Not enough hours in the day

There literally are not enough hours in a day to allow physicians to comply with all the recommendations emanating from the various constituencies involved in issuing these guidelines.

In an article published in the August 2022 issue of the Journal of General Internal Medicine, authors from the University of Chicago asked the following question: How many hours would it take the typical doctor seeing the typical number of patients in an 8-hour long workday to perform and document the care, following guidelines issued by “official medical bodies?”

The answer: a mere 27 hours! You read that correctly. There literally are not enough hours in a day to allow physicians to comply with all the recommendations emanating from the various constituencies involved in issuing these guidelines.

The authors suggest doctors should use a team approach, which translates into hiring nonphysician care providers, such as scribes, to try to get everything completed and documented. I have a somewhat different take on the matter. To my way of thinking, all these guidelines are coming from individuals and organizations that are truly well intentioned. Counseling patients who are obese on the benefits of weight loss at every visit. Recommending smoking cessation for those who are addicted to cigarettes. Performing medicine reconciliation—in which the patient is queried about every medicine they are taking, and correct dosage and frequency is documented—at every visit. Screening patients for mental health issues, domestic abuse, human trafficking, pain symptoms, and more.

In the abstract, it is hard to be against any of these initiatives in the appropriate setting. However, when the various players (eg, insurers, medical societies, government) mandate so many activities and so much documentation for so many patients, the to-do list can quickly become unachievable. The outcomes are predictable: Doctors cannot comply, they are criticized for not meeting this or that standard, and most of the visit may be spent on topics that have nothing to do with why the patient is coming to see the doctor.

One (very expensive) option for dealing with this is to hire a lot of extra staff to work in the office to get all this extra stuff done. I propose a different approach: As doctors, we should demand a higher standard before we agree to maintain or add new guidelines. If the recommending organization cannot prove that the guideline improves patient outcomes, those guidelines are either dropped or not adopted in the first place.

Second, the time required to carry out any new task is carefully determined, and an equal amount of time is deducted by either dropping or streamlining some other mandated guideline.

Third, these guidelines are narrowly applied, such that patients who present to their doctor because they are concerned about a funny-looking mole on their skin, for example, are not subjected to a list of irrelevant questions about their level of pain because of a rule requiring that every patient have a pain assessment on every hospital visit.

The current system in which every well-intentioned idea—often from individuals who aren’t directly involved in patient care—gets added to the doctor’s task list is unreasonable and unsustainable.