Where Does the Time Go?

Monday was one of those days: meeting after meeting after meeting after meeting. Seriously. Plus no space between them. One room to another, to virtual, back to the other room. No space to do a quick prep review before any but the first.

There was no time to process what we'd just discussed, think through next steps, add things to the to do list, look something up, or circle back on a question that needed an answer. No time even to knock out the quick email that came up mid-meeting, the one that takes one minute and saves adding one more thing the to-do list. And definitely no transition time at all: to close out the meeting I'd just left, to prep for the one I was walking into, not even a bio break.

By the end of the day, I was exhausted, had terrible notes and unsynthesized action plans, and hadn't even processed all the things that had been discussed. My brain was saturated. I was late for my daughter's birthday, which my other daughter had flown in for, and walked straight into the fun family gathering without reviewing the day.

It took me three days to organize my notes, thoughts, and plans.

And that led me to really consider how we schedule work.

We tend to account for the thing itself, the 30-minute meeting or the 20-minute patient appointment, but not necessarily everything required before, after, and around it.

The funny thing is, I already know this.

I build transition time intentionally into my coaching practice. My scheduling system automatically leaves 15 minutes before and after every coaching session.

Before a session, I can review my notes and shift my attention to the person I am about to coach. Afterward, I can jot down anything I want to remember, take care of a quick follow-up, tend to bio breaks, and get some steps in before the next call.

And it has been a really nice way to work.

What's new in my new position is that people can invite me to key meetings based on what they see as my availability in Outlook. And I pack them all in because they were all important.

I told you how well that worked out: swamped, exhausted, and uncharacteristically unorganized with a LOT left to do after work. 🥴

So I'm stealing Tina Wheat's recommended 25- and 50-minute meetings rather than automatically filling every available 15-, 30-, or 60-minute block. (BTW, outlook makes this easy in the calendar settings for invites). Our WSU GME team uses another strategy and starts meetings 10 minutes after the hour.

Different strategies, same basic idea: leave some space around the thing.

That got me thinking more broadly about clinic schedules that I've watched evolve over 27 years in primary care and hear physicians across different systems wrestling with now.

It's uncanny how things align sometimes. I was mostly done writing this when I received a call from a former graduate, mentee, colleague and friend who is now a medical director of a primary care safety-net clinic. We were talking about the growing complexity of primary care, particularly for vulnerable patients, and the increasing amount of care happening outside of appointments through direct patient messaging and other channels.

She offered an observation from her experience that I don't think is unique to her setting: 1.0 clinical FTE no longer feels feasible for most physicians. Physicians are asking to work less than 1.0 FTE when they are hired, or asking to reduce their FTE in order to stay.

And that took me right back to Monday. We schedule a patient for 20 or 30 minutes. Sometimes even 15! We treat that time as patient-facing time, as do our patients. But the appointment requires all of the work of caring for that patient. Time to review the chart beforehand. Think or research when something isn't straightforward. Refil the meds, enter the orders, make the referrals, and finish the note. Later, respond to results. Coordinate care. Complete forms. Answer the messages the patient sends.

Where is that time accounted for?

There is rarely time to take a moment after a particularly difficult encounter before the next appointment starts. Often there is actually negative time, if we can call it that, because the next patient is already waiting and their official appointment start time has passed.

So, to make room for the other work associated with patient care, physicians work through lunch, stay late, and do pajama time. They ask for fewer patients per week and fewer appointments and decrease their FTE, mostly to stop that work from bleeding into their personal and family lives.

It is too easy to just tell a narrow story about a generation of physicians who don't want to work as hard, don't seem to care as much, or simply need better boundaries.

I know, I know. Back in the day, we did plenty of work outside the appointment. Primary care medicine has never been a 40-hour workweek. But the work was more contained.

The work itself has changed. Medicine is more complex. More administrative tasks have landed directly on physicians. Click the right ICD-10 code. Click through five steps to adjust a dose and refill it. Enter each lab order. Close the HCC. Guess which med their coverage will pay for, then later do the prior auth or five more clicks to change it when you guessed wrong.

Appointments have been compressed, sometimes because of organizational productivity expectations and sometimes because physicians themselves are responding to system incentives that reward higher volume.

When access backs up, strep throat and UTIs go to urgent care instead, and primary care schedules fill with only patients who have multiple co-morbidities and psychosocial complexity that rarely fit neatly into 20 minutes.

Add portal messages, some a quick question and some requiring an entire chart audit and literature review, with wild variation in how systems triage and support that work. Add the panel itself, not just Tuesday's schedule: results, refills, consult recommendations, preventive care, the sick patient who messages instead of coming in because you don't have an opening. That ongoing responsibility for the entire panel is part of being someone's personal physician, and it's work I value. But it's often invisible and undervalued.

The bottom line is that we are left with a lot of physician-required work tasks, increasingly complex patients, shorter visits, and pressure to see more people, both because patients desperately need access and because the financial model demands it.

Which brings me right back to my Monday.

Where is the transition time? How do we allow for prep time, documentation, inbox work, research, care coordination, follow-up, and increasingly direct asynchronous communication with patients? If none of that time appears on the schedule, it either has to get done in the already short appointment time, outside of work hours, be done hastily, or be left to back up in the inbox.

For most physicians, that work gets done in time that was never actually allocated for it.

And eventually, there isn't any more time to absorb.

At that point, the choices can become pretty stark:

• Reduce clinical FTE.

• Leave.

• Continue absorbing the work personally.

• Or draw increasingly rigid boundaries: refer, go to urgent care or the ED, make another appointment (even when the next available appointment is six weeks away), "Don't send these messages to me.”

And this seriously impacts our patients, especially the complex, vulnerable ones.

So, many of those “Bad Doctor” remediation plans for large inboxes or refusal to address individual patient requests and demanding the system do it, are actually asking to treat the symptom rather than the cause.

We need to build in pressure-release valves for a system whose capacity has already been exceeded.

Most of us, including the people leading healthcare systems, are trying to solve the same problem: give increasingly more patients excellent, responsive care with finite people, time, and resources in a complex, expensive world.

There are important strategies many systems are already working toward: true team-based care that allows everyone to work at the top of their license and technology - both that could reduce physician-required work. (PS - no industry kickback here - I'm hearing increasingly impressive feedback about Ambience by from the front line in primary care)

There is individual work, too. Many physicians are realizing their own mindsets may need to shift from: “How do I give the ideal care I wish I could provide?” to “Given the resources, time, and constraints that actually exist, what is the best care I can responsibly provide while also preserving my own capacity to keep doing this work? And what is my part, if any, to make system and policy change?”

But I think we also have to talk about time and the schedule itself.

Where are the upstream pressure-release valves we could open before the only ones left are physician self-sacrifice, reduced FTE, leaving, or rigid boundaries that often may not serve our patients well?

Can we put in the transition time? The administrative time?

And how do we build it into the work in a way that is financially feasible?

My Monday was just one ridiculous day of meetings. I could look at it, realize it didn't work, and change my calendar.

For physicians whose clinical schedules are built this way day after day, the solution and agency isn't quite so simple.

Reflection

• What would a sustainable 1.0 clinical FTE actually look like if it accounted for all of the work?

• And how do we make that financially viable?