In light of the allegations that some Veterans Affairs Department health clinics used elaborate schemes to hide the records of patients who had waited months for care, I began to wonder what a normal caseload would look like for an average physician outside the VA system. And if your doctor has a larger-than-average caseload, is he or she able to give you the attention you need?
The numbers are pretty stunning. A 2012 article in the Annals of Family Medicine noted that the average primary-care physician has about 2,300 patients on his "panel"— that is, the total under his or her care. Worse, it said that each physician would have to "spend 21.7 hours per day to provide all recommended acute, chronic and preventive care for a panel of 2,500 patients." I'm not sure I'd want that doc seeing me at the end of that long a day at the office.
According to a 2013 survey by the American Academy of Family Physicians, the average member of that group has 93.2 "patient encounters" each week — in an office, hospital or nursing home, on a house call or via an e-visit. That's about 19 patients per day. The family physicians said they spend 34.1 hours in direct patient care each week, or about 22 minutes per encounter, with 2,367 people under each physician's care.
Remember, these are primary-care doctors, who may be among the most heavily burdened — as measured by patient load — in medicine. The shortage of primary-care doctors, whose practices are less lucrative than, say, those of neurologists or cardiologists, has been a concern for years.
In 2012, the Physicians Foundation, a nonprofit group, surveyed 13,575 doctors across the United States and found that 39.8 percent see 11 to 20 patients per day and 26.8 percent see 21 to 30 a day. Here, however, there is a little good news: The second number is down substantially from 41.3 percent in the group's previous survey, taken in 2008. Perhaps this reflects the impact of the recession; no one from the foundation was available to comment.
Update 6:40 p.m.: In an email, Lou Goodman, president of the foundation, wrote that "physicians are working fewer hours, seeing fewer patients and limiting access to their practices in light of the significant changes to the medical practice environment. The research estimates that if these patterns continue, 44,250 full-time-equivalent physicians will be lost from the work force in the next four years."
He predicted that within the next three years, "more than 50 percent of physicians will cut back on patients seen, work part-time, switch to concierge medicine, retire or take other steps likely to reduce patient access." With millions of people newly insured under the Affordable Care Act, patients may face even more challenges finding access to doctors, he said.
About 75 percent of the doctors in the survey described themselves as "overextended and overworked" or "at full capacity," about the same who said that in 2008. But 58 percent said they spend zero to 10 hours on paperwork each week, and 26.1 percent said they spend between 11 and 20 hours on those duties each week. Again, the 11 to 20 hour group was smaller than it was in 2008.
So what is a good size for a family practice, one that keeps the patients happy and the doctor from keeling over from exhaustion? A 2007 article in "Family Practice Management" took a stab at this one and suggested that at 3.1 visits per year, a doctor who sees 20 patients a day could have about 1,400 people under his care — a heck of a lot fewer than the 2,300 or so mentioned above. At 25 patients a day, that doctor could handle a "panel" of 1,750, still far fewer than the actual average.
There are many variables I haven't found a way to consider here: the number of tasks, including paperwork, that can be transferred to other staff, both people like nurse-practitioners and those without medical training; the difference between private-practice physicians and those who work for HMOs like Kaiser Permanente and hospital-based staff; and the workload of specialists, to name just a few. But the numbers clearly show how overextended primary-care physicians appear to be, and may provide a hint of what some of those veterans seeking care are going through.