Why primary care physicians are working harder than ever

  | August 9, 2016

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.

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It would be great to know if these changes were statistically significant.
Name: 
Martha Carter
Email: 
test@test.com
Sad but very true! I saw this personally with my brother who “was” a primary care physician. After several years he decided to leave the practice he was with to run an occupational health clinic for these very reasons. He has since moved into emergency medicine which has much fewer of the “burnout” concerns that PCP’s have.
Name: 
Hamish
Email: 
test@test.com
I've been in practice 21 years doing Urologic Surgery. I believe the workload is more difficult because despite the gov best efforts to put the burden and blame on physicians....as a whole Americans aren't that healthy and don't take responsibility in many ways for their own health. So it seems there is more obesity, more DM more HTN more CAD etc etc etc....second the more rules, regulations and just plain old red tape BS and EMR documentation for less and less and less reimbursement makes one patient encounter seem like a bad nightmare....so for example I used to get a prescription pad with a diagnosis from a family doc with what I was seeing the patient for. Easy....now I get twelve pages of absolute nonsensical BS of EMR ....that says everything about nothing but I can't make heads or tails about the patients medical problem they are in my office for or what's being done or not about it. At the end of the day I see maybe 66% of what I used to be able to see and feel like I've been through hell and back by the end of the day. ...oh wait I have to document I discussed smoking cessation with them....then they come back screaming when they see it on their EOB. More mid level providers....in the ER and with hospital docs ...nightmare It's like ER PA admits to night hospitalist PA ....transfers to day PA of which there may be ten with one Hospitalist overseeing them ....sometime around 1400 the next day you find out like your patient that just had a TURP had a bladder spasm but had red and white blood cells in their urine (which they all do) got admitted as a bounceback for "Urosepsis" with no associated symptoms of urosepsis ...or worse your patient with a solitary kidney obstructed with a stone and 104 fever in renal failure is sitting on the floor eating ...(surgical emergency)....got admitted at 7 pm the night before ...nobody recognized the bottom like...."surgical emergency"....but the EMR is done correctly for max hospital billing....yeah great!!! Yet nobody knows why the patient is really there....and then you see articles like...wow physician burnout is high...wow doctors are working harder...(and making way less)....it's like...really? Ya think? Then some horses butt answer ...work smarter not harder....breath deeply every morning three times...drink tea...go to the gym physicians need to take care of themselves...it's almost comical.
Name: 
Frank L Simoncini DO
Email: 
Cocdoc23@yahoo.com
I totally agree with you. Physician burnout will not be resolved if the burden of coping with it is placed only on us. Unless working conditions, appropriate pyment and time for the level of complexity and meanigful documentation are assured, I don't think tht breathing deeply three tiems before starting your day will help. Yes, being a psychiatrist I understand that developing coping mechanisms to deal with stress are very useful. Finding a balanced life is important to preserve health in general. yet, a physician like any human being needs time for vacation, family , hobbies, and personal development. Unfortunately, because of current laws physicians cannot fight together and that makes it more difficult to be able to make a difference that benefit us. Nobody is looking out for the physicians and physicians can only act in an independent manner. As a consequence, patients and physicians suffer.
Name: 
Virginia
Email: 
vbukimd@comcast.net
Burnout is driven largely by "office managers" and "administrators" of large institutions who is making the cultural change and bringing "employed practice". Physicians used to be the owners of the practice and were much happier that way and kept all patients happy. However, now we are forced to see patients every 10 minutes and reimbursement is 1/3rd of what revenue we generate. ( check with any private practitioner to verify ). I was an employee ( aka slave ) and moved out and started my own practice. I am much much happier.
Name: 
Palak Patel
Email: 
dr_palak@yahoo.com
There is much more that can be done in terms of diagnostic testing and therapeutics than years ago. This causes decision making to be more complex and time consuming. Precertification of tests and medications is another increasing demand on physician time.
Name: 
Kenneth W Franklin
Email: 
kfranklin@72med.com
I work for the VA where mid-levels practice as independent practitioners, so I don't necessarily have the more complex cases. The only way this affects us is that the mid-levels are assigned fewer patients. In reviewing their charts or when I see their patients, they don't necessarily pick up on or work up issues that I and others who are Internal Medicine, board certified, notice. What I do notice that takes more time (I've been in practice a long time): - Physicians enter a lot of information and - orders that was previously entered by clerks or nurses are entered by physicians. This continues to be done in some medical centers and is a MAJOR help, but not at the VA. - We are doing a lot of preventive medicine. I always did this but there is more to do now. My LPN signs people in and does many of the checklists, but I need to do several more; We have 1.25 hours per patient per year and this includes everything including referrals for home nursing, exams, preventive health, etc. Naturally, this is not a good plan and leads to a lot of turn over. - We have to personally enter a lot of consults. It, for some reason, it can't be done, it is cancelled and we often have to do it again. - I picked up about 300 patients on chronic pain medicine and we are trying to work with those patients. I am tapering most patients but it takes a lot of time and dealing with angry/worried/upset patients. - We are not allowed to save time for emergency patients but we have to see everyone who walks in. We have to see people timely after discharges, and we have to see people from other VAs any time they walk in. I actually agree with seeing people in emergencies, but this plan is a non-plan and leads to a lot of unnecessary stress. Why not save spots for emergencies and urgent visits and spread out the routine follow up visits? - I have to look through an average of 1-2 consultation records per patient visit. Medicare requirements for documentation mean that these records contain PAGES of routine information. It takes an extra few minutes with every patient to find the crucial information. The EHR companies could help a lot by figuring out ways to bring the crucial information to our attention. By this, I mean HPI, abnormal exam findings, impression and plan. All this extra documentation leads to errors also. For instance, providers have to document so many normal findings to get paid that they will often omit abnormal findings. For instance, they will see a patient with a stroke and not document that they are paralyzed on the left side! - The VA also requires us to put in the requests for non-formulary drugs. This is typically done by RNs on the outside. The reason this is an issue for EHR companies is that every payer has its own rules. Then patients will pick a pharmacy plan and a lot of documentation is required for different pharmacy plans. The payers and EHR providers and pharmacy plans need to get together to have one system. Payers should pay providers for the time needed to provide information required if it is more than a simple prescription or a simple form. We do it now to help the patients but the information requests can be extreme.
Name: 
Lillian Burke
Email: 
BurkeL@eimsnc.net

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Why primary care physicians are working harder than ever