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Time Pressure During Primary Care Office Visits: a Prospective Evaluation of Data from the Healthy Work Place Study

  • Kriti Prasad
  • Sara Poplau
  • Roger Brown
  • Steven Yale
  • Ellie Grossman
  • Anita B. Varkey
  • Eric Williams
  • Hannah Neprash
  • Mark LinzerEmail author
  • for the Healthy Work Place (HWP) Investigators
Original Research

Abstract

Background

The relationship between worklife factors, clinician outcomes, and time pressure during office visits is unclear.

Objective

To quantify associations between time pressure, workplace characteristics ,and clinician outcomes.

Design

Prospective analysis of data from the Healthy Work Place randomized trial.

Participants

168 physicians and advanced practice clinicians in 34 primary care practices in Upper Midwest and East Coast.

Main Measures and Methods

Time pressure was present when clinicians needed more time than allotted to provide quality care. Other metrics included work control, work pace (calm to chaotic), organizational culture and clinician satisfaction, stress, burnout, and intent to leave the practice. Hierarchical analysis assessed relationships between time pressure, organizational characteristics, and clinician outcomes. Adjusted differences between clinicians with and without time pressure were expressed as effect sizes (ESs).

Key Results

Sixty-seven percent of clinicians needed more time for new patients and 53% needed additional time for follow-up appointments. Time pressure in new patient visits was more prevalent in general internists than in family physicians (74% vs 55%, p < 0.05), women versus men (78% vs 55%, p < 0.01), and clinicians with larger numbers of complex psychosocial (81% vs 59%, p < 0.01) and Limited English Proficiency patients (95% vs 57%, p < 0.001). Time pressure in new patient visits was associated with lack of control, clinician stress, and intent to leave (ESs small to moderate, p < 0.05). Time pressure in follow-up visits was associated with chaotic workplaces and burnout (small to moderate ESs, p’s < 0.05). Time pressure improved over time in workplaces with values alignment and an emphasis on quality.

Conclusions

Time pressure, more common in women and general internists, was related to chaos, control and culture, and stress, burnout, and intent to leave. Future studies should evaluate these findings in larger and more geographically diverse samples.

KEY WORDS

time pressure physician satisfaction health services research medical culture primary care workforce 

Notes

Acknowledgments

HWP Investigators include those listed in the author group and Diane Kohnhorst, Marshfield Clinic, Marshfield WI; Jill Wallock, Loyola University School of Medicine, Chicago, IL; Michael Barbouche, Forward Health Group, Madison, WI; and Dr. Lanis Hicks, University of Missouri, Columbia, MO. Ms. Kohnhorst and Ms. Wallock were involved in data collection, Mr. Barbouche in study design, and Dr. Hicks in study design and data interpretation.

Funding Information

This study is supported the Agency for Healthcare Research and Quality (AHRQ) Grant No. 5R18-HS018160-03.

Compliance with Ethical Standards

Site-specific Institutional Review Boards provided approval.

Conflict of Interest

Mark Linzer and Sara Poplau acknowledge support by the American Medical Association and the American College of Physicians for worklife training and oversight of ongoing projects. Dr. Linzer is supported by the Institute for Healthcare Improvement for his role in the Joy in Work initiative. All other authors declare that they have no conflicts of interest.

Healthy Workplace Investigators: Dr. Hicks receives royalties from a textbook; Mr. Barbouche is the Founder and CEO of a healthcare data management company in Madison, WI, Forward Health Group, and owns stock in the company.

Supplementary material

11606_2019_5343_MOESM1_ESM.docx (22 kb)
ESM 1 (DOCX 21.9 KB).

