Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Primary care is more than just office visits

Robert Wachter, MD
Physician
June 13, 2010
Share
Tweet
Share

If you’ve ever been on a diet, you know that it really helps to keep a food log. Seeing your consumption chronicled in one place is illuminating – and often explains why those love handles aren’t melting away despite two hours on the treadmill each week.

In a recent issue of the New England Journal of Medicine, internist Rich Baron Rich Baron chronicles the work of his 5-person Philadelphia office practice during the 2008 calendar year. Rather than “Why am I not losing weight?”, Rich’s study aims to answer the question, “Why does my work day feel so bad?” The answer: an enormous amount of metaphorical snacking between meals.

In the NEJM study, Rich (who is a dear friend – we served together on the ABIM board for several years) found that each of the physicians in his practice conducted 18 patient visits per day (a total of 16,640 visits over the year for the practice). That’s not an unmanageable workload, you say. You’re right, but that was just the appetizer. On top of these visits, daily each physician also:

* Made 24 telephone calls
* Refilled 12 prescriptions (a vast underestimate of the daily refills, since a) the number reported in the study doesn’t count refills done during an office visit, and b) the study counted the act of refilling 10 meds for a single patient as one refill)
* Wrote 17 e-mails to patients
* Looked at 11 imaging reports, and
* Reviewed 14 consultation reports.

A little math tells us that, beyond what happens during the 18 patient visits, the docs perform nearly 80 acts of data exchange and review each day. After Rich’s practice analyzed this workflow, they re-defined a “full-time physician” as one with 24 scheduled visit-hours per week, embedded in a 50 hour work-week. In other words, docs in Rich’s practice can expect to spend half their time on office visits with patients, and the remaining half on non-visit paper/computer/telephone work.

This wouldn’t be such a big deal if – like attorneys – primary care doctors billed out their time in six-minute aliquots, or by activity. But PCPs aren’t paid that way – the office visit is ostensibly the only billable event in the life of the practice (except when they buy and use an office ultrasound or treadmill – small wonder that so many PCPs do just that). The Catch-22 is obvious and tragic: the incentives drive PCPs to maximize office visits, while both patients and “the system” clearly benefit from these non-visit activities.

A few weeks ago, I asked Rich how he’d overhaul the payment system in light of his office’s experience. “I would favor a DRG-type payment based on age, gender and diagnosis,” he wrote me, adding that CMS has considered such a model as part of its Medical Home demonstrations, but it hasn’t gained much traction.

But payment reform won’t be enough – the NEJM study demonstrates the necessity of comprehensive practice redesign. In fact, after seeing these data, Rich’s group hired an RN whose job is “information triage” – managing the mountains of lab reports, consult notes, and phone calls.

Ultimately, the work of primary care must be greased by a superb ambulatory electronic health record (EHR). Rich told me that, while his office is far more computerized than the average practice, it is still not quite there. The ideal EHR, he writes, would, “understand the ‘data aggregation’ task we face: when I refill a prescription, there are predictable pieces of clinical data I need, and there could/should/must be a way to present those ‘automatically’ upon entering into the refill work. Our EHR does a fair amount of this – it does show last refill date conveniently but not relevant lab data or problem lists (even as it does show body-mass index and body surface area). Someone wanting to do this re-design would need to follow one of us around for a while to figure out what we actually do.”

Without question, creating a higher “value” – better quality at lower cost – healthcare system will depend on having adequate primary care capacity. (So too will caring for tens of millions of newly insured patients under health reform.) Unfortunately, the trends point in the opposite direction: the primary care infrastructure is collapsing and very few trainees are choosing careers as primary care docs (can you blame them?). Creating the primary care workforce and capacity we need will require a deep understanding of today’s practice environment, which makes Rich’s study essential reading for those concerned about the future of American healthcare.

Bob Wachter is chair, American Board of Internal Medicine and professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.

Prev

Top medical blog posts of the week, ending June 11, 2010

June 13, 2010 Kevin 1
…
Next

Unnecessary tests and treatments are commonly ordered for patients

June 14, 2010 Kevin 6
…

Tagged as: Primary Care, Public Health & Policy

Post navigation

< Previous Post
Top medical blog posts of the week, ending June 11, 2010
Next Post >
Unnecessary tests and treatments are commonly ordered for patients

ADVERTISEMENT

More by Robert Wachter, MD

  • Surviving an EHR launch: The trauma of Go Live

    Robert Wachter, MD
  • Natural language processing in health care: The breakthrough we’ve been waiting for?

