From Individualized Interactions to Standardized Schedules: A History of Time Organization in U.S. Outpatient Medicine

Nguyen, Michelle; Schotland, Samuel V.; Howell, Joel D.

doi:10.7326/m22-1575

Cited by 4 publications

(6 citation statements)

References 31 publications

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“…Our analyses highlight the fundamental tension between the volume incentives embedded in fee-for-service reimbursement systems and quality of care . While our results do not suggest an optimal visit length, they do suggest that physicians’ time is not always allocated based on patient complexity . Such findings suggest opportunities for a more equitable distribution.…”

Section: Discussionmentioning

confidence: 52%

“…25,[31][32][33] While our results do not suggest an optimal visit length, they do suggest that physicians' time is not always allocated based on patient complexity. 34 Such findings suggest opportunities for a more equitable distribution. While risk adjusting visit length to match individual patients' needs may be prohibitively complex from a logistical standpoint, practice leads could consider building in more flexibility than typically exists now.…”

Section: Jama Health Forum | Original Investigationmentioning

confidence: 99%

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Association of Primary Care Visit Length With Potentially Inappropriate Prescribing

et al. 2023

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ImportanceTime is a valuable resource in primary care, and physicians and patients consistently raise concerns about inadequate time during visits. However, there is little evidence on whether shorter visits translate into lower-quality care.ObjectiveTo investigate variations in primary care visit length and quantify the association between visit length and potentially inappropriate prescribing decisions by primary care physicians.Design, Setting, and ParticipantsThis cross-sectional study used data from electronic health record systems in primary care offices across the US to analyze adult primary care visits occurring in calendar year 2017. Analysis was conducted from March 2022 through January 2023.Main Outcomes and MeasuresRegression analyses quantified the association between patient visit characteristics and visit length (measured using time stamp data) and the association between visit length and potentially inappropriate prescribing decisions, including inappropriate antibiotic prescriptions for upper respiratory tract infections, coprescribing of opioids and benzodiazepines for painful conditions, and prescriptions that were potentially inappropriate for older adults (based on the Beers criteria). All rates were estimated using physician fixed effects and were adjusted for patient and visit characteristics.ResultsThis study included 8 119 161 primary care visits by 4 360 445 patients (56.6% women) with 8091 primary care physicians; 7.7% of patients were Hispanic, 10.4% were non-Hispanic Black, 68.2% were non-Hispanic White, 5.5% were other race and ethnicity, and 8.3% had missing race and ethnicity. Longer visits were more complex (ie, more diagnoses recorded and/or more chronic conditions coded). After controlling for scheduled visit duration and measures of visit complexity, younger, publicly insured, Hispanic, and non-Hispanic Black patients had shorter visits. For each additional minute of visit length, the likelihood that a visit resulted in an inappropriate antibiotic prescription changed by −0.11 percentage points (95% CI, −0.14 to −0.09 percentage points) and the likelihood of opioid and benzodiazepine coprescribing changed by −0.01 percentage points (95% CI, −0.01 to −0.009 percentage points). Visit length had a positive association with potentially inappropriate prescribing among older adults (0.004 percentage points; 95% CI, 0.003-0.006 percentage points).Conclusions and RelevanceIn this cross-sectional study, shorter visit length was associated with a higher likelihood of inappropriate antibiotic prescribing for patients with upper respiratory tract infections and coprescribing of opioids and benzodiazepines for patients with painful conditions. These findings suggest opportunities for additional research and operational improvements to visit scheduling and quality of prescribing decisions in primary care.

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Section: Discussionmentioning

confidence: 52%

Section: Jama Health Forum | Original Investigationmentioning

confidence: 99%

Association of Primary Care Visit Length With Potentially Inappropriate Prescribing

et al. 2023

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“…The median overall Mini-Z survey score was 30 (range, [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37]. Most participants were satisfied with their current job (median, 4 [agree]; range, 1-4).…”

Section: Resultsmentioning

confidence: 99%

“…Redesigning or transforming primary care without attending to scheduling risks perpetuating a foundational weakness in our current health care delivery systems . We suggest that policy leaders urgently look for and address any mismatch between their scheduling policies and the work expectations they demand of their PCPs.…”

Section: Discussionmentioning

confidence: 98%

“…Redesigning or transforming primary care without attending to scheduling risks perpetuating a foundational weakness in our current health care delivery systems. [36][37][38] We suggest that policy leaders urgently look for and address any mismatch between their scheduling policies and the work expectations they demand of their PCPs. More specifically, we suggest leaders (1) increase slack in outpatient clinical scheduling by introducing more flexible time and (2) recognize their agency and responsibility to set care expectations that are realistic and match the time structures they create for their physicians.…”

Section: Recommendationsmentioning

confidence: 99%

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Primary Care Physicians’ Experiences With and Adaptations to Time Constraints

Nguyen,

Honcharov,

Ballard

et al. 2024

JAMA Netw Open

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ImportanceThe primary care workforce shortage is significant and persistent, with organizational and policy leaders urgently seeking interventions to enhance retention and recruitment. Time constraints are a valuable focus for action; however, designing effective interventions requires deeper understanding of how time constraints shape employees’ experiences and outcomes of work.ObjectiveTo examine how time constraints affect primary care physicians’ work experiences and careers.Design, Setting, and ParticipantsBetween May 1, 2021, and September 31, 2022, US-based primary care physicians who trained in family or internal medicine were interviewed. Using qualitative analysis of in-depth interviews, this study examined how participants experience and adapt to time constraints during a typical clinic day, taking account of their professional and personal responsibilities. It also incorporates physicians’ reflections on implications for their careers.Main Outcomes and MeasuresThematic analysis of in-depth interviews and a measure of well-being (American Medical Association Mini-Z survey).ResultsInterviews with 25 primary care physicians (14 [56%] female and 11 [44%] male; median [range] age, 43 [34-63] years) practicing in 11 US states were analyzed. Two physicians owned their own practice, whereas the rest worked as employees. The participants represented a wide range of years in practice (range, 1 to ≥21), with 11 participants (44%) in their first 5 years. Physicians described that the structure of their work hours did not match the work that was expected of them. This structural mismatch between time allocation and work expectations created a constant experience of time scarcity. Physicians described having to make tradeoffs between maintaining high-quality patient care and having their work overflow into their personal lives. These experiences led to feelings of guilt, disillusionment, and dissatisfaction. To attempt to sustain long-term careers in primary care, many sought ways to see fewer patients.Conclusions and RelevanceThese findings suggest that organizational leaders must align schedules with work expectations for primary care physicians to mitigate physicians’ withdrawal from work as a coping mechanism. Specific strategies are needed to achieve this realignment, including incorporating more slack into schedules and establishing realistic work expectations for physicians.

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“Good Care Is Slow Enough to Be Able to Pay Attention”: Primary Care Time Scarcity and Patient Safety

Satterwhite,

Nguyen,

Honcharov

et al. 2024

J GEN INTERN MED

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From Individualized Interactions to Standardized Schedules: A History of Time Organization in U.S. Outpatient Medicine

Cited by 4 publications

References 31 publications

Association of Primary Care Visit Length With Potentially Inappropriate Prescribing

Association of Primary Care Visit Length With Potentially Inappropriate Prescribing

Primary Care Physicians’ Experiences With and Adaptations to Time Constraints

“Good Care Is Slow Enough to Be Able to Pay Attention”: Primary Care Time Scarcity and Patient Safety

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