The Unrelenting Struggle: The Challenge of Providing Quality Care in a Limited Time

Recently, I received commendation for having the highest patient satisfaction scores in the physician's group. This doesn't astonish me. I understand my strengths: I dedicate time to my patients, allowing them to share their stories. I listen, educate, and collaborate. When faced with gaps in my knowledge, I diligently seek answers. I embody the essence of "AIDET."

In light of the inescapable constraints of time, I strive for efficiency. I delegate tasks, make referrals, and employ order sets. But when the system fails repeatedly, a moral dilemma arises: should I allocate my finite time to guarantee patients receive adequate care, or should I prioritize data entry to attain the reimbursement I deserve? And if I exhaust my time during business hours on patient care, only to spend post-work hours documenting, when do I eat, rest, or engage in non-work activities? (I'm writing this at 7:00 p.m., yet I haven't had a meal or seen my family today—just a typical day.)

A recent study has uncovered a daunting revelation: for primary care physicians to deliver the required quality and quantity of preventive, acute, and chronic disease care and maintain profitability, they must work for over 26 hours each day. When accounting for personal time, this impossible mathematical feat becomes even more ludicrous. It's important to note that while critical thinking and teaching are pivotal to healthcare delivery, these functions aren't monetarily rewarded. As a result, primary care physicians are coerced into shortcuts, realizing that their financial stability hinges on swiftly ticking off boxes and processing encounters.

In this complex landscape, factors such as staffing shortages, high turnover, record retrieval challenges, referral delays, unplanned walk-ins, and emergent situations make each day unpredictable. For instance, during a routine lab follow-up, a patient revealed increasing depression and sexual dysfunction. This unexpected turn shifted my focus and thinking, especially since he'd suffered a stroke elsewhere (unbeknownst to me due to missing records). Suspecting vascular dementia, I had to swiftly adjust my approach, all while a roomful of patients awaited attention.

Amidst these pressures, time keeps ticking.

As three patients wait in rooms and four others sit in the lobby, I notice a walk-in patient has been attended to before a scheduled one due to a communication lapse. I must address this with my staff and apologize to patients.

Meanwhile, the electronic health system alerts me about urgent patient requests and a slew of lab and imaging results, some critical. A drug representative waits outside my door, seeking my signature on crucial samples but bypassing the customary pitch. My nurse practitioner approaches, seeking guidance on a complex case she's not handled before. Simultaneously, another issue arises: an incorrectly printed EKG that the medical assistant can't troubleshoot. And then, a patient has a seizure in the lobby.

All this unfolds within a mere 20 minutes.

"Tell me, Brenda, when do I even begin documenting that first encounter?"

In fact, when can I even determine my course of action?

Here's what I did: I adroitly harnessed the limited resources available to make prompt, sound medical decisions. I dedicated my entire lunch break to rectify well-intentioned but erroneous documentation, completing morning encounters while dealing with a cascade of results, phone calls, MyChart messages, and staff inquiries. (The non-RVU-generating tasks were, unsurprisingly, left for "later," i.e., after business hours).

There's no time to eat, rest, or connect meaningfully with colleagues. Despite my sacrifice and dedication, my open encounter count for the day increased because I only spent one evening hour on administrative tasks. The subsequent day was as demanding as the one before, with even more patients, including my staff and their families. I realized I hadn't seen my own daughters for days; they're usually asleep by the time I return home.

The bottom line? The four hours of administrative time allocated on Friday afternoons hardly suffice for a practice like mine, which serves a growing, underserved population. This might be adequate for well-established or healthier patients, with consistently available, well-trained staff and physicians who aren't firefighting throughout their days. In my case, I require at least two hours every day from Monday to Thursday, in addition to the four hours on Fridays.

Until I'm granted dedicated time during the week for administrative tasks, I'm forced to work 12 to 14 hours most days just to stay afloat. Failing to do so results in a mounting in-basket, encroaching on weekends, vacations, and future workdays. With burgeoning schedules and responsibilities, there's no relief in sight. It's simply not sustainable.

Jacqui O'Kane is a dedicated family physician.