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Date
Jun
06
2006

Time allocation in primary care with competing demands

Presenter:

Ming Tai-Seale

Authors:

Ming Tai-Seale, Thomas McGuire

Chair: Michael Morrisey; Discussant: Jessica Vistnes Tue June 6, 2006 10:45-12:15 Room 313

Rationale: In analyses of physician behavior, how physicians allocate their time plays a central role. The time a physician spends during a visit is often put forward as the example of the “effort” the physician puts into a visit. Effort (time) is costly to the physician and the main input into the quality of a visit. In spite of its central importance, little is known about what determines how much time physicians spend with patients. While observable by the patient, time is regarded as not contractible. Empirical examination of how physicians spent clinic time is scarce.

Objectives: To develop a theoretical model of physician time allocation building on Becker’s theory of the allocation of time and to test the model, with videotaped behavior of physicians and patients. We study how time is allocated during a visit across the problems patients bring to the attention of their doctors.

Methodology: Direct observation of videotapes of 390 routine office visits that took place between 1998 and 2000 from three primary care practice sites in the Midwest and Southwestern regions of the U.S and surveys of participating patients and physicians inform the study. We break visits into “topics,” a natural unit of clinical decision making, and document how clinical time is spent. Using a mixed-level duration model, we analyze the effects of the nature of topics, the dynamics of time, and characteristics of patient, physician, and physician’s practice setting on how clinic time is spent.

Results. The average visit in our sample lasted 17.4 minutes and covered 6.5 topics. Patient and physician each spoke, on average, less than 1 minute per topic. Out of over 2,500 topics examined, more than 70% of the topics addressed biomedical issues. Psychosocial topics were 12%, and personal habits, 7%. Less than 4% of the topics involved mental health concerns. What happens in clinic is influenced by the contents of the discourse, physician practice setting characteristics, patient’s gender and race, and physician’s gender. When a topic was introduced during the visit and how much time has already been spent on it are also significant determinants of time allocation.

Conclusions. Physicians are likely to reduce time spent on a topic if it is raised later during the visit when the opportunity cost of physician time is higher. A large number of topics are discussed during a primary care visit, with little time spent on each topic. Efforts to improve the quality of primary care need to recognize the time pressure on both patients and physicians, and the time costs of improving information exchange.

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