Constrained Physicians: Time and Responsibilities

Authored By: Anwesa Brahmachary Art By: Stefanie Chen

“The good physician treats the disease; the great physician treats the patient who has the disease” - Adam Kay. However, is it as simple as choosing to treat the patient rather than the disease? What barrier stops the physician from truly getting to know the patient from a comprehensive lens? As time has changed, so has the role of physicians. With the rising rate of metabolic diseases in the United States, the number of factors to consider in patient care has also risen, while patient-physician visit time has decreased [1,2]. Further adding to time constraints, administrative responsibilities of physicians have also changed with structural changes in the U.S. healthcare system [3,4]. Furthermore, changing U.S. healthcare policies from insurance to abortion have also changed the scope of physicians' decisions regarding patient care. When looking at primary care, how physician-patient relationships and visits operate in other countries compared to the United States provides insight into how changing patient-physician relationships can be addressed [5]. Despite changes in the healthcare system, it is still possible for physicians to focus on the patient rather than the disease, as Adam Kay suggests. 

To begin, structural changes in the healthcare system have led the division of physician time to change immensely over the years. A key driver is that physicians are now employed by hospitals, thus increasing physician administrative responsibilities. More of these hospitals are also owned by for-profit organizations, resulting in a competitive environment and the involvement of new factors such as market value competition. As a result, physician autonomy has decreased, and physicians have to spend more time following the rules implemented by hospitals [6]. Furthermore, the rise of technology, such as the Electronic Medical Records System, although offering numerous benefits, has also increased required documentation for physicians, adding to administrative responsibilities [3]. With these changing factors, physicians have less time than ever for patient visits themselves. A study done regarding chronic disease and acute care by PCPs showed that if PCPs tried to follow the guidelines for primary care, it would take them 26.7 hours a day [3]. With the rising rates of chronic diseases, an increase has occurred in the emphasis on preventative, chronic disease, and acute care [1]. At the same time, the amount of time physicians have available in a day has decreased with structural changes in the healthcare system, thus imposing a limit on the care physicians can provide their patients with.

Even when time is available, the role of PCPS in medicine has also changed due to changing U.S. healthcare policies. A prime example of this is changing reproductive laws. For instance, in Texas, a woman died from sepsis due to confusion regarding what type and degree of reproductive care could be provided under changing statutes [7]. With the risk of making a healthcare decision that could be considered a felony and of losing one’s medical license, physicians’ decisions have changed. Another example of policies impacting the physician role in the United States is with insurance and prior authorization. According to an article on the AAMC website, Dr. Mukkamala states that healthcare companies often decide what services are and aren’t covered by insurance by the insurance companies. As a result, physicians might want to provide a specific service plan but instead have to pick an alternate one due to the insurance company’s decision [8]. As a result, the question of how much a physician can do compared to before and the autonomy physicians have in changing years comes into play. 

The physician’s role in the healthcare system has been changing not just in the U.S. but worldwide. Eighteen countries have patients spending 5 minutes or less with their PCPS, thus showing this decline in visit time worldwide and indication of changes in healthcare systems worldwide. A range was shown, however, from an average 48-second consultation length in Bangladesh to 22.5 minutes in Sweden [5]. This displays the variability in healthcare system structures and physician roles worldwide.  The consensus was that longer visits tend to have higher healthcare outcomes [9]. When analyzing varying consultation times across countries, differences in the priorities and types of visits. For instance, the United States has fewer home visits than other countries, which shows a difference in how consultations are structured [5].

Furthermore, the priorities of visits vary among countries, such as the United States and Germany being more likely to ask questions about housing, food insecurity, etc. In contrast, other countries prioritize different questions [5]. There are also differences in how certain countries, including the United States, prioritize coordination with specialists and access to this care. In contrast, other countries such as Canada, with universal healthcare, have less access to specialist care. These differences in consultation creation and prioritization during them lead to differences in healthcare systems worldwide.

As times change, so does the patient population, availability of technology, and more; however, what should stay constant is the prioritization of patient care and physicians’ abilities to do this. Current changes can be countered by analyzing other countries’ healthcare systems, such as the questions asked during visits. The Rochester General Health System is an excellent example of physicians having the opportunity to voice their thoughts on the workplace environment and physician buy-in [10]. Our priorities and ways to ensure them must remain even with changing structures.

References:

1. Porter, J., Boyd, C., Skandari, M. R., & Laiteerapong, N. (2023). Revisiting the Time Needed to Provide Adult Primary Care. Journal of General Internal Medicine, 38(1), 147–155. https://doi.org/10.1007/s11606-022-07707-x

2. Butler, R., Monsalve, M., Thomas, G. W., Herman, T., Segre, A. M., Polgreen, P. M., & Suneja, M. (2018). Estimating Time Physicians and Other Health Care Workers Spend with Patients in an Intensive Care Unit Using a Sensor Network. The American Journal of Medicine, 131(8), 972.e9–972.e15. https://doi.org/10.1016/j.amjmed.2018.03.015

3. Woolhandler, S., & Himmelstein, D. U. (2014). Administrative work consumes one-sixth of U.S. physicians' working hours and lowers their career satisfaction. International Journal of Health Services: Planning, Administration, Evaluation, 44(4), 635–642. https://doi.org/10.2190/HS.44.4.a

4. Williams, S. J., O. Nightingale, E., & Filner, B. (1983, January 1). The physician’s role in a changing health care system. Medical Education and Societal Needs: A Planning Report for the Health Professions. https://www.ncbi.nlm.nih.gov/books/NBK217690/#:~:text=Reimbursement%20Practices,results%20of%20which%20are%20unclear;&text=contracting%20arrangements%20such%20as%20the,systems%20typified%20by%20the%20HMOs. 

5. Irving, G., Neves, A. L., Dambha-Miller, H., Oishi, A., Tagashira, H., Verho, A., & Holden, J. (2017). International variations in Primary Care Physician Consultation Time: A systematic review of 67 countries. BMJ Open, 7(10). https://doi.org/10.1136/bmjopen-2017-017902 

6. Boyle, P., & Weiner, S. (2024, November 11). Bans on abortion and transgender care have criminalized medicine, putting patients and doctors at risk. AAMC. https://www.aamc.org/news/bans-abortion-and-transgender-care-have-criminalized-medicine-putting-patients-and-doctors-risk

7. The physician role in changing health care: How does the AMA support medical specialty societies? American Medical Association. (2024, April 5). https://www.ama-assn.org/about/leadership/physician-role-changing-health-care-how-does-ama-support-medical-specialty 

8. Gumas, E. D., Lewis, C., Horstman, C., & Gunja, M. Z. (n.d.). Finger on the pulse: Primary care in U.S. and nine other countries | commonwealth fund. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2024/mar/finger-on-pulse-primary-care-us-nine-countries 

9. Dugdale, D. C., Epstein, R., & Pantilat, S. Z. (1999, January). Time and the patient-physician relationship. Journal of General Internal Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC1496869/ 

10. Chandrashekar, P., Jain, S.H. (2019). Understanding and Fixing the Growing Divide Between Physicians and Healthcare Administrators. https://scholar.harvard.edu/files/poojachandrashekar/files/mar_apr_2019_264-268.pdf