Working alone, a primary care provider (PCP) would need nearly 27 hours daily to meet all of the guidelines for preventive care, chronic disease management, and acute care, a recent study found.
The research quantifies what many PCPs have anecdotally described: They just don’t have enough time in their day for patients and administrative duties.
Team-based care models may alleviate the time crunch, but systemic problems may limit these models’ viability.
There literally are not enough hours in the day for PCPs to meet preventive, chronic disease, and acute care standards.
A recently published study found that if a lone PCP were to address all of the guidelines with their patients, they’d need almost 27 hours a day. How can they meet the demands of their job without spending every waking hour at work?
Study findings explained
To better understand this study, which was published in July 2022 in the Journal of General Internal Medicine, MDLinx spoke to its lead author, Justin Porter, MD, an assistant professor of medicine at the University of Chicago and an internist and hospitalist.
Dr. Porter and his colleagues wanted to determine how much time it would take a PCP to meet all of the guidelines for preventive, chronic disease, and acute care. The research team looked at time requirements for PCPs working alone, as well as PCPs who are part of a team-based care model. They found that these demands add up.
“It's kind of death by a thousand cuts,” Dr. Porter said. “For a large number of the interventions, it's actually not that much time per day. But the reality is the sum total of all these."
"When you have dozens of interventions, the sum total becomes a lot."
— Justin Porter, MD
The study involved hypothetical patient panels of 2,500 patients, chosen to represent demographics of the US population based on the National Health and Nutrition Examination Survey from 2017–2018. In addition to the mean time PCPs needed to provide guideline-adherent care, the researchers also calculated time requirements for documentation and inbox management.
Porter and the team found that PCPs working alone would need 26.7 hours to address all of the guidelines.
That breaks down to:
14.1 hours daily for preventive care
7.2 hours for chronic disease care
2.2 hours for acute care
3.2 hours for documentation and inbox management
Things looked better for PCPs working in team-based care settings, who needed 9.3 hours daily, which broke down to:
2.0 hours daily for preventive care
3.6 hours for chronic disease care
1.1 hours for acute care
2.6 hours for documentation and inbox management
“PCPs do not have enough time to provide the guideline-recommended primary care,” the researchers concluded. “With team-based care the time requirements would decrease by over half, but still be excessive.”
What’s taking so long?
The time crunch stems from the onerous nature of changing human behavior, Dr. Porter said. It takes time to do the counseling-based interventions called for by the US Preventive Services Task Force, addressing conditions such as diabetes, being overweight, or CVD.
“In a sense, we intuitively know that this takes a long time to do,” Porter said. “Behavioral change, in general, doesn't happen if you just tell someone to do something different in a couple of minutes. I think anyone who's in a marriage kind of understands that.”
Moreover, Dr. Porter said that the research team’s estimates were conservative. They consistently chose time estimates on the low end of the ranges. Also, patients want these counseling-based interventions, he said.
“I sometimes hear criticisms like, ‘Doctors are just very focused on giving medications and doing these kinds of interventions, and less focused on talking to me and to changing my behavior,’” Dr. Porter said.
Analyzing time-on-task, as his research team did, offers a possible explanation as to why.
"It takes 2 minutes to prescribe a medication; it takes hours to cause someone to change their behavior. "
— Justin Porter, MD
So if we can’t add hours to the day, how do we give PCPs more time?
What do we do about it?
As the study suggested, team-based care is one option. It's been shown to improve the quality of care.
A study published in the Journal of General Internal Medicine in 2018 found that practices which embraced team-based care had higher Accountable Care Organization metrics than groups that were less engaged with team-based care models.
Care-quality improvements with team-based care were also cited in a study published in Healthcare in 2019. From observing care interactions in safety-net clinics in California, researchers concluded that team-based care can improve outcomes and improve relationships among clinicians.
Not only is team-based care better for patients; Dr. Porter said it’s also better for PCPs.
“This could potentially save PCPs time, because you could shift tasks that are currently done by the PCP to other members of the healthcare team,” Dr. Porter said.
But of course, time and money are often intertwined.
Financial hurdles to clear
While it would be ideal to have dieticians, pharmacists, and other clinicians leverage their knowledge to counsel patients, they might not get paid for their efforts.
For example, Medicare or Medicaid might reimburse a practice if a patient had specific needs, such as proper nutrition following a renal transplant. But the practice wouldn’t get paid for counseling a patient with obesity.
Good luck getting a primary care clinic to employ a dietician under this compensation model.
Also, Dr. Porter said the PCP shortage and PCP compensation are playing roles here, too. What’s the financial incentive to become a PCP?
“You have to think about this as an individual in medical school deciding what type of specialty they would like to go into, and it's very clear that it makes much more financial sense to sub-specialize rather than to stay as a primary care provider,” Dr. Porter said.
And while alternative care models such as concierge medicine may be attractive, they’re cost-prohibitive for many patients, and they draw PCPs out of the general workforce.
Ultimately, the problem of not enough time, and its solution, are bigger than PCPs themselves, Dr. Porter said.
"The problem is, we as individuals can take actions to try and improve our particular situation, but in reality, this is a systems problem. "
— Justin Porter, MD
“And it’s really hard for individuals to take action to solve that. It requires larger changes to the way that medicine is structured, financed, and organized,” Dr. Porter concluded.
What this means for you
PCPs face a confluence of factors that eat away at their time. These include a shortage of providers, increased administrative demands, and expanding guidelines for delivering comprehensive patient care. Although team-based care can make meeting quality metrics more achievable, current reimbursement models fall short and must evolve to make this a reality.