During an office visit with your doctor, you might spend part of your 10- or 20-minute appointment discussing your symptoms. The doctor takes notes. A test or a prescription might be ordered. Maybe there’ll be reassurance there isn’t anything seriously wrong with you, or a plan to follow up if there are any concerns.
This is what patients see, and it’s not surprising when they conclude this is how the doctor spends his or her entire day. What they’re seeing, though, is only the tip of the proverbial iceberg. A new study, published this week in the New England Journal of Medicine, quantifies how much time primary care doctors devote to all the extras – extras that are largely invisible to the public and for which they don’t get paid.
The authors asked the question: What’s keeping us so busy? The answer is eye-opening.
The study tracked a private practice in Philadelphia with five internists and an active caseload of 8,440 patients. Here’s how some of the numbers broke down: In 2008 each physician saw an average of 18 patients a day, Monday through Friday and Saturday mornings. Each day they made 23.7 phone calls and received 16.8 e-mails. They reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports, and processed 12.1 prescription refills.
Here’s a further look at just one of these categories, prescription refills:
Each physician processed 12.1 prescription refills per day, not including refills that were handled during a visit or requested as part of a telephone call involving other issues; multiple medications that were refilled at the same time were counted as a single refill. Each refill request required some level of chart review (e.g., determining the patient’s history with the drug and whether any required monitoring had been performed).
What many people may not realize is that physician practices don’t get paid for these tasks. The revenue that’s generated must come from actual patient visits to the office. You don’t have to be good at math to figure out that as primary care doctors spend an increasing amount of time on charting, paperwork, communication and behind-the-scenes patient care management, it means less time for face-to-face care and significantly more pressure on the practice’s overall resources.
Is it all about the money, then? Well, yes, it is, in the sense that practices need to generate enough cash to keep the doors open so they can continue seeing patients. And the more time that’s spent on uncompensated tasks, the more challenging this becomes.
Some medical practices are addressing this by charging office fees or service fees – an add-on to help defray the cost of, for instance, taking care of a prescription refill or sending a lab report. One private cardiology practice in California, for example, this year began charging annual fees ranging anywhere from $500 to $7,500. Patients who don’t want to pay the fee can still see the cardiologist, of course, but as NPR’s Shots blog explains, they’ll face some restrictions, such as limited telephone availability except in emergencies.
The situation is arguably worse in primary care. Over the years, primary care has become increasingly cognitive. It involves managing, coordinating, communicating, coaching – important skills that unfortunately are devalued in a payment system where procedures and office visits reign supreme.
I suspect even the authors of the NEJM study were a little taken aback to discover just how much time they spend on all these invisible tasks. It should be eye-opening for the public as well. Now that we know, it becomes harder and harder to come up with excuses for maintaining the status quo.
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