physicians to take new patients until their panels were so large that they couldn’t provide any same-day care and the wait for routine care was several weeks. When physicians work like this, they feel like they’re on a perpetual hamster wheel and that they can never catch up.

Yet another solution would be to shift some of the work to the patients themselves  through self-service programs or outreach. It’s fairly easy for organizations that have implemented certified EHRs to generate lists of patients who need a particular service and queue them up for outreach. Even if you can pick off a certain percentage of the patients by delivering asynchronous education through a patient portal, you’re still helping the practice with workflow. Throw some patient self-scheduling on top of it and that’s a winner.

I’m still baffled by the number of practices that won’t allow patients to self-schedule for routine visits. When I press the issue, they’ll argue with me that self-scheduling doesn’t help the provider. I counter that it can when the FTE employee positions that used to schedule are instead redeployed as more clinically relevant roles such as health coaches, care navigators, etc.

Automation can be a big piece of the solution as well. I’ve seen some very cool functionality recently that allows automated rerouting of patient messages based on their content, so that the most appropriate staff member can manage them as opposed to everything having to come through the physician first. It can also be used to send pre-visit questionnaires to patients to help identify whether they’re doing well with their chronic conditions or whether they’re having issues that might merit another team member helping with the visit, such as a pharmacist, social worker, or health coach. Questionnaires can return data that can auto-populate the visit note, reducing documentation time.

Not all patients will be amenable to reading patient education materials via a patient portal, or to interacting with a chatbot or other virtual assistant, but at this point offices are so congested that any number of patients you can divert from the “same old, same old” workflow is a bonus. There’s often an argument that older patients aren’t candidates for digital engagement, but I call baloney on that. Thinking of the retirees with whom I interact the most, they might have some small struggles with technology, but overall they find their time to be valuable and are willing to try solutions that might allow them to spend more time with their grandchildren versus hanging on the phone with a medical office.

Most of the primary care colleagues I reached out to about this updated research said they feel the drain of all that work directly and on a daily basis. One recently decided to give up primary care because she didn’t feel she could deliver the kind of care she wanted to do, or was trained to do, with the constraints her employer had placed on her. She isn’t able to hire additional team members and is expected to run a full family medicine panel with only one medical assistant helping her, which is ludicrous. Several have closed their panels to new patients, and others are limiting office hours. The only ones that sounded even remotely hopeful for the future were the ones who had transitioned to Direct Primary Care models, where they’re only caring for 200-400 patients at a time versus the thousands that physicians are conventionally expected to manage.

One colleague I spoke with said that society needs to double down on public health education everywhere, not just in the physician office. Patients need to make healthier choices and need to be hearing about prevention regularly, not just during an annual visit. Healthier patients make for much quicker and easier office visits than those featuring patients with multiple chronic conditions. However, requirements for health education have been cut in many schools and we’re certainly not flooding the airwaves with evidence-based health education. I’ll keep doing my part with healthcare IT, advocating for patient engagement, outreach, automation, and increased self-service options. I’ll lobby my representatives to support public health efforts.

What do you think is the answer to the ever-expanding burden placed on primary care delivery organizations? Leave a comment or email me.

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