The statistics of today’s patient totals

Excerpted from “How many patients should your doctor see each day?” commentary by Lenny Bernstein in The Washington Post. May 22, 2014 — 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.”

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.

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. 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.”

Commentary

CMDA Member Thomas Eppes, MD:“The article from the Post raises multiple questions and thoughts from multiple perspectives in seeking to answer the question of how many patients a doctor should have under their care. If you are the patient, the answer is easy, one and it’s me. If you are the physician, the answer is enough to survive, enough to ‘bring home the bacon, enough to pay back the loans, enough to meet the requirements of my contract, enough for whatever your financial goals might be, etc. If you are the physician’s spouse, just enough to support the family and still get home to be with them and the kids. We could go on and on.

“The world is creating multiple pressures on physicians to see more patients, more efficiently, more electronically, with higher quality and even perfect quality, at no greater cost.

“Solutions for individuals include abandon ship, to retire, to go part-time, to do concierge practices or to build highly efficient teams. The days of seeing patients on a merry-go-round at full speed ahead are quickly disappearing as we move from volume driven care to quality proven population management. The proven and comfortable model of the past has to be altered in a quantum way as new and unproven ‘solutions’ pop up. It is quite unsettling, especially for those nearing the end of their practice life.

“What did our Lord do? Obviously, if there ever was one under a time constraint it would have been He. Yet He never ran anywhere, and He was fussed at for not being timely by others not being cared for at that moment. Yet the Bible tells us He met every ‘patient’ where they needed to be met.

“As each of us struggles with our individual station in our walk on this earth, we need to be ever mindful that we are accountable to only our Lord for how we meet His calling for our lives. We should each day see each patient encounter as our opportunity and appointment to glorify Him as we do His work on this earth, whether it be one patient, 30 or 100. This is what those who are trusting us to care for them want and deserve. Prayerfully, each healthcare professional can do this only if our eyes are on Him as He gives us the wisdom, energy, grace, insight and stamina to do His will every day.”

Resources
Faith and Health Resources

Doctors Look For A Way Off The Medical Hamster Wheel

Excerpted from “Doctors Look For A Way Off The Medical Hamster Wheel,” Shots: Health News from NPR. August 14, 2013 -- Doctors are on a hamster wheel these days. We're compelled to run faster just to stay in place. It's about to get worse. Obamacare means millions more people will want our services, with not enough primary care doctors to meet demand. Government incentives that are pushing us toward computer-based records mean that doctors now spend as much time documenting our visits with patients as we do examining them.

As the hassles have gotten worse, I've seen many colleagues jump ship. But there might be another way. Dr. Christine Sinsky, an internist in Dubuque, Iowa, has made it her mission to find ways to mitigate the drudgery of modern doctoring. With funding from the American Board of Internal Medicine Foundation, she and four colleagues traveled the U.S. in search of practices that provide top-notch, effective primary care, while making the work satisfying for the doctors and other health professionals. Sinsky and her team found 23 examples of innovative practices from coast to coast, and reported on them in both an academic journal and an in-depth white paper.

Dr. Ben Crocker was so burned out in in 2007 that he lamented, "Working at Starbucks would be better." Now, his practice at Massachusetts General Hospital employs health coaches to work with patients on making the lifestyle changes that doctors recommend but can't adequately teach or monitor. Virtual visits have replaced some in-person visits. Perhaps most incredibly, the practice offers staff downtime each week to come up with innovations.

Sinsky offers examples of tedious tasks that take doctors away from providing undivided attention. No. 1 among them is data entry. "Inbox management" — all the phone calls, emails, forms to sign and prescription refills — can take up to two-thirds of a physician's day. "All of this inbox work can and should be handled by nonphysician personnel, freeing us up," she says. "So many mandatory tasks are crowding out the work of real doctoring.”

Commentary

CMDA Member Julie Griffin, MD: -- “Demanding schedules, flawless precision and an enduring calm in calamity—these are expectations of physicians. We have often placed these ultimatums on ourselves with our detailed, driven personalities pushing us to unattainable perfection. Nevertheless, the culture increasingly demands a new maximum.

Hardly imaginable is Hippocrates rushing around the office, then being paged across town for a delivery. Medicine’s revered father never had to defend his decisions to a third-party payer. We prefer the tableau of a wise, forbearing professional to grateful patients and an engaging professor to eager students. In truth, we were in this picture ourselves as we entered medical school.

Have our dreams run amuck? Perhaps, if we lose the focus of our callings in light of career demands. Yet, if we are confident of our callings and moved with the same compassion which moved Jesus (Matthew 9:36), we will not be distracted from our opportunities to serve.

