Our findings suggest that general internists spend a substantial part of their workday performing AOVs and that much of this work substitutes for office or ER visits that would otherwise have occurred. Physicians perceived that care provided through AOVs saved a median of 5 patient visits per day, with each AOV performed in less than a quarter of the time that a visit required. They believed that most AOVs were best performed by themselves, although some could be performed by non-physician support staff.
have also found that primary care physicians perform a substantial amount of AOVs. Ours is the first direct observational study we are aware of to evaluate primary care physicians’ perceptions of the extent to which AOVs substituted for visits, the extent to which AOVs could have been performed by support staff, and the extent to which office visits that did occur could have been substituted for by AOVs. It is also the first direct observational study of which we know that examines AOVs performed by general internists.
Comparing our main outcome measures between subgroups of participating physicians was not an aim of this descriptive study. Given the wide variability within groups and presence of potential confounding variables, a substantially larger sample size would be necessary to carry out subgroup analyses. However, it is notable that the main outcomes of our study (total AOV time, AOV time substituting for visits, and visits that could be substituted for by AOVs) were similar between private and public physicians, although public physicians believed that more AOV time could have been performed by support staff than private physicians. Future studies employing larger scale methodologies should be conducted to further investigate this as well as to compare physicians’ use of AOVs by other factors such as EMR use, reimbursement mechanism, payment for AOV time, and practice and payer structures.
Our study has several limitations of note that should inform or be the subjects of future study. First, our study included 33 general internists from 20 different practices in one metropolitan area, and our results may not be generalizable to all physicians. However, our study includes the largest number of physicians of any direct observational study of primary care physician time spent in patient care outside of visits of which we are aware. Participants were similar in gender distribution although, slightly older than general internists from the American Medical Association Masterfile16
. Participants were comparable to non-participants in gender and years in clinical practice. Participants’ mean job satisfaction score of 3.66 was similar to Grembowski’s score of 3.65 in a larger sample of 498 primary care physicians15
, suggesting that it is unlikely that our study attracted physicians who were particularly satisfied or dissatisfied. Participants may have differed from non-participants in other ways, but it is unclear in which direction, if any, differences would bias our results. Physicians who do more AOVs might have been too busy to participate; alternatively, physicians not interested in AOVs might have declined to participate. Systematic bias is unlikely because we found a wide distribution among participants in time spent on AOVs and also because our finding that 20% of the workday was spent in AOVs is similar to both Gilchrist’s and Gottshalk’s findings of 23% in community-based family physicians1,2
. Our finding of a median of 18 office visits per day is similar to Gilchrist’s findings of 21 visits per day1
. Our median visit duration of 15 min is the same as both Gilchrist’s finding and data reported by internists from the 2006 National Ambulatory Medical Care Survey1,17
A second limitation is that we did not address AOVs performed by non-physician staff or their perceptions of AOVs. Third, we did not directly observe AOVs that physicians may have performed off-site prior to or after the workday. Fourth, it is possible that the presence of an observer may have changed the physician’s practice behavior. However, participating physicians indicated that being observed did not change their behavior, consistent with findings from Gottshalk’s direct observational study2
. Fifth, each physician was observed for one full day of practice, and this day may not have been representative of a typical workday. Sixth, we directly observed and documented AOVs but report only physicians’ perceptions of the extent to which these AOVs substituted for visits and could be performed by support staff. Seventh, because physicians gave their perceptions based on their practice situations as they currently exist, our results may underestimate the extent to which AOVs could substitute for visits and be performed by support staff as well as the extent to which visits could be substituted for by AOVs. Generally speaking, practices only receive reimbursement for face-to-face encounters between physicians and patients6,7
. If payment methods of ambulatory care were changed so that AOVs were directly or indirectly reimbursed18–21
and if staff with training in AOVs were more common, physicians might perceive that a larger number of visits might be substituted for by AOVs performed by either physicians or staff.
Since physicians are generally not reimbursed for AOVs6,7
, AOVs may be undersupplied compared to the optimum. Payment policies supporting use of AOVs by physicians and other staff (e.g., additional payments to practices that function as patient-centered medical homes or capitation with performance bonuses based on quality measures) may improve care coordination, reduce costs, and save patients’ time by reducing unnecessary office or ER visits.
Primary care physicians face significant time constraints22,23
. Along with time spent in AOVs, physicians often spend additional non-patient care-related time dealing with health plans24
and other administrative issues that were not fully captured by our study. Adverse workflow has been strongly associated with low physician satisfaction, and nearly one third of primary care physicians intend to leave their practices within 2 years25
. Crucial time may be saved by substituting more AOVs for visits and more staff time spent on AOVs for physician time. Appreciation of AOVs as valued, integral parts of the workday may enrich the primary care environment for physicians, staff, and patients.