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Dr. Elaine Schattner

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Doctors Need Time to Think

Posted: 05/02/10 08:00 AM ET

There's a new reality view of doctors' lives at work. The scoop's provided by the venerable New England Journal of Medicine in "What's Keeping Us So Busy in Primary Care? A Snapshot from One Practice." This article, by Dr. Richard Baron, documents the mundane, every-day activities of five primary care physicians in Philadelphia.

Dr. Baron's group is tech-forward; he and his colleagues adopted an electronic records system in 2004. The study assessed the volume and types of electronic medical documents of the practice, Greenhouse Internists, in 2008. The doctors participate in a pilot Patient Centered Medical Home project. This aims to compensate doctors for preventive and routine care.

The published details cover a typical workday starting around 7AM. On average, each doctor sees 18 patients and fields some 23 phone calls, 17 emails, 11 imaging reports, 20 lab panels and 14 consult notes per day. In addition, the physician provides 12 prescription refills, besides writing new orders for patients seen in the office. Other sorts of paperwork the physicians routinely complete, like physical exam records for work or camp, didn't count in the analysis because they're not standard electronic documents.

The study author suggests a physician typically works between 50 and 60 hours per week. Many tasks go uncompensated. As best I can tell, there's no mention of time the doctors set aside for reading journals, continuing medical education or attending conferences.

The Washington Post reported that Dr. Baron was surprised by the findings: "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.

The article highlights why primary care physicians need more support and payment for the work they do. This relates to health care reform and the anticipated physician shortage.

"There is already enormous pressure on primary care, and more is coming," said Dr. Thomas Bodenheimer, a professor of family medicine at the University of California, San Francisco in a New York Times report on the new study.

The point I'd add to this discussion is that despite the demand for greater efficiency, doctors need time, and perhaps compensation, for reading and critical thinking about their cases and the conditions they treat. This applies not just to primary care, but to all fields of medicine including surgery, radiology, pathology and subspecialty fields like hematology and endocrinology.

As things stand, most doctors pay out of pocket for their journal subscriptions and attending medical conferences. Maintenance of certification, a process by which physicians can study and take new exams after practicing for 10 years, is costly and time-consuming. Some argue that there's no reason for older, experienced physicians to go through the motions of recertifying, that their daily work activities are sufficient to keep them up-to-date. (A recent vignette in the New England Journal, published along with two competing viewpoints and an ambivalent editorial, considers both sides of this issue.)

I think doctors need time to take in new developments and consider those in the context of the patients they see. Physicians' work requires continual learning and thinking:

1. Keeping up with the literature. Depending on the physician's specialty, this could mean an hour or so of reading several days each week, just for a cursory flip through the most important journals and perhaps a careful review of one or two papers. (The unfortunate reality is that many doctors keep a stack of periodicals on their desk, or nightstand, and read only of fraction of what they'd like.)

2. Attending conferences. Meetings provide an opportunity for doctors to exchange ideas and gain insight on new findings. At conferences, physicians can challenge new data and learn about the limits of studies by listening carefully to their colleagues' questions and hearing experts' responses.

3. Considering cases in detail. If doctors lack the time to carefully evaluate their patients - whether that's by physical, x-ray or other forms of examination - they're less likely to provide effective care.

Recently I considered that doctors should think more, and order less to reduce health care costs. For example, in oncology, a field I know very well, if physicians had the time to examine patients thoroughly - including the lymph nodes, liver and spleen - and did so often enough that they'd be confident in their physical examination skills, they might order fewer CT scans.

The practice of medicine is changing rapidly, so much so that some physicians are having a hard time keeping up with the technology, in itself, of providing care - electronic health records, processing of digital images and the like. But science and medical knowledge are advancing, too, and progress in each field bears on the quality and costs of current practice.

In primary care, physicians need to know what's happening in preventive health, diabetes management, cancer screening, hypertension, vaccine recommendations and more. In psychiatry, new drugs come with new toxicities for physicians to keep in mind, besides new science. In surgery there's been constant development of instruments and techniques, some of which help by reducing post-op deaths, infections and durations of hospital stays. Some new devices don't work out so well, and certainly I hope that my surgeons are aware of the new findings.

Earlier this year Dr. Pauline Chen considered in a "Doctor and Patient" column what makes physicians effective aside from the usually-considered factors like standardized test scores. She refers to a published study on personality-testing of medical students, which found that certain traits - extraversion, openness, and conscientiousness - predict success in early years of practicing medicine.

I agree that these personal qualities are important, but only to a degree. Sure, I like doctors be the nice, caring and responsive individuals. But even now, with electronic and sometimes accessible records, better Internet search tools, some public-domain medical articles and IT decision support, we still depend on doctors to know their stuff.

In a previous post I considered how enhanced public literacy would improve health while reducing the costs of care in the U.S. That's because when people are sufficiently educated that they can understand what their doctors tell them, know what they read and get basic math and science concepts, they're less vulnerable to misleading information. The price people pay for selecting bad medicine isn't just money; botched care impairs the quality of lives.

How doctors are educated matters equally, and this includes continuing education after they graduate from medical school. The extent to which physicians keep abreast of new developments and the facility with which they can evaluate information as it becomes available are critical to modern, efficient and good-quality care.

 

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