Study finds many unpaid tasks in a primary-care doctor's workday

By David Brown
Washington Post Staff Writer
Thursday, April 29, 2010

In addition to seeing patients, a primary-care physician each day must address more than three dozen urgent but uncompensated tasks, according to a study that provides a rare, quantitative look into the mechanics of office practice.

Answering telephone calls and e-mail messages, refilling prescriptions, reviewing lab test results and consulting with other doctors consume large amounts of time each day, even though none of it is paid for, according to the study.

Primary care is a centerpiece of the recently enacted health-care law, which provides incentives for doctors, nurses and physician assistants to enter the field. Many experts -- and President Obama -- have said that the 32 million additional people expected to get health insurance over the next decade will need primary-care providers if the law is going to both improve the quality of medical care and contain spending, its two goals beyond expanding coverage.

Primary care, however, is an increasingly unpopular field, and the new study sheds light on possible reasons.

A five-physician practice in Philadelphia caring for 8,440 people used its electronic medical records system to analyze the daily work of each practitioner. Each physician had an average of 18 patient visits per day, with the average patient coming to the office twice a year. The workweek was 50 to 60 hours.

In addition to the patient visits, each doctor got 24 phone calls a day. About three-quarters were fielded by the doctor, with the rest answered by someone else in the office.

A third of the calls concerned an acute medical problem and resulted in a prescription or an order for a test. The doctors also received an average of 17 e-mail messages a day, about half seeking explanations of test results.

Each physician processed 12 prescription refills a day (in addition to refills that were part of a patient's visit). There were 20 lab reports and 11 diagnostic imaging reports (for tests such as X-rays, CAT scans and MRI studies) to review. There were 14 reports from consultants -- usually other physicians, but also visiting nurses, physical therapists and other practitioners -- to look at and respond to, as well.

The results of the analysis "absolutely surprised me," said Richard J. Baron, a 56-year-old internal medicine physician who conducted the study and wrote about it in Thursday's New England Journal of Medicine.

"Like everybody else who practices primary care, I feel like I'm running from when I get there to when I leave and take work home. But when I actually saw the numbers of all the tasks, I was really stunned," he said.

Whether the Philadelphia practice is representative of others isn't known. Only a few studies have attempted to measure the components of the "time budget" of office physicians. In general, they have painted a similar picture: days filled with short patient visits and dozens of just-in-time interruptions.

In a 2007 study, Ming Tai-Seale of Texas A&M University analyzed 392 videotapes of visits by elderly people to 35 physicians in numerous clinics. The average visit lasted 17 minutes and covered an average of six topics.

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