Primary Care in the Modern Age

While the demands on primary care clinicians have changed, the model of care clinicians work within has not. Clinicians are asked to do increasing amounts of work asynchronous to the clinic visit, driven by the EMR and patient portal, while maintaining historic levels of face-to-face visits. This misalignment of workload supply and demand increases risks burnout. Our goal is to develop a new clinic scheduling template to acknowledge and accommodate this shift in workload that is financially sustainable and professionally rewarding.

We assembled a workgroup of clinicians to evaluate the current state, establish goals, and develop new template designs.

We designed a template to better align the workday with modern expectations of primary care, include clinical flexibility, and leverage existing space to improve capacity for new patients. In doing so, we remained cognizant of monitoring key balancing measures, such as visit volume, continuity of care, patient satisfaction, and performance on quality measures.

We then conducted a three-month feasibility trial of five pilot interventions with 19 (35%) participants across four primary care practices. This feasibility trial informed decisions about which pilots worked operationally and which seemed to have a positive impact on burnout. All pilots included dedicated time within each four-hour clinical session to do asynchronous work. Some pilots included dedicated time for telehealth outside of the clinic.

We estimated that the total annual cost to our division in lost collections should all faculty participate in this intervention in the future would be $245,000, far less than the estimated $750,000 organizational cost to replace one new clinician. We saw a small improvement in burnout for participants similar to non-participants, though the initial pilots were not powered to be statistically significant. We saw a greater change in clinicians’ career plans. There was a 48% decrease in plans to reduce clinical hours and a 54% increase in plans to continue in their role as is amongst participants compared to a 24% decrease in plans to reduce clinical hours and 14% increase in plans to continue their role as is in non-participants.

After evaluating the five template designs, two modified pilots advanced and are currently being tested over six months across our clinics with a marked increase in clinician participation. Having data from our initial pilot was critical in helping us design template changes that we hope will provide maximal benefit with minimal operational costs.

Modifying clinical templates to better align the workday with modern expectations of primary care can be successfully implemented and evaluated. Partnering with hospital/school leadership to engage in meaningful conversations about realistic workload and productivity targets that are data-driven will lead to a shared vision of success in delivering primary care in a modern setting. Early results indicate this may be a viable approach to improving clinician satisfaction that could address the significant cost of clinician attrition.

In the new normal of asynchronous care, it is imperative that we embrace new ideas about clinic schedules by engaging all stakeholders in the conversation.