U.S. physicians practicing in ambulatory care settings have become increasingly discontent with their work environment in recent years, and authors of new research(annals.org) published online Sept. 5 in the Annals of Internal Medicine may have discovered why.
AAFP President John Meigs, M.D., of Centreville, Ala., uses a laptop computer in his exam rooms and spends additional time entering information -- some of which is mandated by new rules and regulations -- into patient charts after each encounter.
They noted in the introduction to their article -- "Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in Four Specialties" -- that there is "minimal quantitative data on how physicians' time is allocated in primary care," and that previous studies "predate the widespread use of (electronic health records [EHRs]) and the current regulatory environment."
Lead author Christine Sinsky, M.D., the AMA's vice president for professional satisfaction, told AAFP News that the research team was well aware of physicians' growing concerns about the amount of time they were spending on documentation and paperwork -- and the resulting reduction in time available for direct patient care.
"We wanted to shed light on this subject by rigorously quantifying how physician time is allocated throughout the day," said Sinksy, a general internist who has practiced in Dubuque, Iowa, since 1987.
- Researchers share their findings from a study on how ambulatory physicians spend their time during a day at the office.
- Study authors note physicians' growing concerns about the amount of time they spend on documentation and paperwork -- and the resulting reduction in time available for direct patient care.
- The researchers discovered that for every hour physicians were involved in face-to-face clinical time with patients, they spent almost two additional hours during clinic hours on documentation tasks, paperwork and the electronic health record.
"In addition, rates of physician burnout are high and have risen dramatically in just three years. We suspected that time spent away from direct patient care contributes to burnout and wanted to quantify that time," she added.
Sinsky said the research team expected to find that physicians spent a "substantial amount of time on EHR and desk work." However, she said what they found "was higher than we might have predicted."
The researchers discovered that for every hour physicians were involved in face-to-face clinical time with patients, they spent almost two additional hours during clinic hours on documentation tasks, paperwork and the EHR.
Furthermore, many physicians took work home with them, spending one to two more hours each night on the computer or completing clerical work.
"I don't think that is either ideal or inevitable," said Sinsky. "The cumulative impact of many well-intended initiatives has resulted in this current utilization of the physician workforce. Now that we know how physician time is spent, we can work to more responsibly utilize this limited resource," she added.
Sinsky said the study likely confirmed what many family physicians and other physicians in ambulatory care settings suspected about their workday.
"But the magnitude might have surprised them. In addition, some physicians have previously thought, 'It's just me,' and now understand that the changes in the external environment -- such as the EHR and increased requirements for documentation for audit and billing purposes -- add up and are affecting physicians across the country and across multiple specialties," she said.
Researchers recruited 57 physicians from 16 practices in four states -- Illinois, New Hampshire, Virginia and Washington -- to participate in the study. Physicians were distributed across family medicine, internal medicine, cardiology and orthopedics.
Trained observers used a "time-and-motion" approach (the Work Observation Method by Activity Timing) during clinic office hours and physicians completed self-reported diaries for after-hours work.
Direct observation data were collected during weekday hours (7 a.m. to 8:30 p.m.) between July 7, 2015, and Aug. 11, 2015.
Ultimately, four broad activity categories were analyzed by researchers.
- Direct clinical face time between physician and patient, or physician and staff, included taking a history; performing a physical exam or procedure; and assessing, planning and discussing facts with a patient or with family members.
- EHR and desk work involved recording details about the patient encounter, activity related to accessing tests results, arranging for medications and vaccinations, and setting up referrals and other non-medication and test orders.
- Administrative tasks included activity related to patients' health insurance such as preauthorization, workers' compensation and claims submission.
- Other tasks involved meetings, education, business tasks such as audits, physician travel time between exam rooms or office locations, and personal time for restroom breaks, meals and personal phone calls.
Additional Study Highlights
Authors detailed exactly how physicians spent their time. They noted that observational data reflected both examination room and non-exam room time such as workstation or office.
During the office day, physicians spent 27 percent of their total time on direct clinical face time with patients and 49.2 percent on the EHR and desk work.
While in the exam room with patients, physicians spent 52.9 percent of time on direct clinical face time and 37 percent on EHR and desk work.
A total of 21 physicians kept after-hours diaries and reported devoting one to two hours of work each night primarily to EHR tasks.
Researchers noted that 26 of the 57 physicians had the benefit of documentation support in the form of dictation services or a documentation assistant; none of the primary care practices in the study had documentation support.
Notably, physicians who utilized documentation support personnel had more face time with their patients. Physicians with dictation assistance had 31.4 percent face time, physicians with a documentation assistant had 43.9 percent face time and physicians without documentation support had 23.1 percent face time.
Authors noted that previous studies suggested that "decreased time with patients and increased workload from EHR tasks are major contributors to career dissatisfaction among physicians."
Furthermore, they pointed out those changes in physician work activity patterns synced with "high physician burnout rates that increased rapidly between 2011 and 2014." Authors recommended further study on the topic "to identify links between variations in use of physician resources and clinical, financial and professional satisfaction outcomes."
Sinsky said the research could be extended in many useful directions.
"For example, it would be useful to know how changes in staffing ratios and task distribution across team members impact the percentage of time the physician can devote to direct patient care. Similarly, one could compare the percentage of the workday physicians spend on documentation and other data entry tasks across different EHR products," she said.
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