Patients Or Paper?

We’ve all seen the headlines – “Primary Care Physicians Becoming a Scarce Breed”, “Wait Times for Appointments Increasing”, “Primary Care in Crisis” – and have heard the pundits pontificating on the deteriorating state of primary care, but rarely do we hear what’s happening from physicians on the front lines, those actually seeing patients. Consequently, with direct access to the primary care trenches, replete with an overworked physician and staff members, I decided to investigate the life of a primary care physician a little further.


Although my research involves an unenviable sample size of one physician (me), I think it sheds light on some of the critical issues facing the majority of PCP’s. The simple question I set out to explore was: Do I spend more of my time working with paper than with patients?

The methodology was also straight forward – I documented my daily tasks during an average day in the office, including time spent caring for patients and administrative work.

Data collection kicked off at 10:00 am when I arrived at my office after early morning rounds with my patients in the hospital. (Interestingly, I am one of only four physicians in our community, population ~45,000, that still chooses to admit and care for my own patients rather than transfer their care to a hospitalist; a topic for another day.) Data collection ended at 6:00 pm when the final paper of the day was pushed.

The raw data are somewhat interesting but tell a typical tale … patients outnumber hours in the office by roughly 4 to 1; if signatures equated to money I would be rich; and sometimes doctors fill out forms and call people on their own! Here are the numbers for your consideration:

Total hrs in office (10-6):                                                8
Total patients seen:                                                         18
Number of times I signed my name:                                77
Number of prescriptions (new and refills):                       36
Forms completed:                                                          7
Required telephone calls:                                                3
Minutes doing paper work during patient hours:              75
Minutes doing paper work during non-patient hours:      170
Total minutes seeing patients during patient hrs:               225

Although interesting in their untransformed state, when you begin parsing the numbers, they begin to tell a much more interesting story. Using advanced statistical techniques that I learned in 4th grade – addition, subtraction, and division – it appears that I spent more time with my pen and computer then with patients.

I spent eight hours at the office, which I can confirm is typical, and 47%of that time was devoted to patient care (225 min/480 min). Averaged across the 18 patients, that works out to ~12.5 minutes with each patient (range 7 to 45 min). This is right in line with the national estimates that range from 10 to 18 minutes for patient visits and 55% of total office time devoted to patient care.1-2 Yeah, I’m average! … or as scholarly-types like to say, I am consistent with my peer group.

Despite uniformity with my cohort in these categories, I wonder whether I’m on the right track if I am devoting only half of my time to patient care? In other words, if 100% efficiency is spending every minute with patients, is 50% efficiency good enough? Although it seems unreasonable to expect 100% efficiency since few systems, biological or mechanical, come close to 100% efficiency. For example, the diesel engine, which is famous for its efficiency, only approaches 50%1, so should we expect healthcare to do any better? Am I better than a diesel?

Intuitively we all know reaching 100% efficiency is beyond utopian and probably defies some law of thermodynamics. However, important questions remain: Where does rest of the time go? How productive is that time spent? How does it impact patients?

In my little study the answer to the first question is fairly simple: 35% of my time was spent doing paperwork during non-patient hours (4-6 PM), and another 15% was devoted to paperwork during patient hours. So 50% of my day – actually 51% when decimals are accounted for – went to filling out paperwork and administrative tasks, which answers the primary study question: Indeed, I spend more time pushing papers than seeing patients.

Obviously, if none of these administrative tasks were completed, I could not bring in the revenue required to pay myself, the staff, malpractice insurance or the overhead, so some of this effort is necessary. But it seems counter-intuitive that after jamming so much potentially useful information into my brain for so many years that half of my working hours should be used signing my name and ordering batteries for a scooter!

This split – 50% patients: 50% paperwork – is what frustrates so many of us. Like my colleagues, I became a doctor to care for patients and understand that documentation and paperwork are necessary but wonder if a more productive split such as 80:20 in favor of patient care (of course) couldn’t be achieved?

I hope you can understand the frustrations PCP’s are feeling now. We’re not a group prone to complaining; we are trained to endure and we do it gladly for patients, but for the sake of paper and the insurers lurking behind them, never. I have not even begun to enumerate the endless piles of paper my two staff members must read, label, fax, shred, trash, shovel, and curse on a daily basis – a moment of silence for all the trees that have sacrificed for this country, oh, I mean insurer paperwork!

The conclusions of my study are quite clear and simple, time allocation in primary care is loathsome, and those that suffer the most from the system are patients. Every 12 minutes spent with paperwork is another patient not seen or an important health question not answered.

The question is what is the solution? One place we-the-PCP’s of the country would start is lowering the administrative hurdles and barriers to getting the care our patients need. Never again should there be days that include spending 30 minutes on hold to simply speak to a human regarding a prior authorization for one patient. Never again should the fax machine that fields requests to change patients’ medicines require more reams of paper than the copy machine used for patient charts. Never again shall someone without a medical degree put up their proverbial hand through the phone or on paper and deny a patient the care they need because their manual told them so. And for the record I do not believe a single payer system or capitation would change the 50:50 split one iota. In fact, the forms Medicare requires are some of the most cumbersome.

Building checks on the paperwork required by insurers would dramatically improve the efficiency of my care and, most likely, primary care physicians across the country (since I’m such a good representation of my cohort). It’s time to re-focus our attention on taking the ‘honorary’ medical degree off insurance company walls.