Not as many as required — but delegation can lessen the workload, says a university study.
The average patient, if she’s fortunate, feels a warm, individual rapport with her family doctor.
The average patient, if he’s fortunate, thinks of his internist as a sympathetic confidante.
But how many other patients do they imagine their own personal physician shares this intimate bond with? Would they be surprised to realize it might be 2,500 — or more?
Thirty-four years ago, when he began his career with the Kaiser health care system, Southern California Permanente Medical Group executive medical director and board chairman Edward Ellison, MD, says, it was not unusual for the number of patients in a primary care doctor’s panel to exceed 3,000.
Now do some arithmetic. According to criteria used by Duke University researchers in a series of 2009 studies, to deliver all the recommended preventive, chronic and acute care services needed by 3,000 patients with a typical U.S. age and disease distribution, a doctor would have to work 17 hours a day — seven days a week, all year, without a break.
Since this is humanly impossible, the quality of care patients ought to receive has suffered nationwide, studies show. Meanwhile, burnout and suicide rates among physicians have soared.
However, advances in technology and in team support have eased doctors’ workload significantly. Today, Ellison says, the size of patient panels nationally “probably ranges from 1,800 to 2,000. And most physicians would probably tell you it needs to drop more.”
According to a 2018 survey by the Physicians Foundation, doctors on average work 51 hours a week and see 20 patients a day. Almost a quarter of their time is taken up with nonclinical (and frustrating) paperwork.
The number of patients to whom a doctor can deliver excellent care without sacrificing health and job satisfaction depends on many factors. A key determinant is the number of tasks that can be delegated.
A study by the University of California at San Francisco’s Center for Excellence in Primary Care in 2012 looked at this issue and determined that if a primary care physician does everything herself — screening, counseling, immunization, drug prescription, routine chronic care plus treatment of acute conditions — working 43 hours a week for 47.1 weeks a year (the average estimated by the American Academy of Family Physicians), she can accommodate a maximum panel of only 983 patients.
As much as 77 percent of a doctor’s time spent on preventive services, however, could be safely delegated to nonclinician care-team members, the UCSF researchers proposed. And another 47 percent of the hours a doctor devotes to patients managing common chronic conditions, they calculated, could be shifted to other personnel — registered nurses, pharmacists, health educators and medical assistants — aided by health information technology and working under standing physician orders.
In a practice in which a support team frees primary care physicians of all those noncritical care responsibilities, the UCSF researchers concluded, as many as 1,947 patients would constitute a reasonable panel.
“Some doctors may have 1,000 geriatric patients who need a lot of attention,” observes pediatrician Russ Libby, MD, of the Medical Society of Northern Virginia and the Physicians Foundation. “Others who’re treating mostly healthy 20-somethings can have a really large panel.
“There are individual factors as well,” he points out. “Some physicians just eat it up and spit it out, always delivering high-quality care. I had one colleague who’d walk into the room, spend five minutes with a patient and the patient would think it had been an hour. It’s a matter of physician skill. There’s significant variability.”
At Kaiser, Ellison notes, new physicians start with a reduced patient load that slowly ramps up over a period of six months to allow for acclimatization. “Some physicians adapt more quickly than others,” he allows. “Exactly how many patients are on a panel is not fixed in stone. The numbers fluctuate, even by month. It’s a dynamic process.”
What’s more, he says, “we allow physicians to go on reduced schedules. If they want to be on 80 percent time, or 50 percent, we will work to accommodate them.
“You can’t just pick an ideal number in isolation,” he advises. “You’ve got to look at this holistically. We want to get away from widgets. It’s not about how many patients you’re seeing during the day, it’s about how many problems you’re solving.”
David Ollier Weber is a freelance journalist based in California.