The administrative burden on today’s physician practice, coupled with increasing medical complexity, inevitably spills over into patient care. For every 100 Medicare patients, a typical primary-care physician interacts with 99 other doctors in 53 practices. The chance that a primary-care visit will result in a referral nearly doubled between 1999 and 2009.
About half of physicians say that they feel time pressure during office visits and that their work pace can be chaotic. More than 3 out of 4 feel they have little control over their work.
The frenetic pace of most physician offices is often characterized as hamster-wheel activity designed to maximize revenue. Physicians need to diagnose and treat quickly. Hasty diagnoses can lead to errors.
Best Doctors is a Boston-based healthcare organization that treats 20 million people in 30 countries, essentially providing second opinions for large employers and insurance plans. It estimates that it changes the diagnosis in about 20 percent of the cases it reviews, and changes treatment in more than 60 percent of cases.
Job satisfaction among physicians is strongly tied to their relationships with patients. Those ties have been frayed by time and productivity pressures and administrative burdens, Best Doctors found. Physicians’ sense of little control have fueled this disconnect—and discontent.
Attempting to keep up with voluminous—and sometime conflicting—practice guidelines and peer-reviewed literature is nearly impossible. A group of researchers attempted to gauge the amount of effort required to keep up with primary care research. They found 341 active journals with 8,265 articles in one month. They estimated that physicians would need 627 hours a month—nearly 21 hours a day—to evaluate the literature.
The Cochrane Collaboration created 1,837 systematic reviews addressing intervention-related questions and more than 11,600 abstracts of additional systematic reviews. That is barely scratching the surface. Cochrane personnel estimated it would take 30 years to summarize the existing controlled trials for Cochrane reviews—excluding the new evidence published during those 30 years.
Nine prominent physician groups have created a list of 45 frequently prescribed tests and treatments they say are often unnecessary and may even be harmful.
Each group, representing both primary-care doctors and specialists, picked five procedures that medical evidence shows have little or no value, and that they say should be questioned automatically by patients and their doctors.
Dr. David Sackett, a pioneer in evidence-based practice, said the effort integrates three important components: clinical expertise, a patient’s values and preferences, and the best research available.
The problem is the third component. Two Welsh medical school professors appraised the “avalanche of information” heaped upon clinicians. They calculated that medical students training in cardiac imaging would need to read 40 papers every weekday for 11 years to become current with the specialty.
A chief reason many doctors cannot meet national clinical care guidelines is a lack of time. A physician with a 2,500-patient panel would need 21.7 hours a day to meet recommended national clinical-care guidelines.
There are several barriers to adopting medical evidence as the standard for treatment, including the difficulty of changing physician practice patterns and the sheer volume of research. Translating science into medical practice takes an average of 17 years from discovery into practice, and monitoring the more than 10,000 randomized, controlled trials published annually is impossible for a busy clinician.
The research findings also change at a dizzying pace. An Archives of Internal Medicine study found that 13 percent of research articles published in the New England Journal of Medicine in 2009 were reversals of earlier research findings about prescription medications, screening tests and procedures.
A JAMA article examined studies that had found a particular medical practice effective. One-third were later followed by trials that found those practices either ineffective or less effective than originally reported.
Mayo Clinic Proceedings researchers examined articles from 2001 to 2010 in The New England Journal of Medicine and found 363 studies that tested a medical practice constituting the standard of care at the time. The published articles contradicted the established medical practice 40 percent of the time, adding up to 146 cases in which new evidence questioned the care physicians had been advised to provide.
Time constraints place even more pressure on physician-patient communication. Patients add to the burden by not taking care of their own health or demanding care that is inappropriate.
Patient participation in care decisions scarcely existed until 1960. Physicians were expected to promote patient welfare without necessarily acknowledging patient rights. Shared decision-making has been fueled by readily available information on the Internet and by consumer-driven health plans. Physicians increasingly are being seen as expert advisers to patients who want their care preferences and values to be part of the treatment equation.
This desire for patient autonomy creates different pressures for physicians. Complex medical science is difficult for physicians to explain and patients to understand. Mutual frustration creates the default scenario in which physicians are not inclined to engage in long discussions of treatment pros and cons, and patients often want doctors to make decisions for them.
The average physician visit lasts 18 minutes. A patient is able to speak for an average of 23 seconds before the physician interrupts. One out of 3 parents reported spending less than 10 minutes with the clinician at their last well-child visit, compared with only 1 out of 5 who spent more than 20 minutes. In a landmark 1984 study, fewer than 1 out of 4 patients were allowed to express their needs completely without interruption.
Trying to have a meaningful discussion under these circumstances is difficult. Physicians often select treatments based on what they believe their patients would want, absent an actual conversation.
Patient satisfaction is directly tied to more time with the physician and less time in the waiting room. DrScore.com, a physician-rating website, analyzed 36,000 patient surveys. It found physicians were considered less caring when wait times were longer than 15 minutes and visits were less than 10 minutes.
Most physician offices are set up to deal with acute conditions. However, nearly half of Americans have at least one chronic condition, requiring complex care and often involving coordination with several clinical, occupational and social services. More than 4 out of 10 physicians function without non-physician staff that can work with chronic-disease patients, such as nurse case managers and social workers.
Researchers taped 34 physicians during more than 300 patient visits. They found that physicians spent an average of 1.3 minutes imparting important information about the patient’s condition and treatment, and much of that was too technical for most patients to understand. The physicians in this study remembered things differently: They estimated that they had spent more than eight minutes communicating about the patient’s care.
Physicians forget important information their patients give them from one visit to the next about one-third of the time.
About 1 out of 3 elderly adults said their physicians did not review their medications, even though adverse drug events lead to more than 177,000 emergency-department visits annually. About 2 out of 3 said their doctors or nurses did not ask whether they had fallen or give advice about tripping on carpets or stumbling on stairs. Falls account for more than 2 million injuries annually for people 65 and older.
About 3 out of 5 patients believe their doctors are rushing through exams, a proportion that has barely moved for three decades.
There has been improvement in some aspects of physician-patient relations over time. NPR took questions from a 1983 poll and asked them again. This time, respondents gave doctors higher ratings in some categories. About 2 out of 3 said doctors usually explained things well to them, compared with 49 percent in 1983. More said doctors are trying to hold down medical costs.
The above is an excerpt from his new book So Long, Marcus Welby, M.D.: How Today’s Health Care Is Suffocating Independent Physicians—and How Some Changed to Thrive. D Healthcare Daily founding editor Steve Jacob draws on dozens of interviews and more than 500 published sources to cover these issues and describe how the landscape is changing for doctors.
