Time Allocation in Primary Care Office Visits

Time is a scarce resource in a physician's office practice. How physicians use clinic time has important implications for quality of care, patient trust (Fiscella et al. 2004), malpractice suits (Levinson et al. 1997), and is one of the bases of physician payments (Hsiao et al. 1988). Mechanic, McAlpine, and Rosenthal (2001) reported that the average length of a physician visit had increased from 16.3 to 18.3, between 1989 and 1999, based on survey data from the National Ambulatory Medical Care Survey (NAMCS) and the Socioeconomic Monitoring System (SMS). Data from direct observation of primary care office visits by nurse researchers called into question these results, however. Yawn et al. (2003) found that primary care physician office visits lasted about 10 minutes. Further, Gilchrist et al. (2004) found physicians or their office staff over-reported visit length by almost 4 minutes when completing the NAMCS encounter forms. Patient–physician conversations are complex, multidimensional, and multifunctional (Mishler 1984). Visits vary not only in length but also in the division of time among topics. Patients typically present multiple complaints during an office visit requiring physicians to divide time and resources during a visit to deal with competing demands. A unique and critical role of primary care physicians has been to provide patients with an “advanced medical home” where complex comorbidities are diagnosed and treated. Braddock et al. (1999) analyzed audiotapes of office visits to primary care physicians and surgeons and reported a median of three patient concerns per visit. Beasley et al. (2004) reported an average of 3.9 concerns discussed with elderly patients by family physicians. Studying how physicians use clinical time through examining the contents of the visit is also important to illuminate the process of care (Donabedian 2005). Our review of the literature (Hsiao et al. 1988; Charon, Greene, and Adelman 1994; Thompson et al. 2003; Heritage and Maynard 2006) and personal communications with other researchers lead us to believe that this study is the first to directly measure the actual amount of time spent by patients and physicians on topics occurring during office visits. In this paper, we took advantage of a unique data set consisting of videotaped elderly patients' visits with their primary care physicians in three distinct organizational settings: salaried group practice in an academic medical center, a managed care group (MCG) practice, and fee-for-service inner city solo (ICS) practitioners with an Independent Practice Association contract. We examined not only the length of visits, but more importantly, the content of visits in terms of units of clinical decision making we refer to as “topics,” operationalized as clinical issues raised by either participant. Our approach was in the spirit of the multidimensional interaction analysis (MDIA) system, which codes an interaction directly from an audiotape of the visit based on topics sequentially introduced by patient or physician. The MDIA lists 36 categories subdivided into five major content areas: biomedical, personal habits, psychosocial, patient–physician relationship, and other (Charon, Greene, and Adelman 1994). We partitioned a visit into similar topics, and took a step further by recording the amount of time spent on each topic by patient and physician. Our approach allows us to examine how much time is dedicated to specific topics, and the factors that influenced how clinical time is allocated. This paper addresses a series of questions about visits and topics within visits. First, what was the length of a primary care office visit for these elderly patients? Second, how many topics were discussed, and how much time was devoted to each topic? Third, what were the topics of discussion and how did the length of time speaking by patient and physician vary across different types of topics? Lastly, we analyze the influence of patient, physician, and physician's practice setting characteristics on how clinic time was spent using duration (or survival) analysis. Our main goal is to characterize physician–patient encounters in a new way, in order to study how physicians and patients allocate the scarce resource of physician time to deal with the complex set of problems arising in an office visit.