He is director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times.

Peter McDonnell, MD

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There literally are not enough hours in a day to allow physicians to comply with all the recommendations emanating from the various constituencies involved in issuing these guidelines.

In an article published in the August 2022 issue of the 

, authors from the University of Chicago asked the following question: How many hours would it take the typical doctor seeing the typical number of patients in an 8-hour long workday to perform and document the care, following guidelines issued by “official medical bodies?”

The answer: a mere 27 hours! You read that correctly. There literally are not enough hours in a day to allow physicians to comply with all the recommendations emanating from the various constituencies involved in issuing these guidelines.

The authors suggest doctors should use a team approach, which translates into hiring nonphysician care providers, such as scribes, to try to get everything completed and documented. I have a somewhat different take on the matter. To my way of thinking, all these guidelines are coming from individuals and organizations that are truly well intentioned. Counseling patients who are obese on the benefits of weight loss at every visit. Recommending smoking cessation for those who are addicted to cigarettes. Performing medicine reconciliation—in which the patient is queried about every medicine they are taking, and correct dosage and frequency is documented—at every visit. Screening patients for mental health issues, domestic abuse, human trafficking, pain symptoms, and more.

In the abstract, it is hard to be against any of these initiatives in the appropriate setting. However, when the various players (eg, insurers, medical societies, government) mandate so many activities and so much documentation for so many patients, the to-do list can quickly become unachievable. The outcomes are predictable: Doctors cannot comply, they are criticized for not meeting this or that standard, and most of the visit may be spent on topics that have nothing to do with why the patient is coming to see the doctor.

One (very expensive) option for dealing with this is to hire a lot of extra staff to work in the office to get all this extra stuff done. I propose a different approach: As doctors, we should demand a higher standard before we agree to maintain or add new guidelines. If the recommending organization cannot prove that the guideline improves patient outcomes, those guidelines are either dropped or not adopted in the first place.

Second, the time required to carry out any new task is carefully determined, and an equal amount of time is deducted by either dropping or streamlining some other mandated guideline.

Third, these guidelines are narrowly applied, such that patients who present to their doctor because they are concerned about a funny-looking mole on their skin, for example, are not subjected to a list of irrelevant questions about their level of pain because of a rule requiring that every patient have a pain assessment on every hospital visit.

The current system in which every well-intentioned idea—often from individuals who aren’t directly involved in patient care—gets added to the doctor’s task list is unreasonable and unsustainable.

Articles

There literally are not enough hours in a day to allow physicians to comply with all the recommendations emanating from the various constituencies involved in issuing guidelines.

Not enough hours in the day

Burnout can be a problem for physicians. (

Burnout among physicians who deliver “primary care” is so bad that 20% of them intend to stop practicing, according to some surveys.

 By contrast, rarely during my career have I seen an ophthalmologist friend truly retire. 

They may stop operating or cut back on their hours in clinic, but I have colleagues in their 70s and 80s working away and loving being ophthalmologists. Some of them even tell me they hope one day to die (hopefully suddenly with minimal discomfort) while in the office.

I have a theory to explain this difference between ophthalmologists and our primary care brothers and sisters, and a recently published study from my own institution convinces me that my theory has validity. In the study, 43 internal medicine interns were given infrared badges so that their exact physical locations could be tracked throughout each working day for one year.

The results showed that the interns spent a lot of time in their workrooms (no doubt diligently documenting things in the medical record, entering orders, performing medicine reconciliation, hunting down laboratory results, calling to ask other physicians for a consultation, dictating discharge summaries, etc), in the hallways (discussing patients with the other house officers outside the patient rooms), in grand rounds lecture halls, etc. But the bottom line from the precise tracking data was this (and I quote): “

The patient-physician clinical encounter is the cornerstone of medical training, yet residents spend as little as 12% of their time in direct patient contact

I kid you not: In a 12-hour workday, these interns were physically in a room with a patient for an average of 90 minutes!

My theory is that young people work their tails off to earn a spot in medical school because they want to experience the satisfaction that comes from caring for people and saving or improving patients’ lives. We ophthalmologists and our ophthalmology residents spend almost the entire day with our patients—in clinic rooms or in the operating room—and we constantly get the positive feedback that comes from getting to know our patients and hearing them express appreciation for what we do.

