More and more patients are taking their aches and pains to retail clinics. Nurse practitioners and other mid-levels are handling more routine clinical care.

Even so, primary care doctors are working harder than ever.

That’s the takeaway from an athenahealth study that analyzed medical billing and EHR data from approximately 40 million visits, by 5 million patients, to 4,900 primary care practices. Between 2010 and 2015, it found:

• The average work performed during each primary care visit increased by 6 percent.
• The average number of diagnoses recorded per visit increased by 10 percent.
• The proportion of visits with high-complexity evaluation and management codes increased by 12 percent.

It’s possible that some primary care providers are simply recording more patient data as required by Medicare rules and risk-based contracts. But some believe that frontline physicians are, in fact, doing more work in every patient encounter, largely because the simpler cases have been farmed out to other providers.

“The easier visits — the pink eye, the runny nose — more of those patients are now going, very appropriately, to their nearest Minute Clinic,” says Liselotte Dyrbye, M.D., associate director of the Program on Physician Well-Being for the Mayo Clinic.

Meanwhile, more patients with complex problems have become insured and are filling the schedules of primary care physicians.

“The patient we tend to see now has diabetes, depression, hypertension, and heart failure. That patient comes in because their foot hurts, but there is more to take care of than their foot. We have to take care of all those comorbidities,” Dyrbye says.

And the more complex the patient, she says, the more lab tests, images, prescriptions, and consultations are required.

That increased workload comes at a time when physician burnout is a top-of-mind concern, and when research shows an engagement gap among primary care physicians.

A full day of seeing patients who truly need a doctor’s care “is rewarding,” Dyrbye says. “It gives our work meaning.”

Yet that change in patient panels, she says, represents a dramatically increased “cognitive load.”

“You’re going all day from one complex patient to the next complex patient without a breather — the simple, routine patient — and that is very taxing,” she says.

And even when patient care is provided by nurse practitioners and physician assistants, “I still have to review those results and make decisions,” Dyrbye says. “It’s hard to find time for everything on the plate of the primary care physician. And that is contributing to career dissatisfaction, turnover, early retirement, and burnout.”

One silver lining for PCPs: They’re beginning to be paid more. According to the study, overall revenue per supervising PCP increased from 2013 to 2014 by 2.4 percent.

Gale Pryor is a senior writer for athenaInsight. Illustration by Michele Kondrich.