An Elephant in the Middle of the Office: The Cumulative Burdens in Primary Care

From the archives: Below is an essay I wrote in 2005. Many of the issues remain, but the burdens of primary care are no longer the unspoken elephant in the room. 

Can primary care survive? At a time when the services of a well trained, well supported primary care physician are needed more than ever before to help patients negotiate through the confusing health care maze, the specialty is under siege.

We are overwhelmed. Those of us in primary care are overwhelmed by the growing weight of medical, legal, financial, and clerical responsibilities placed on our shoulders. The quality of care we can provide, the level of patient and physician satisfaction we can achieve, as well as the future viability of primary care depends on our ability to successfully address this issue.

The forces which threaten to dismantle primary care, including the growing complexity of patient care, increasing non-physician work responsibilities placed on physicians, mounting pressures to fragment care and inequitable and perverse reimbursement, are identified. Patient-centered, physician-sensitive, deliverable recommendations are developed. 

Consider the example of a yearly exam for a common patient in primary care, a patient with diabetes, heart disease, hypertension, osteoarthritis, and a new complaint of fatigue. The workload is substantial; let’s look at its component parts.

First the medical issues: This patient requires three distinct services:  prevention, chronic disease management, and acute symptom evaluation. Provision of any one of these services separately would constitute a significant office visit. Taken collectively, such simultaneous care represents an organizational and intellectual challenge for the physician, integrated care for the patient, and a bargain for the third party payer. (1)

Next the clerical responsibilities: The dictation will be composed for good future care of this patient, but also as a defense toward auditors, lawyers, and insurance representatives. The physician must count bullet points for the history, bullet points for the physical exam, determine the level of complexity, and then integrate each component into a final grid to choose the correct Current Procedural Terminology (CPT) service code, a clerical task estimated by our in house auditors to require ten to fifteen minutes per encounter.

Finally the bureaucratic responsibilities: Medicare and others have increasingly burdened physicians with unmanageable paperwork for everything from canes and commodes to hearing aid batteries and Meals on Wheels; from a three-page authorization for a motorized scooter to a 29-question Family Medical Leave application. Complex insurance regulations require duplicate copies of prescriptions, systems for formulary compliance, and gatekeeper authorizations. The cost of such unreimbursed work falls disproportionately on the primary care physician.

The primary care physician is allocating resources to maintain the profitability of other organizations. Should physicians continue to be the unpaid workforce of private for-profit companies, such as health insurance companies, suppliers of durable medical equipment, mail order pharmacies, commercial screening ventures (such as mobile vascular labs) and home health agencies? Does every institution and business entity have the right to create additional paperwork with the expectation that the physician will assume responsibility for its completion? How much longer can physicians remain the unfunded agents of the Department of Transportation (2) and the Office of Inspector General (3)?

Given the accumulating burdens placed on primary care physicians, is it any surprise that the number of medical students applying for primary care residencies is steadily declining? (4) Or that job satisfaction among primary care physicians is low?(5)

How can this situation be addressed? We need to affirm that doctors should spend most of their time doing the things both patients and physicians find most important (listening, thinking, talking) and a much smaller amount of time performing clerical, bureaucratic, and defensive tasks. Every element of practice, every technological implementation, every new responsibility should be evaluated in this light.

Specific Recommendations:

Develop community based primary care research initiatives.

Most medical research is done at academic centers, often from the perspective of a single disease entity, yet most health care is delivered as the complex integration of multiple medical problems over time, usually in a community setting. This disconnect has created a gap between research and reality. Practical clinical trials (6), and collaboration between academic and community physicians could frame research questions to maximize applicability to clinical practice.

Analyze optimal strategies for structuring an outpatient primary care practice.

Apply a systems analysis approach to the microenvironment of the physician’s office to facilitate comprehensive, efficient, and quality care.

Quantify the workload in primary care.

Expand on the work of Yarnell et al (7), who estimated that full compliance with US Preventive Task Force-recommended prevention issues alone would require 7.5 hours per day per primary care physician. Quantify the number of patient care issues addressed at an average office visit in primary care; the number of guidelines that apply to an average patient visit; the time required to address each of these guidelines; and the amount of unreimbursed work in primary care for paperwork, phone care, coordination of care, and services for which reimbursement has simply been eliminated.

