Patient Care Outside of Office Visits

To the Editors:— The significant time spent nowadays by primary care physicians on patient care outside office visits has been the subject of two recent articles in the Journal 1,2. This is an unquestionably important topic, but it should not detract attention from one of its major causes. Time constraints have become an increasingly significant problem for physicians caring for ambulatory patients. The problem is widespread and common to many different health care systems 3. An often quoted study found that contrary to common belief, physician's time-per-patient has not decreased and may even have slightly improved over recent years 4. However, the increasing demands upon physician's time have already been widely acknowledged 5. We propose a new term and reference standard for future research—the time-to-task ratio (TTR), which is the time allocated for the patient–physician encounter divided by the number of obligatory assignments.

A patient–physician encounter whether in hospital or ambulatory care must include at least ten components as follows:

• 1. Deal with patient's chief complaint including listening and examination

• 2. Review chart for relevant history, medications and previous tests

• 3. Relate to the patient as a person and show caring

• 4. "e-Vidence": complement any level of knowledge and skill by looking up information and options in appropriate databases

• 5. Respect patient's autonomy: review diagnostic / treatment options with the patients towards shared decision-making

• 6. Attend to the patient's health literacy regarding current problems, new medications and health-related behavior

• 7. Cover early detection of occult disease and primary prevention potential, acting where necessary

• 8. Order or arrange for tests, write prescriptions and provide directions

• 9. Record the contents of the encounter in the patient's (electronic) chart

• 10. Manage the computer

Even a cursory glance reveals that 5/10 tasks constitute new tasks (No. 4, 5, 6, 7, 10) and No. 3 is an old task that has deteriorated and has to be resurrected 6. Thus, assuming 15-20 minutes of physician time per patient 3,4, a TTR of 2 min/task vividly demonstrates the pressing need to reconsider time allocation as well as educate physicians in time management. In hospitalized patients too, time issues assume increasing importance since length of stay has decreased and patient's age and complexity; choice of diagnostic and therapeutic modalities, and the number of tasks have similarly increased, decreasing TTR. These changes mirror those in ambulatory care and all are time demanding. Research suggests that time allocation is a major determinant of patient satisfaction and compliance; physician satisfaction and burnout; and the quality of care 5. An unreasonable TTR would inevitably lead to undesirable shortcuts and omissions by the physician in the encounter. Thus, considering and studying TTR and its individual components may promote improved time management in the future.