My hypothesis is that we do not work hard to spend hours and hours documenting in medical records, tracking down x-rays, etc. I feel sorry for physicians who spend 80% to 90% of their day performing various administrative tasks and a minimal amount of time talking to and examining their patients. 

I don’t blame doctors who only get to spend 12% of their time actually being doctors for being dissatisfied and wanting out. If the primary care fields want to attract and retain the best and brightest, I believe they should start all over with how they structure their training programs.

1. Abbasi J. Pushed to their limits, 1 in 5 physicians intends to leave practice. 

 2022;327(15):1435-1437. doi:10.1001/jama.2022.5074

2. Rosen MA, Bertram AK, Tung M, Desai SV, Garibaldi BT. Use of a real-time locating system to assess internal medicine resident location and movement in the hospital. 

 2022;5(6):e2215885. doi:10.1001/jamanetworkopen.2022.15885

Surveys have found that burnout among physicians who deliver “primary care” is so bad that 20% of them intend to stop practicing.


My theory regarding physician burnout

“The only difference between death and taxes is that death doesn’t get worse every time Congress meets.” - Will Rogers

Fifty years ago, an event occurred that led to dramatic improvement in our understanding of how the eye works and how to treat eye disease. No, that event was not my becoming an ophthalmology resident (but I understand how you might think I am that old). And no, the event was not my becoming chief medical editor of Ophthalmology Times (it only seems like forever that you have been forced to tolerate these columns of mine).

Rather, the event to which I refer is the creation of the National Eye Institute (NEI) within the National Institutes of Health.

At a time when members of Congress routinely worked across the aisle, our elected representatives became educated to the fact that although Americans feared loss of vision second only to cancer when it comes to health, very little federal research funding was being directed toward addressing eye disease.

The education of our elected representatives did not occur by accident. Rather it resulted from concerted efforts of leaders from academia, professional societies, industry, and charitable organizations who shared concerns over the increasing numbers of blind Americans and the lack of appropriate research to stop or reverse this trend.

Prior to the NEI’s formation, scientists wishing to study eye disease might apply to another one of the institutes within NIH, such as the National Institute of Neurological Diseases and Blindness. “After all,” went the thinking, “isn’t the eye part of the brain?”

Predictably, review panels composed of large numbers of neurologists or neuroscientists with no experience in eye disease did not consider eye research a priority in comparison with neurological diseases.

NEI’s creation by Congress represented the firing of a starter’s pistol when it came to making major investments in the study of eye disease. Federal funding for research has paid dividends to American taxpayers by improving our understanding of the pathogenesis of eye diseases.

These funds have resulted in better therapies or provided the scientific basis for industry to find drugs/devices to address the targets identified in federally funded research labs. In retinal diseases alone, think of the argon laser, anti-VEGFs, OCT, and more.

The track record of NEI-supported research is impressive. Still, polls of Americans rank fear of blindness as a top healthcare concern across all racial and ethnic groups.

The Alliance for Eye and Vision Research (AEVR) was founded 25 years ago to educate Americans about the importance of funding for research into eye disease. Privately funded by professional organizations, private foundations (such as Research to Prevent Blindness) and industry (you can guess the names), AEVR’s three founding members are the American Academy of Ophthalmology, ARVO and AUPO (the organization of ophthalmology department chairmen).

AEVR allows all of its member organizations to speak with one voice about the need for research that will lead to the improved drugs and devices that we ophthalmologists need to better care for our patients. (Full disclosure: Since 2013, yours truly has served as President of AEVR).

Surprisingly, a decade or so ago the proposal was raised of eliminating the separate NEI budget and folding it into a “Brain Institute.” Harkening back to the old days, researchers wanting to understand eye disease would have had their grants graded by neurologists and others with little to no knowledge of eye disease. Fortunately, this proposal did not gain traction. This step back in time failed, I believe, at least in part to the educational efforts of AEVR, which emphasized the potential loss of critical front-of-the-eye research.

Like Will Rogers, you might occasionally make fun of Congress. But the creation of the NEI augured a half century of stunning progress in understanding eye disease and better care for patients.

Peter McDonnell, MD

Articles

Not enough hours in the day

My theory regarding physician burnout

Why the NEI is crucial

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