Useful myths and new perspectives on spending time with patients

FigureIn the perpetual turf wars in the US healthcare workforce, healthcare professions have at times attempted to identify specific features of their practice that they believe give them a particular clinical advantage over others. Because physicians have tended to dominate healthcare delivery for the past century, other professions typically compare their practice effectiveness against the physician standard, asserting, for example, that the care they deliver is just as safe and effective (using a variety of measures and proxy measures) as physician care. One of the most common and longstanding of these assertions that is perpetuated by the professions themselves and their professional organizations is the canard that physician associates/assistants (PAs) and NPs spend more time with their patients than do physicians. In my work as a teacher, speaker, and researcher, I regularly encounter student groups and professional audiences, all of whom tend to share the impression that spending more time with patients is one of the signature characteristics of PA and NP practice. When I ask PA program applicants why they are seeking to become PAs, they invariably state that it is because they want to spend more time with patients. The perception seems to be ubiquitous and serves as a useful myth that favors the clinical reputation of PAs and NPs. ADDRESSING THE MYTH Generally speaking, some evidence exists supporting the claim that spending more time with patients is associated with better patient satisfaction, and NPs have posited that one of the reasons patient satisfaction has been high for NPs is the additional time they spend with patients.1,2 PAs seemed to benefit from this perception as well. Despite this, the assertion that PAs and NPs spend more time in visits than physicians has been clearly disproven by health services researchers associated with both professions.3,4 A study by noted nursing researcher Peter Buerhaus and colleagues looked at a variety of NP patient care characteristics and showed that primary care physicians and primary care NPs “deliver similar services and spend their time in nearly identical ways, that primary care NPs work less [sic] hours and see fewer patients than physicians, and that only a handful of primary care NPs have their salary adjusted for productivity and quality performance.”3 Another study aiming to determine if PAs and NPs spend more time with patients than physicians was conducted by PA Perri Morgan and colleagues in 2014.4 They used data from the National Ambulatory Medical Care Survey (NAMCS) community health center (CHC) database. Their analysis examined clinician characteristics and variables related to time spent with patients across provider types, using multivariate linear regression controlling for patient and visit characteristics. The study of visits to federally qualified CHCs included 670 physicians, 245 NPs, and 103 PAs who made 24,528 patient visits from 2006 to 2010.4 The researchers found no differences in the number of visits by clinician type but noted that PAs saw patients for a slightly larger portion of the week (3.8 days) than did physicians (3.5 days, P < .05) or NPs (3.4 days, P < .05).4 No statistical differences were found in the mean time spent per patient, either in the crude or the adjusted analysis. Morgan and colleagues concluded that physicians, PAs, and NPs seemed to spend similar amounts of time—about 20 minutes—with each patient in the CHC setting, a time allocation similar to that seen in other settings and possibly driven by clinic scheduling practices.4 This finding seems to make sense. In our fragmented, highly monetized healthcare system, the notion that all clinicians have a defined timeframe to see each patient seems logical. This finding would particularly apply in primary care private medical offices or managed care settings, where clinicians have only so much time in which to conduct the patient visit. Economic pressures affect all clinicians, and it would be an unusual luxury for clinicians to be given an unlimited timeframe in which to see each patient. Both studies had important limitations. Both examined only PAs and NPs working in the primary care setting, and thus, the variable of specialty was not considered. Neither study was able to directly measure visit time. NEW FINDINGS A newly published paper from a group at Harvard University that included one PA researcher as an author examined how physicians, PAs, and NPs are integrated into care teams and shed new light on the question of time spent with patients.5 This work expanded on previous research on the work patterns of PAs and NPs compared with physicians and used more modern methods with more precise measurement tools, specifically data derived from electronic health records (EHRs). The researchers used a cross-sectional design that included 217,924 clinicians across 389 organizations (174,939 physicians and 42,985 PAs and NPs). They identified weekly total time spent by clinicians using the EHR, including time spent after hours, and on the specific activities of notes, the Epic EHR system's In Basket feature, and clinical review. Among all clinicians, 70,576 (32.4%) were in medical specialties, 85,973 (39.5%) were in primary care specialties, and 61,375 (28.2%) were in surgical specialties. Most worked in an organization with hospital and clinic facilities. More than half of PAs and NPs were in primary care specialties. Physicians were more equally distributed across specialties, with roughly a third each in primary care specialties, medical specialties, and surgical specialties.5 The findings were reported in two categories—patient visits and time spent using the EHR. Significant differences in visit and EHR use patterns were observed for physicians, PAs, and NPs by specialty type.5 Physicians in medical and surgical specialties had more new patient visits than PAs and NPs, but primary care physicians had 2.8 percentage points fewer new patient visits than did PA and NP counterparts. In terms of EHR use, medical and surgical physicians spent 34.3 and 45.8 fewer minutes per day, respectively, using the EHR than did PAs and NPs in their specialties; primary care physicians spent 17.7 more minutes per day than did PAs and NPs in primary care. In terms of new patient visits, both medical and surgical specialty physicians had more new patient visits than PAs and NPs. Primary care physicians had more established visits than did PAs and NPs; medical and surgical physicians had fewer established visits. Primary care physicians were significantly more likely than PAs and NPs to have more than 3 days with appointments per week, but in medical and surgical specialties, physicians were significantly less likely to have more than 3 days with appointments per week.5 An important limitation of this study is that the methodology was unable to differentiate between PAs and NPs who work collaboratively with physicians compared with those who carry their own patient panels. The authors note that this prevented accurately normalizing time measures to the visit level rather than the day level. The Rotenstein and colleagues study marks an important contribution to the healthcare research literature comparing the roles and practice patterns of PAs, NPs, and physicians and reveals the critical dimension that differences in specialties play in practice activities.5 The matter now is far beyond the simple question of who spends more time with patients. The new perspectives show that the time spent with patients varies by clinical specialty and whether the visit is with a new or established patient. As the research on PA and NP practice continues to advance, more sophisticated and powerful methods with sharper measurement tools will provide us with a clearer picture of the complexities of the physician-PA and NP team interaction and reveal the optimal patterns of their clinical effectiveness.

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