To be sure, we must employ new methods, including delegation of duties. Medicine is moving to team-based care. This change is neither revolutionary nor futuristic. It is an overdue move toward our biblical heritage. Jesus readily embraced teamwork in ministry, and we as physicians should do likewise.

We must remember our calling and the true Strength by which we fulfill it—paperwork, phone calls and all. We cannot be chased out of our ministries for there is no joy or peace in life apart from our appointments as God’s coworkers in the gospel of Christ (1 Thessalonians 3:2-3).

Resources
In Search of Balance by Richard Swenson, MD
Practical Practice Issues in Today’s Christian Doctor

Are doctors burned out?

Is your doctor burned out?," CNN, by Alexandra Sifferlin. August 28, 2012--Job burnout can strike workers in nearly any field, but a new study finds that doctors are at special risk. Nearly 1 in 2 U.S. physicians report at least one symptom of burnout, with doctors at the front line of care particularly vulnerable, the study found -- a significantly higher rate than among the general working population. Overtaxed doctors are not only at risk for personal problems, like relationship issues and alcohol misuse, but their job-related fatigue can also erode professionalism, compromise quality of care, increase medical errors and encourage early retirement -- a potentially critical problem as an aging population demands more medical care.

Led by researchers from the Mayo Clinic and the American Medical Association, the study asked participating physicians to fill out a questionnaire asking about their feelings of burnout -- including "emotional exhaustion" or losing enthusiasm for their work; feelings of cynicism or "depersonalization"; and a low sense of personal accomplishment. The 22-item questionnaire, called the Maslach Burnout Inventory (MBI), is considered the gold standard for measuring burnout; the doctors also completed a shorter, modified version of the MBI, the answers to which researchers used to compare with the general population. Researchers also asked doctors how long they worked each week, how satisfied they were with their work-life balance, and whether they had any symptoms of depression or thoughts of suicide.

The data showed that rates of burnout were high: 45.8 percent of doctors experienced at least one symptom of work-related burnout. "Our finding is concerning given the extensive literature linking burnout to medical errors and lower quality of care," says study author Dr. Tait Shanafelt of the Mayo Clinic. "Most previous studies of physicians from individual specialties have suggested a burnout rate of 30 percent to 40 percent. Thus, the prevalence of burnout among physicians appears to be higher than in the past." In addition, while higher levels of education were associated with less risk of burnout for people in other professions, doctors' advanced degrees didn't afford them the same protection from job-related stress. "While individuals in other professions do experience burnout, it seems to be largely driven by the hours," says Shanafelt. "In addition to their high work hours, there appears to be factors related to the nature of the work that increase the risk for physicians." "Unfortunately, little evidence exists about how to address this problem," the authors write, urging additional research to figure out what can be done to support doctors at the individual, organizational and societal level. "Policy makers and health care organizations must address the problem of physician burnout for the sake of physicians and their patients." Full story can be found here.

Commentary

CMDA Member and Chair of Women in Medicine & Denistry, Leslie Walker, MD: "This important but distressing study on burnout shows the first large sample of U.S. physicians across specialties compared to the general population. The results of the study show that levels of depression (on a two-question online screen) and suicidal ideation were similar to the general population, but that rates of burnout were significantly higher among physicians. "Burnout or depression can occur when we have limited autonomy but high levels of responsibility, especially in unpredictable and punitive systems. Medical internship is one of the best examples, and previous studies linked medical errors by residents to high levels of burnout and depression. In the past, doctors expected more autonomy after residency, along with increasing levels of responsibility, respect from patients and more control over schedules to balance work and personal activities, all of which reduce the risk of burnout. But that’s not necessarily the case today.

"'Treatment' for burnout typically involves taking a break, contemplating one's goals and considering whether the schedule or the type of work should be changed. While I do see physicians who take the time to do this, most burned-out doctors just keep working. The authors suggest reducing burnout may require changing the entire U.S. medical system. However, current suggestions for change are likely to increase burnout. Successful practice is increasingly based not on clinical expertise but on 'outcomes' that have less to do with a doctor's skills and more to do with monitored data in computers.

"Vibrant faith in Christ does not universally prevent burnout, but it does remind us that our identity and worth as God's children have nothing to do with how well we've met a series of benchmarks. As Christians, we gain strength from the body of Christ. If you dread going to work or see patients as just a means to a paycheck, take a break to engage with one of CMDA’s resources such as the Completing Your Call program or Grasping Power through Surrender retreats for women physicians and dentists. Join a local CMDA group where you can pray with like-minded colleagues and consider what changes might help you find joy again in the work God called you to do. This community is one of the best weapons against burnout. It serves as a reminder that you are not alone."

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