Not all physicians practice the same way, so why do administrators treat them the same way?

Increasing patient visits without adding to staff and physician burnout is very challenging. Empathetic administrators offer up solutions such as adding NP/PA to increase capacity to absorb lower acuity patients and freeing up the physician to see more complex patients. This does not work and often physicians feel it actually adds to their workload because they have to answer the PAs or NPs questions. Another popular suggestion (especially in primary care) is going to 10-hour days, 4 days a week to improve after-hours access and providing one extra non clinical day for physicians. This is often misguided as the 2 extra clinical hours on practice days leaves the physician further burnt out and quality of care suffers. The fundamental issue with these approaches is that it paints all physicians with the same brush. It does not take into account the difference in practice styles and experience levels among physicians. The time it takes a physician to complete patient care related tasks varies widely. We have observed over 30,000 patient visits in ambulatory care and noticed huge variation for the same visit type and complexity of care. Using RVUs as the sole metric to conclude who needs to see more patients is insufficient and ill advised.

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It is time to take a more nuanced approach to solve the problem. All physicians fall into one of four categories.

1)????? Working at the maximum capacity and efficiency. These physicians need to applauded and their work methods should studied so others can emulate them. Their patients are often in the waiting area the longest. Leave their schedules alone!!!

2)????? Working below capacity. These physicians have room in their schedule to see more patients. Their patients have short wait times. Feel free to add more to their schedule.

3)????? Working at maximum capacity but not at optimum efficiency. These physicians need help with improving efficiency and it often is as simple as getting better at using Epic. Their patients are waiting a long time before being roomed. Help them with improving efficiency and learning from those that fall into the first category before adding more patients to their schedule.

4)????? Working very efficiently but below maximum capacity. These physicians are typically spending more time between patients completing patient care related tasks such as emails, phone calls, entering orders, etc. Their patients are not waiting too long before being roomed. The only way they can see more patients is by providing them additional support. LPNs are the best form of additional support for this category.

In order to decide which category a physician belongs to requires a new measure. Schedule fill rate and RVUs are grossly inadequate. A new capacity ratio which uses non face to face time as the numerator and patient true wait (rooming time – appointment time) as the denominator is the most accurate measurement to place physicians in the right category among the four described above. Unfortunately EMR timestamps do not provide the granularity required for these measurements. The good news is that alternatives exist and sensor based patient flow measurements are easy to accomplish that provide the right level of accuracy. This combined with pre visit planning, schedule curation, and team based care are proven ways of increasing patient visits without adding to burnout.