How Many Problems Do Family Physicians Manage at Each Encounter? A WReN Study

I’d like to weigh in from a different perspective – that of a professor of industrial and systems engineering (specialty in human factors engineering) who studies health care quality and safety. I’d first like to disclose that Beasley and I are research collaborators, though I had no part in this particular study. Also, though I study health care, I have no medical training, so my comments come from my observations and experiences.

One of the things that I immediately thought of upon reading the results had to do with the limits of human information processing. It was a bit scary to think that family docs might have to perceive, process, integrate and make decision about close to 4 different problems (in the case of those over 65) or even up to 5 (in the case of diabetics) problems during a single visit. Not only are these numbers not reflected in billing codes, but they suggest to me that, perhaps, many patient encounters operate at the edge of what is reasonable for a single physician to process and solve during a single encounter, given the time constraints of a typical visit.

With each problem, the doc has to identify that the problem exists, determine the nature of the problem and the cause, and determine what to do about it. With each additional problem, the answer to each of those steps becomes complicated and confounded by the other problems. This poses a serious data management and decision making problem, again, especially given typical time constraints. In such cases, people tend to rely on many of the well-researched rules of thumb to help guide decisions, but these rules are thumb are not in any way necessarily accurate. This all translates into potential compromises in quality of care that are NOT the fault of the physician doing his/her best or of the patient who cannot necessarily help the fact that they have so many problems! This is just bad system design in that the system of care is designed without consideration, or at least effective support, for the performance needs of the doctor!

So, what should be done about this? The gut reaction is typically –TECHNOLOGY! An EMR or decision support system (or both) can, if designed correctly, provide some help. If designed correctly, an EMR system can help the physician locate pertinent information quickly which can improve problem identification and solution accuracy and speed. If not designed correctly, an EMR can slow down the entire process, increase the likelihood of entering the wrong information in the wrong place, etc. A decision support system, if designed well, can help a physician to strategize about the best course of action given the multiple, interacting problems. A poorly designed decision support system will provide the physician with unwanted advice, impractical advice, etc.

Perhaps new patient interaction processes are needed (a more low tech approach). Knowing that patients have multiple problems, perhaps methods need to be developed to better facilitate problem extraction from patients at the start of the visit so the physician has the bulk of the time to strategize about how to solve the problems.

I don’t have an answer, but I do know that we are dealing with a problem that will impact human (the physician) performance. Now that we know (though I suspect all of you have known) that FPs face this many problems per visit it is time to study ways to make that situation manageable for effective and safe care. That means not just focusing on technological solutions, but also studying the nature of care encounters, the type of information needed for problem identification and solution, the methods of decision making............

Competing interests:   None declared