Such data will help to clarify the extent of the workload, can provide perspective when additional responsibilities are proposed for primary care, and may point to ways to improve care.

Acknowledge that reimbursement matters.

Adequate reimbursement is necessary to support quality care. Take a hard look at the reimbursement in primary care. Is it sufficient to support the services required, and does it represent an equitable distribution of health care resources?

As an example: using literature estimates for time (7, 8) and regional third party reimbursement rates for payment, I have estimated that procedural preventive services (screening colonoscopy) are reimbursed at about 4 x the rate of cognitive preventive services (annual preventive medicine exam.)

Reimbursement for primary care must be adjusted to reflect the scope of services provided and to fund the type of support systems necessary to provide quality care.

Establish the link between workload, reimbursement, and quality.

The cumulative effect of the demands on primary care has an inevitable impact on quality. Americans are getting only half of the recommended care for a series of common ailments. (9). Compliance with published guidelines was highest for conditions cared for as single entities (cataracts, prenatal care, breast cancer), and lowest for conditions typically cared for in the context of multiple medical problems, and at an overall lower rate of reimbursement, (headache, diabetes, depression, atrial fibrillation, hyperlipidemia).

Develop a conceptual and computational framework to analyze multiple services provided at a single visit.

Primary care specialists provide preventive care, chronic disease management, and acute symptom evaluation services within a single office visit. There is currently no satisfactory mechanism for equitable reimbursement of these distinct services.

Recognize that integrated care is better than fragmented care.

Integrated care is what we do in primary care. The patient described above could be cared for in a single visit by a well trained primary care physician or receive the same care by five separate visits to five separate clinics:  cardiology, endocrinology, rheumatology, hypertension, and preventive medicine. What would be the financial and social costs of the patient’s care if it were fragmented into single organ system clinics? What would be the overall quality, coordination, and contextualization of that care? What would be the patient acceptance and compliance?

Realize that technology can serve or enslave.

The details matter. Technology must be scrutinized to assure that it assists in the overall care of the patient. If a new technology adds transcriptionist, receptionist, and pharmacist duties to the primary care physician’s already full slate of responsibilities, then its adoption may be premature. Computerized Physician Order Entry (CPOE) and decision support technologies need to be further refined to efficiently accommodate the simultaneous management of multiple complex conditions.

Evaluate practice guidelines from a primary care perspective.

Guidelines should be developed in a collaborative approach which includes the perspective of practicing primary care internists.


Primary care involves the complex integration of multiple medical problems over time. Simultaneous care of multiple chronic illnesses, acute symptom evaluation, and preventive medicine is a difficult but worthy task. Added to this has been an insupportable layer of clerical and bureaucratic duties.

I believe that most physicians are trying to meet these challenges. But none of us can shoulder all of the increasing burdens that suck the life out of our practice and still maintain the intellectual and emotional reserves to deliver quality and compassionate care. None of us can do ten hours of work in eight for the price of one. 


Primary care is at the breaking point. Something is giving; we are just not measuring it.  We aren't measuring it because we aren't even talking about it. That is the elephant in the middle of the room.



1. Sinsky CA. Reimbursement Differential Between Cognitive and Procedural Preventive Medicine. Am J of Public Health eletters/93/4/635.

 2. Wang CC et al.  Physician’s Guide to Assessing and Counseling Older Drivers. Washington, DC. National Highway Traffic Safety Association; 2003.

3. Hawryluk, M. Medicare to Reign in Prescription Wheelchair Prescriptions, Sales. American Medical News, 2003. 46;37:9.

4. Wheby, W. To Revitalize Internal Medicine, Look Back to its Roots. ACP Observer, September, 2003.

5.Leigh, JP.  Physician Career Satisfaction Across Specialties Arch Intern Med. 2002;162:1577-1584.

6. Tunis SR et al. Practical Clinical Trials: Increasing the Value of Clinical Research for Decision Making in Clinical and Health Policy. JAMA. 2003;290:1624-1632

7. Yarnall K et al. Primary Care: Is There Enough Time for Prevention? Am J Public Health. 2003;93:635-641.

8. Garrett DW. Colonoscope Length and Procedure Efficiency. Am J Gastroenterol. 2002. Jan;97(1):6-8.

9. McGlynn EA et al. The Quality of Health Care Delivered to Adults in the United States. N Engl J Med 2003;348:2635-45.