    Robert Wachter, MD
  • Dr. Robert Wachter: In defense of the ABIM

    Robert Wachter, MD

More in Physician

  • A pediatrician’s role in national research

    Ronald L. Lindsay, MD
  • The danger of calling medicine a “calling”

    Santoshi Billakota, MD
  • Physician work-life balance and family

    Francisco M. Torres, MD
  • Love and loss in the oncology ward

    Dr. Damane Zehra
  • The weight of genetic testing in a family

    Rebecca Thompson, MD
  • A surgeon’s view on RVUs and moral injury

    Rene Loyola, MD
  • Most Popular

  • Past Week

    • A doctor’s letter from a federal prison

      L. Joseph Parker, MD | Physician
    • When language barriers become a medical emergency

      Monzur Morshed, MD and Kaysan Morshed | Physician
    • A surgeon’s view on RVUs and moral injury

      Rene Loyola, MD | Physician
    • Why doctors are losing the health care culture war

      Rusha Modi, MD, MPH | Policy
    • A cancer doctor’s warning about the future of medicine

      Banu Symington, MD | Physician
    • Why caring for a parent is hard for doctors

      Barbara Sparacino, MD | Conditions
  • Past 6 Months

    • Rethinking the JUPITER trial and statin safety

      Larry Kaskel, MD | Conditions
    • The ignored clinical trials on statins and mortality

      Larry Kaskel, MD | Conditions
    • How one physician redesigned her practice to find joy in primary care again [PODCAST]

      The Podcast by KevinMD | Podcast
    • I passed my medical boards at 63. And no, I was not having a midlife crisis.

      Rajeev Khanna, MD | Physician
    • The silent disease causing 400 amputations daily

      Xzabia Caliste, MD | Conditions
    • Why medicine needs a second Flexner Report

      Robert C. Smith, MD | Physician
  • Recent Posts

    • Why caring for a parent is hard for doctors

      Barbara Sparacino, MD | Conditions
    • A pediatrician’s role in national research

      Ronald L. Lindsay, MD | Physician
    • How older adults became YouTube’s steadiest viewers and what it means for Alphabet

      Adwait Chafale | Conditions
    • The danger of calling medicine a “calling”

      Santoshi Billakota, MD | Physician
    • How retraining the physician mindset can boost resilience and joy in medicine [PODCAST]

      The Podcast by KevinMD | Podcast
    • How AI on social media fuels body dysmorphia

      STRIPED, Harvard T.H. Chan School of Public Health | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • A doctor’s letter from a federal prison

      L. Joseph Parker, MD | Physician
    • When language barriers become a medical emergency

      Monzur Morshed, MD and Kaysan Morshed | Physician
    • A surgeon’s view on RVUs and moral injury

      Rene Loyola, MD | Physician
    • Why doctors are losing the health care culture war

      Rusha Modi, MD, MPH | Policy
    • A cancer doctor’s warning about the future of medicine

      Banu Symington, MD | Physician
    • Why caring for a parent is hard for doctors

      Barbara Sparacino, MD | Conditions
  • Past 6 Months

    • Rethinking the JUPITER trial and statin safety

      Larry Kaskel, MD | Conditions
    • The ignored clinical trials on statins and mortality

      Larry Kaskel, MD | Conditions
    • How one physician redesigned her practice to find joy in primary care again [PODCAST]

      The Podcast by KevinMD | Podcast
    • I passed my medical boards at 63. And no, I was not having a midlife crisis.

      Rajeev Khanna, MD | Physician
    • The silent disease causing 400 amputations daily

      Xzabia Caliste, MD | Conditions
    • Why medicine needs a second Flexner Report

      Robert C. Smith, MD | Physician
  • Recent Posts

    • Why caring for a parent is hard for doctors

      Barbara Sparacino, MD | Conditions
    • A pediatrician’s role in national research

      Ronald L. Lindsay, MD | Physician
    • How older adults became YouTube’s steadiest viewers and what it means for Alphabet

      Adwait Chafale | Conditions
    • The danger of calling medicine a “calling”

      Santoshi Billakota, MD | Physician
    • How retraining the physician mindset can boost resilience and joy in medicine [PODCAST]

      The Podcast by KevinMD | Podcast
    • How AI on social media fuels body dysmorphia

      STRIPED, Harvard T.H. Chan School of Public Health | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Primary care is more than just office visits
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...