References

  1. 1.
    Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the Patient’s Agenda: Have We Improved? JAMA. 1999;281(3):283–287. doi: https://doi.org/10.1001/jama.281.3.283 CrossRefPubMedGoogle Scholar
  2. 2.
    Rhoades DR, McFarland KF, Finch WH, Johnson AO. Speaking and Interruptions During Primary Care Office Visits. Fam Med.:5.Google Scholar
  3. 3.
    Geraghty EM, Franks P, Kravitz RL. Primary Care Visit Length, Quality, and Satisfaction for Standardized Patients with Depression. J Gen Intern Med. 2007;22(12):1641–1647. doi: https://doi.org/10.1007/s11606-007-0371-5 CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    for the Association of Chiefs and Leaders in General Internal Medicine (ACLGIM) Writing Group*, Linzer M, Bitton A, et al. The End of the 15–20 Minute Primary Care Visit. J Gen Intern Med. 2015;30(11):1584–1586.  https://doi.org/10.1007/s11606-015-3341-3 CrossRefGoogle Scholar
  5. 5.
    Hawkings M.2016 Survey of America’s Physicians. The Physicians Foundation; :84. https://physiciansfoundation.org/wp-content/uploads/2018/01/Biennial_Physician_Survey_2016.pdf.
  6. 6.
    Linzer M. Working Conditions in Primary Care: Physician Reactions and Care Quality. Ann Intern Med. 2009;151(1):28. doi: https://doi.org/10.7326/0003-4819-151-1-200907070-00006 CrossRefPubMedGoogle Scholar
  7. 7.
    Linzer M, Konrad TR, Douglas J, et al. Managed Care, Time Pressure, and Physician Job Satisfaction: Results from the Physician Worklife Study. J Gen Intern Med. 2000;15(7):441–450. doi: https://doi.org/10.1046/j.1525-1497.2000.05239.x CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    McMurray JE, Linzer M, Konrad TR, Douglas J, Shugerman R, Nelson K. The Work Lives of Women Physicians. J Gen Intern Med. 2000;15(6):372–380. doi: https://doi.org/10.1111/j.1525-1497.2000.im9908009.x CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Plessas A, Nasser M, Hanoch Y, O’Brien T, Bernardes Delgado M, Moles D. Impact of time pressure on dentists’ diagnostic performance. J Dent. 2019;82:38–44. doi: https://doi.org/10.1016/j.jdent.2019.01.011 CrossRefPubMedGoogle Scholar
  10. 10.
    Syrek CJ, Apostel E, Antoni CH. Stress in highly demanding IT jobs: transformational leadership moderates the impact of time pressure on exhaustion and work-life balance. J Occup Health Psychol. 2013;18(3):252–261. doi: https://doi.org/10.1037/a0033085 CrossRefPubMedGoogle Scholar
  11. 11.
    Tsiga E, Panagopoulou E, Sevdalis N, Montgomery A, Benos A. The influence of time pressure on adherence to guidelines in primary care: an experimental study. BMJ Open. 2013;3(4):e002700. doi: https://doi.org/10.1136/bmjopen-2013-002700 CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21(e1):e100-e106. doi: https://doi.org/10.1136/amiajnl-2013-001875 CrossRefPubMedGoogle Scholar
  13. 13.
    Linzer M, Poplau S, Grossman E, et al. A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study. J Gen Intern Med. 2015;30(8):1105–1111. doi: https://doi.org/10.1007/s11606-015-3235-4 CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Linzer M, Sinsky CA, Poplau S, Brown R, Williams E, the Healthy Work Place Investigators. Joy In Medical Practice: Clinician Satisfaction In The Healthy Work Place Trial. Health Aff (Millwood). 2017;36(10):1808–1814. doi: https://doi.org/10.1377/hlthaff.2017.0790 CrossRefPubMedGoogle Scholar
  15. 15.
    Williams ES, Konrad TR, Linzer M, et al. Refining the measurement of physician job satisfaction: results from the Physician Worklife Survey. SGIM Career Satisfaction Study Group. Society of General Internal Medicine. Med Care. 1999;37(11):1140–1154.CrossRefGoogle Scholar
  16. 16.
    StataCorp. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC; 2017.Google Scholar
  17. 17.
    Linzer M, Harwood E. Gendered Expectations: Do They Contribute to High Burnout Among Female Physicians? J Gen Intern Med. 2018;33(6):963–965. doi: https://doi.org/10.1007/s11606-018-4330-0 CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Linzer M, Gerrity M, Douglas JA, McMurray JE, Williams ES, Konrad TR. Physician stress: results from the physician worklife study. Stress Health. 2002;18(1):37–42. doi: https://doi.org/10.1002/smi.917 CrossRefGoogle Scholar
  19. 19.
