Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties

Sinsky, Christine MD
Colligan, Lacey MD
Li, Ling PhD
Prgomet, Mirela PhD
Reynolds, Sam MBA
Goeders, Lindsey MBA
Westbrook, Johanna PhD
Tutty, Michael PhD
Blike, George MD

From the American Medical Association, Chicago, Illinois; Sharp End Advisory, Hanover, New Hampshire; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia; and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.

Acknowledgment: The authors thank each of the medical students who assisted in this work: Komal Dhir, Eyitemi Fregene, Michelle Kim, Timothy Nobbee, Timothy O'Dowd, Nirali Patel, Max Schmidt-Bowman, Fernando Vasquez, Kathryn Whittington, and Sylven Yaccas. They also thank Louis Shelzi (Dartmouth-Hitchcock), who supported training and fieldwork, and Sheree Crick (Australian Institute of Health Innovation, Macquarie University), who provided essential support for all WOMBAT work.

Financial Support: By the American Medical Association.

Disclosures: Dr. Sinsky serves on the advisory committee for healthfinch, a start-up that works on practice automation. Dr. Li reports grants from Mary Hitchcock Hospital and Dartmouth-Hitchcock Clinic during the conduct of the study. Ms. Goeders reports that the study was paid for by her employer, the American Medical Association. Dr. Westbrook reports funding from Dartmouth-Hitchcock Clinic during the conduct of the study. Dr. Tutty reports that the study was paid for by his employer, the American Medical Association. Dr. Blike reports a grant from the American Medical Association during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-0961.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.

Reproducible Research Statement:Study protocol: Not available. Statistical code: Available to approved persons through written agreement with the authors from Dr. Li (e-mail, [email protected]). Data set: See Tables 1 through 4.

Requests for Single Reprints: Christine A. Sinsky, MD, American Medical Association, 330 North Wabash Avenue, Suite 39300, Chicago, IL 60611.

Current author addresses and author contributions are available at www.annals.org.

For author affiliations, see end of text.

This article was published at www.annals.org on 6 September 2016.

Current Author Addresses: Drs. Sinsky and Tutty and Ms. Goeders: American Medical Association, 330 North Wabash Avenue, Suite 39300, Chicago, IL 60611.

Dr. Colligan: Sharp End Advisory, LLC, PO Box 222, Hanover, NH 03755.

Drs. Li, Prgomet, and Westbrook: Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW 2109, Australia.

Mr. Reynolds: American Medical Association, 4622 North Damen Avenue, Chicago, IL 60625.

Dr. Blike: Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Building 50, Lebanon, NH 03756.

Author Contributions: Conception and design: C. Sinsky, L. Colligan, L. Li, M. Prgomet, S. Reynolds, J. Westbrook, M. Tutty, G. Blike.

Analysis and interpretation of the data: C. Sinsky, L. Colligan, L. Li, M. Prgomet, S. Reynolds, J. Westbrook, G. Blike.

Drafting of the article: C. Sinsky, L. Colligan, M. Prgomet, S. Reynolds, L. Goeders, M. Tutty, G. Blike.

Critical revision of the article for important intellectual content: C. Sinsky, L. Colligan, L. Li, M. Prgomet, S. Reynolds, L. Goeders, J. Westbrook, M. Tutty, G. Blike.

Final approval of the article: C. Sinsky, L. Colligan, L. Li, M. Prgomet, S. Reynolds, L. Goeders, J. Westbrook, M. Tutty, G. Blike.

Provision of study materials or patients: L. Colligan, S. Reynolds.

Statistical expertise: L. Li.

Obtaining of funding: C. Sinsky, L. Colligan, M. Tutty, G. Blike.

Administrative, technical, or logistic support: L. Colligan, S. Reynolds, L. Goeders, M. Tutty, G. Blike.

Collection and assembly of data: L. Colligan, M. Prgomet, S. Reynolds, L. Goeders.

Annals of Internal Medicine 165(11):p 753-760, December 6, 2016.

Background:

Little is known about how physician time is allocated in ambulatory care.

Objective:

To describe how physician time is spent in ambulatory practice.

Design:

Quantitative direct observational time and motion study (during office hours) and self-reported diary (after hours).

Setting:

U.S. ambulatory care in 4 specialties in 4 states (Illinois, New Hampshire, Virginia, and Washington).

Participants:

57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics who were observed for 430 hours, 21 of whom also completed after-hours diaries.

Measurements:

Proportions of time spent on 4 activities (direct clinical face time, electronic health record [EHR] and desk work, administrative tasks, and other tasks) and self-reported after-hours work.

Results:

During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks.

Limitations:

Data were gathered in self-selected, high-performing practices and may not be generalizable to other settings. The descriptive study design did not support formal statistical comparisons by physician and practice characteristics.

Conclusion:

For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.

Primary Funding Source:

American Medical Association.