Fwd: PDF - www.pnas.org;Re: [IMPROVEDX] HHS, CMS, RVUs, APMs, & Burnout

HM Epstein hmepstein at GMAIL.COM
Wed Sep 7 12:43:51 UTC 2016

While this isn't a direct answer to Lucia's wish for an error and burnout
rate study that's not dependent on self report, yesterday a new study was
released on physician ​time, in the *Annals of Internal Medicine* funded by
the AMA. ​It's titled "Allocation of Physician Time in Ambulatory Practice:
A Time and Motion Study in 4 Specialties​."​

​ ​
I don't have access to the full article but the link leads to the abstract.​

In it, they quantified the proportion of patient facing clinical time
versus administrative work. The methodology was a mix of "quantitative
direct observational time and motion study (during office hours) and
self-reported diary (after hours)".

The conclusion? "During the office day, physicians spent 27.0% of their
total time on direct clinical face time with patients..." Among the 21
doctors who self-reported after hours work, on average they spent 1 to 2
additional hours on electronic medical records for their patients.

That means in a 10 hour workday, the physician is spending only two hours
and 42 minutes with patients and the other seven hours and 18 minutes doing
administrative and EMR "paperwork" in the office plus possibly more
afterwards. It seems miraculous that the majority of the time their
diagnostic conclusions are correct.


*-- *

On Aug 31, 2016, at 4:18 PM, Sommers, Lucia <Lucia.Sommers at UCSF.EDU
<Lucia.Sommers at ucsf.edu>> wrote:

I am a new subscriber to the IMPROVEDX  list and also not conversant with
current approaches to 'improvement processes' and 'physician champions'. (I
was one of the first quality assurance coordinators in California in the
late 1970's but left the field in the early 80's). Nonetheless, the
comments in response to the piece, "Boosting Medical Diagnostics by Pooling
Independent Judgments,"  particularly those touching on issues of
group-based diagnostic approaches and their application to daily clinical
life, possibly to reduce diagnostic error, encouraged me write and let you
know about the work my colleagues and I have been doing in the SF Bay Area
for the past 11 years as part of a UCSF CME program.

In brief, we are about marshalling collegial support in
regularly-scheduled, practice-based meetings to help primary care
clinicians engage case-based clinical uncertainty, be it diagnostic,
management, relationship, prognostic, or any combination thereof. You can
read about *practice inquiry (PI)* *colleague groups*, as well as other
small group approaches to case-based work, in "Clinical Uncertainty in
Primary Care: The Challenge of Collaborative Engagement." (

Of the ~ 450 cases presented in the PI groups I personally have facilitated
over the years, clinicians presented 11% as adverse events, seeking help in
trying to understand what had happened. (We are planning to present and
write about cases that very much look like diagnostic mishaps.) The good
news about this work is that most of the colleague groups that began
meeting regularly lasted at least 3 years with some going strong as long as
10 years; the bad news is that we have yet to do anything close to an RCT
to look at impact on practice.  Nonetheless, with newly-minted PCPs looking
for support within many of the large networks in Northern CA (e.g., Kaiser,
Sutter, and federally-funded health centers), we're finding people eager
for a lunch meeting with their older colleagues who, in turn, welcome the
breath of fresh air the younger ones offer. We struggle with the 'pile on'
(our term for the-blind-leading-the blind) and in training clinician group
facilitators, we diligently practice 'And what else could be going on?,'
and 'What would be the name of the article that could inform this
uncertainty?'  No question that clinicians bring cases to their colleagues
where they are very well aware that they are stuck. Yet every now and then
a colleague at the table says something to the effect of, 'I didn't know I
didn't know that,' and it feels like, just possibly, an error down the line
might have been prevented.

So we soldier on, no hard proof of effectiveness in improving decisions but
keen on improving the facilitation process when leaders are willing to get
together and talk about what's happening in their groups, a relatively
infrequent occurrence given the treadmill most clinicians are on these
days. Recently, in two systems, physician administrators have seized on PI
as an antidote to burn-out and freed up more clinician time for training.
This is fine and if fear of burnout can result in better clinician
decisions and fewer errors, so be it.

One of these days, it would be terrific to study error and burn-out rates
beyond self-report as Williams et al did back in 2007. (

I'd welcome your comments.


*Lucia S. Sommers, MSS, DrPH*

*Adjunct Assistant Professor*

*Department of Family & Community Medicine*

*University of California, San Francisco*

*415.929.8111 <415.929.8111>*


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