Curbside Consult with Dr. Jayne 11/11/24

I’m always on the lookout for interesting research, and this recent article in JAMIA did not disappoint. The title was certainly eye-catching: “The number of patient scheduled hours resulting in a 40-hour work week by physician specialty and setting: a cross-sectional study using electronic health record event log data.” That’s a mouthful, but it calls attention to one of the pressing issues in ambulatory care today – packed physician schedules. It also alludes to the significant concerns around burnout and lack of work/life balance for clinicians, who are typically working longer hours than they want to.

A large amount of physician work occurs outside the confines of the office visit. These tasks include things like managing phone and patient portal messages, reviewing and managing laboratory and diagnostic testing results, collaborating with other members of the care team, crafting insurance appeals and compiling documentation for prior authorizations and referrals, completing documentation, and reviewing correspondence.

Efficient physicians who have strong support staff can often tackle many of these during patient care hours, i.e., they cram the tasks in between patients. Organizations that can afford scribes or ambient documentation solutions help physicians complete their visit notes before they leave the patient room, which frees up time that was formerly used for patient documentation that can now be used for all the other work.

Organizations that don’t prioritize that kind of support leave the physician to manage the rest of the burden themselves, which creates other issues. Physician burnout is one, which can lead to physicians leaving a practice for alleged greener pastures elsewhere, retiring early, or leaving medicine altogether.

Another issue is avoidance, where physicians are so overwhelmed they just don’t do the work, either leaving it to accumulate in their inboxes or just clicking through it without reading or addressing it. This approach creates patient safety issues. Some organizations have strong policies around it, but others wait until the levels of delinquent work reach ridiculous levels before taking action. Those actions are typically punitive rather than supportive, so one can guess at their level of effectiveness in making the physician want to behave differently in the future. 

The authors start with an introduction about the current state of clinical schedules versus physician time worked, noting that the average full-time US physician works 54 hours. More than 40% of us work more than 55 hours per week compared with 10% percent of workers in other fields. They also provide statistics on something that many of us have experienced first hand – that part-time work isn’t part time, with physicians who are working as 0.8 FTE (full-time equivalent) still averaging 46 hours per week.

The authors set about trying to answer this question — what is the appropriate number of scheduled patient care hours that would result in a 40-hour work week for physicians of various ambulatory specialties? They looked at 186,000 physicians from nearly 400 organizations and used data from November 2021 through April 2022.

I have to say that the timeframe caught my eye. We were still dealing with a substantial burden from COVID at that time, and also those months coincide with respiratory illness season, which disproportionately impacts some specialties. It made me wonder whether the results might look different if they looked at a larger time span that would help control for seasonal variation or one that was more typical and without the additional burden of COVID and its extra work notes, FMLA paperwork, and other administrative tasks.

The authors used EHR metadata to calculate a so-called PSH40 to depict the ideal number of patient scheduled hours that would result in the desired 40-hour work week, noting that the lowest numbers were in the specialties of infectious disease, geriatrics, and hematology. In my experience, patients who are seeing those specialists tend to have complex histories and challenging conditions, so I wasn’t surprised.

The highest numbers were in plastic surgery, pain medicine, and sports medicine. Those specialties had the lowest burden of work to be done outside scheduled patient hours, which the authors described as WOW (Work Outside of Work). Specialties that had fewer than 500 physicians in the sample were excluded, as were non-physician specialties such as dentistry, optometry, and podiatry.

The authors also looked at other practice characteristics, such as academic versus non-academic status, whether a practice was considered part of a safety net, and whether a specialty was considered primary care, a medical specialty, or a surgical specialty. Not surprisingly, academic, safety net, and non-surgical specialties all had lower PSH40 numbers due to their larger volume of WOW.

Although this concept of PSH40 is new, the authors state that, “We believe that health system leaders and physicians will benefit from data driven and transparent discussions about work hour expectations.” They note that current expectations “have been set by historical norms, are not based on objective data regarding the total work hours associated with a given number of PSH, have remained stable despite a growing volume of care outside of PSH through the patient portal and EHR inbox and are a source of uncertainty for organizational leaders and physicians.”

They call for future studies that look at different support staff structures and team care environments to see how the PSH40 might vary. They emphasize that work hours matter, with negative health outcomes associated with work overload. The fact that working more than 55 hours per week is linked to higher rates of heart disease and stroke was a new one for me.

The authors emphasize that physician burnout is linked not only to longer work hours, but also to lower patient satisfaction, lower quality and safety scores, higher rates of medical errors, and higher costs of care. These are all reasons that organizations should care about the data. Even if they don’t care about their physicians’ personal health risks, they definitely care about costs of care.

The authors note some limitations in the data used for the analysis, namely that it was from a single EHR platform (Epic) that has specific constraints about how it tracks physician activity. They recommend that organizations that want to use the PSH50 metric perform calibrations using local specialty-specific data from their own EHR.

The authors also note the limitation that EHR log data doesn’t capture non-EHR work such as phone calls and discussions in the office. Additionally, there would be complexity using the measure for specialties that also see patients in the inpatient environment or in ambulatory surgery centers.

Overall, I enjoyed reading this paper, which is not something I usually say when perusing academic publications. It’s an important topic and one that also impacts physician contracts and compensation.

An informal survey of some of my family medicine colleagues noted that their contracts required anywhere between 32 and 40 patient scheduled hours to be considered full time, with some agreements specifying a number of administrative time hours and others not mentioning that at all. This kind of measure gives institutions the power to monitor whether changes in processes are effective in reducing work outside of work and whether they have the potential to improve patient access.

Is your organization looking at a measure like this, or assessing work outside of work? Are things moving in the right direction to reduce burnout and improve patient care? Leave a comment or email me.

Email Dr. Jayne.