    Warde C. Time Is of the Essence. J Gen Intern Med. 2001;16(10):712–713. doi: https://doi.org/10.1111/j.1525-1497.2001.08020.x CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Linzer M, Levine R, Meltzer D, Poplau S, Warde C, West CP. 10 Bold Steps to Prevent Burnout in General Internal Medicine. J Gen Intern Med. 2014;29(1):18–20. doi: https://doi.org/10.1007/s11606-013-2597-8 CrossRefPubMedGoogle Scholar
  21. 21.
    Jaén CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract. 1994;38(2):166–171.PubMedGoogle Scholar
  22. 22.
    Satterwhite S, Knight KR, Miaskowski C, et al. Sources and Impact of Time Pressure on Opioid Management in the Safety-Net. J Am Board Fam Med. 2019;32(3):375–382. doi: https://doi.org/10.3122/jabfm.2019.03.180306 CrossRefPubMedGoogle Scholar
  23. 23.
    Bitton A, Schwartz GR, Stewart EE, et al. Off the Hamster Wheel? Qualitative Evaluation of a Payment-Linked Patient-Centered Medical Home (PCMH) Pilot. Milbank Q. 2012;90(3):484–515. doi: https://doi.org/10.1111/j.1468-0009.2012.00672.x CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Fam Med. 2017;15(5):419–426. doi: https://doi.org/10.1370/afm.2121 CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Gardner RL, Cooper E, Haskell J, et al. Physician stress and burnout: the impact of health information technology. J Am Med Inform Assoc. 2019;26(2):106–114. doi: https://doi.org/10.1093/jamia/ocy145 CrossRefPubMedGoogle Scholar
  26. 26.
    Hauer KE, Durning SJ, Kernan WN, et al. Factors Associated With Medical Students’ Career Choices Regarding Internal Medicine. JAMA. 2008;300(10):1154–1164. doi: https://doi.org/10.1001/jama.300.10.1154 CrossRefPubMedGoogle Scholar
  27. 27.
    Dorsey ER, Jarjoura D, Rutecki GW. Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students. JAMA. 2003;290(9):1173–1178. doi: https://doi.org/10.1001/jama.290.9.1173 CrossRefPubMedGoogle Scholar
  28. 28.
    Buchbinder SB, Wilson M, Melick CF, Powe NR. Estimates of costs of primary care physician turnover. Am J Manag Care. 1999;5(11):1431–1438.PubMedGoogle Scholar
  29. 29.
    Schloss EP, Flanagan DM, Culler CL, Wright AL. Some Hidden Costs of Faculty Turnover in Clinical Departments in One Academic Medical Center. Acad Med. 2009;84(1):32. doi: https://doi.org/10.1097/ACM.0b013e3181906dff CrossRefPubMedGoogle Scholar
  30. 30.
    Roter DL, Hall JA, Aoki Y. Physician Gender Effects in Medical Communication: A Meta-analytic Review. JAMA. 2002;288(6):756. doi: https://doi.org/10.1001/jama.288.6.756 CrossRefPubMedGoogle Scholar
  31. 31.
    Trowbridge E, Bartels CM, Koslov S, Kamnetz S, Pandhi N. Development and Impact of a Novel Academic Primary Care Compensation Model. J Gen Intern Med. 2015;30(12):1865–1870. doi: https://doi.org/10.1007/s11606-015-3410-7 CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med. 2017;177(2):206–213. doi: https://doi.org/10.1001/jamainternmed.2016.7875 CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Perez HR, Beyrouty M, Bennett K, et al. Chaos in the Clinic: Characteristics and Consequences of Practices Perceived as Chaotic. J Healthc Qual. 2017;39(1):43. doi: https://doi.org/10.1097/JHQ.0000000000000016 CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Kriti Prasad
    • 1
    • 2
    • 3
  • Sara Poplau
    • 1
    • 2
    • 3
  • Roger Brown
    • 4
  • Steven Yale
    • 5
  • Ellie Grossman
    • 6
  • Anita B. Varkey
    • 7
  • Eric Williams
    • 8
  • Hannah Neprash
    • 9
  • Mark Linzer
    • 1
    • 2
    • 3
    • 10
    Email author
  • for the Healthy Work Place (HWP) Investigators
  1. 1.Division of General Internal MedicineHennepin HealthcareMinneapolisUSA
  2. 2.Office of Professional WorklifeHennepin HealthcareMinneapolisUSA
  3. 3.Hennepin Healthcare Research InstituteHennepin HealthcareMinneapolisUSA
  4. 4.School of NursingUW-MadisonMadisonUSA
  5. 5.University of Central Florida College of MedicineOrlandoUSA
  6. 6.Cambridge Health AllianceCambridgeUSA
  7. 7.Loyola University Stritch School of MedicineMaywoodUSA
  8. 8.University of AlabamaTuscaloosaUSA
  9. 9.University of Minnesota School of Public HealthMinneapolisUSA
  10. 10.Department of Medicine Hennepin HealthcareMinneapolisUSA

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