Nationwide, more than one-quarter of hospital-based general practitioners who take over for patients' primary care doctors to manage inpatient care say their average patient load exceeds safe levels multiple times per month, according to a new Johns Hopkins study. Moreover, the study found that one in five of these physicians, known as hospitalists, reports that their workload puts patients at risk for serious complications, or even death.
The research, reported in JAMA Internal Medicine, comes as health care systems anticipate an influx of new patients generated by the Affordable Care Act over the next few years; as restrictions on resident-physicians limit their duty hours; and as one in three physicians is expected to retire or otherwise leave medicine over the next 10 years, cumulatively resulting in increased patient care needs coupled with stressed staffing demands.
"As perceived by physicians, workload issues have the significant potential to do harm and decrease quality," says study leader Henry J. Michtalik, M.D., M.P.H., M.H.S., an assistant professor in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine. "It is the elephant in the room that cannot be ignored. We have to find that balance between safety, quality and efficiency."
The Johns Hopkins study comprised a survey of 890 hospitalists across the United States, 506 of whom responded. Twenty-two percent of the respondents reported ordering costly and potentially unnecessary tests, procedures or consults because they didn't have time to properly assess patients assigned to their care.
"If a hospitalist is short on time and a patient is having chest pains, for example, the doctor may be more likely to order additional tests, prescribe aspirin and call a cardiologist -- all because there isn't adequate time to immediately and fully evaluate the patient," Michtalik says.
For the study, Michtalik, a hospitalist at The Johns Hopkins Hospital in Baltimore, and his colleagues electronically surveyed self-identified hospitalists enrolled in an online physician community, QuantiaMD.com. Of those who responded over the course of four weeks in November 2010, the average age was 38 years and more than half worked in community hospitals. Among other questions, physicians were asked to report what they felt was a safe number of patients to see in a typical shift. Most physicians reported that they could safely see 15 patients in a shift if they could focus 100 percent on clinical matters. When the average actual workload was compared to the perceived safe workload, 40 percent of physicians exceeded their own reported safe level.
Michtalik says that JHH's hospitalists typically stay below that number, while hospitalists at community hospitals often see more than 15 patients per shift.
"Hospitals need to evaluate workloads of attending physicians, create standards for safe levels of work and develop mechanisms to maintain workload at safe levels," he adds.
The study was supported by National Institutes of Health grant T32 HP10025-17-00, the NIH/Johns Hopkins Institute for Clinical and Translational Research KL2 Award 5KL2RR025006 and the Johns Hopkins Hospitalist Scholars Program.
Other Johns Hopkins researchers involved in the study include Hsin-Chieh "Jessica" Yeh, Ph.D.; Peter J. Pronovost, M.D., Ph.D.; and Daniel J. Brotman, M.D.
- Henry J. Michtalik, Hsin-Chieh Yeh, Peter J. Pronovost, Daniel J. Brotman. Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists. JAMA Intern Med., 2013 DOI: 10.1001/jamainternmed.2013.1864
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