What do physicians do all day?

The Pediatric Insider

© 2016 Roy Benaroch, MD

The television doctors: striding purposefully through the ER, giving orders, surrounded by a gaggle of eager learners and a super-team of nurses and techs. Or spending hours operating, then sipping martinis while waiting for the next disaster. Maybe saving lives in between daydreams and liaisons with hot colleagues and nurses. All in a day’s work!

Maybe not. A new study looked at what doctors really do all day. In the real world, there’s precious little time for striding, martinis, or even a quick trip to the bathroom. In the real world, docs spend most of their time doing paperwork and data entry. That’s hardly sexy, and not even remotely fun, and –gasp—not really what we were trained to do.

From the Annals of Internal Medicine, September 2016, comes a downright depressing study: “Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties.” The researchers had medical students (hopefully they were paid) follow 57 US physicians in 4 different specialties in 4 different cities for a total of 430 observation hours. These physicians were all observed during their office hours (excluding time in the hospitals and operating rooms.) Observers used a technique called The Work Observation Method By Activity Timing – I mention this only because it’s abbreviated WOMBAT – to track exactly what the docs did all day. Categories included things like clinical time (either talking or interacting with patients, or talking with staff about matters directly related to a patient), desk work, time spent documenting on an electronic health record, and administrative time. They even recorded “personal time” including bathroom breaks and eating (many of the medical students, I think, were surprised that doctors are even allowed to use the bathroom. Ha!) Separately, they had a few dozen of the physician participants fill out diaries to see what they’re up to in the evenings.

The painful results: doctors, overall, spend about 33% of their net workday actually taking care of and interacting with patients. For every hour of direct patient care activity, two hours are spent on typing, data entry, and paperwork. Over the course of an entire workday, we spend only about half of our time in exam rooms, but even while in the exam rooms we’re focusing on and interacting with actual patients about half of that time. Just as much exam-room time is spent typing or dictating into our computers as spent talking with and examining patients.

And, after the work day is over, doctors spend an average of 1.5 hours working from home, spending most of this time on—you guessed it—more data entry into electronic medical records.

Old school: “Mommy, I want to be a doctor!”

Modern equivalent: “Mommy, I want to type and click boxes and fill out forms!”

I’m imagining medical school deans, with this study in mind, are hastily adjusting the curriculum. Gone is biochemistry – replaced with “Sports forms, basic and advanced.” Physiology can become “Navigating disability and FMLA paperwork”, perhaps with a “Disabled parking permit seminar”. The surgical clerkship can become “Type, click, backspace, repeat”, and all of obstetrics and gynecology can become “Prior authorization jujitsu.” This will surely prepare the next generation of medical students (nurses, too!) for what’s to come. If anyone still wants to do it. We’ll leave the light on when we leave, just in case.

Benjamin Franklin "Hawkeye" Pierce

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5 Comments on “What do physicians do all day?”

  1. Jeanne Says:

    Great article. Thank you for the insight and being flexible with the change. If there’s one thing about change… It’s constant.

    Like

  2. Dr. Naline Lai Says:

    I had a 4 year old patient under the exam table a couple years ago pretending to type. When the mother and I asked him what he was doing, he replied “I’m being a doctor”

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  3. Dr. Roy Says:

    Smart kid. How did we get like this?!

    Like

  4. wzrd1 Says:

    Easy answer, Doc. Insurance companies and regulatory oversight, but mostly insurance companies.

    Meanwhile, from a patient perspective.
    56 YO Female presents with poorly controlled diabetes, additional DX cervical stenosis w/ symptoms at all levels (diagnostic imagery confirmed), L5-S1 herniation with cauda equina syndrome (diagnostic imagery confirmed and significant neurological impairment) and advanced osteoporosis (with multiple healed vertebral fractures and two fresh vertebral fractures). Delaying surgical decompression of the most problematic areas, osteoporosis. Additional complication, biliary cirrhosis, secondary to long ignored cholelithiasis, which has been treated with cholecystectomy.
    Insurance company declines every suggested TX for osteoporosis thus far, adding additional forms to hurdle.

    Current TX, morphine sulfate ER, morphine sulfate immediate release, diazepam, gabapentin and titration of dosage, ongoing to prevent further falls.

    Patient details given with permission of patient and her husband, myself.
    Communication with physicians is extensive, largely via patient portal, allowing time to be more efficiently managed, but receiving notification after 22:30 (mean from range of 20:00 – 23:00) in many cases tells me how many hours doctor is spending working electronically.
    Changed over the past decade: Referrals are easier to acquire. Actually receiving treatment, delayed excessively in some cases.

    With our modern world and life, being constantly connected does give us feedback and insight that was never available before. Receiving a notice of a message from doctor when we used to be tucking our children into bed and reading a bedtime story, well, that’s very telling. We saw those baby pictures on your desk.

    But, an upside of this is, having to incessantly prevent my wife from falling has provided our specialist medical community some additional work. A probable disc failure for me and I have to schedule some PT for an old shoulder injury that’s been aggravated.
    So, one longstanding annoyance gets the needed PT and I was reminded of the joys of what an injection into an angry joint felt like and I’m now using dad’s old cane, while I wait between 60 and 90 days for the injury to satisfy the insurance company enough to get an MRI to confirm the damage that’s already neurologically apparent.
    And doctor gets to spend even more time on one family’s referrals and authorization letters.
    All, while he gets paid $23 by the insurance company, where he’d otherwise get $90.*

    *Cigna loves to send me papers boasting of what they paid, what doctor bills for and what doctor actually receives.
    A sheaf of papers that I dutifully read, the profanity streaming from my mouth, unfit for even a military field environment.

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  5. Dr. Roy Says:

    wzrd, it’s difficult sometimes not to get caught up in the 24hour-doctoring cycle… but those “off hours” are sometimes the only convenient time for me to do stuff like that. I’m (allegedly) off today, but I’ve already spent an hour talking with specialists about a complex patient. It’s just impossible for me to squeeze that kind of stuff into a day when patients are scheuled (tho sometimes there’s just no alternative, and I fall behind, and patients get mad, etc.)

    Amazing how much of this comes down to proving you need something not to a doc or medical professional (who is professionally bound to help you, the patient), but rather to an insurance company employee (who is doubtless being metric’ed at how little he or she spends on patients’ behalf.)

    Like


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