“Good Care Is Slow Enough to Be Able to Pay Attention”: Primary Care Time Scarcity and Patient Safety

Abstract

Background

There is growing, widespread recognition that expectations of US primary care vastly exceed the time and resources allocated to it. Little research has directly examined how time scarcity contributes to harm or patient safety incidents not readily capturable by population-based quality metrics.

Objective

To examine near-miss events identified by primary care physicians in which taking additional time improved patient care or prevented harm.

Design

Qualitative study based on semi-structured interviews.

Participants

Twenty-five primary care physicians practicing in the USA.

Approach

Participants completed a survey that included demographic questions, the Ballard Organizational Temporality Scale and the Mini-Z scale, followed by a one hour qualitative interview over video-conference (Zoom). Iterative thematic qualitative data analysis was conducted.

Key Results

Primary care physicians identified several types of near-miss events in which taking extra time during visits changed their clinical management. These were evident in five types of patient care episodes: high-risk social situations, high-risk medication regimens requiring patient education, high acuity conditions requiring immediate workup or treatment, interactions of physical and mental health, and investigating more subtle clinical suspicions. These near-miss events highlight the ways in which unreasonably large patient panels and packed schedules impede adequate responses to patient care episodes that are time sensitive and intensive or require flexibility.

Conclusions

Primary care physicians identify and address patient safety issues and high-risk situations by spending more time than allotted for a given patient encounter. Current quality metrics do not account for this critical aspect of primary care work. Current healthcare policy and organization create time scarcity. Interventions to address time scarcity and to measure its prevalence and implications for care quality and safety are urgently needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-024-08658-1.

INTRODUCTION

Having a primary care provider is associated with improved health outcomes.^1,2 Meanwhile, there is widespread recognition of time pressure in primary care. Excessive demands perpetuated by structures of care (i.e., large average panel size, rigid scheduling, short visits, administrative burden) create conditions of time scarity.^3–5 Meanwhile, declines in primary care physician (PCP) job satisfaction and increasing burnout have been shown to be associated with declines in quality of care and continuity.^6–11 Research has also shown that patients are sensitive to the time constraints of primary care appointments, feeling unworthy of physician time, or unable to address certain needs and questions.¹² In this article, we add to the existing literature by examining the relationship between socially structured time scarcity and patient safety in individual encounters.

Estimates suggest that for a panel of 2500 patients, it would take 10.6 hours per day for a PCP to satisfy the chronic condition management recommendations for the ten most common conditions and 7.4 hours per day for recommended preventive measures.^13,14 This 18-hour day does not account for diagnosis or management of acute or new chronic conditions; neither does it account for reviewing records to identify patient needs or addressing asynchronous care tasks such as in-basket messages and lab results. Another study estimated that a PCP would require 26.7 hours per day to care for a panel of 2500 and 16 hours a day to care for 1500 patients.¹⁵ In practice, PCPs have to regularly make rapid and implicit decisions about priorities within each visit, neglecting elements of the care they aspire to provide.¹⁶

One recent study found that median primary care visit duration was 18.9 minutes with the longest quartile lasting 24.9 minutes or longer. Half of these visits addressed four or more diagnoses. Shorter visit duration and higher visit complexity were associated with potentially inappropriate prescribing.¹⁷ Visit complexity (the number of issues addressed) has increased over time, outpacing changes in visit duration and leaving less time to address each issue.¹⁸

Other research has addressed diagnostic and treatment delays in primary care settings as they impact patient outcomes.^19–23 Some of these studies acknowledge time constraints as a factor in delayed diagnosis and suboptimal management of chronic conditions.^24–26 Meanwhile, it is well documented that time pressure impairs clinical decision-making and strengthens the influence of implicit bias.^27–30 Little research has directly examined how time scarcity can contribute to harm or patient safety incidents. One theory notes that chaotic practice environments and encounter-level time pressure contribute to missed opportunities for care.³¹

We extend understanding of the impact of time scarcity on patient safety by analyzing encounter-level qualitative data in which PCPs describe “near-misses” in which taking “extra” time allowed them to mitigate risk or prevent patient harm.³² By analyzing these examples, we sought to understand the patient safety and care quality implications of time pressure within encounters. Our work contributes to the existing literature by identifying five types of patient care episodes where time scarcity is likely to cause preventable harm. We further differentiate between forms of time scarcity to inform future work design and policy interventions aimed at improving patient safety and physician retention.

METHODS

Study Design

We utilized a qualitative study design to assess primary care physicians’ perceptions and experiences of work time. We collected data virtually via surveys and conducted semi-structured interviews over Zoom. Data collection commenced in May 2021 and concluded in August 2022, after reaching thematic saturation. The University of California, San Francisco Institutional Review Board reviewed and approved this study (IRB#18-25071).

Study Setting

Participants were recruited from primary care clinics across the United States of America (USA).

Clinician Recruitment

We used convenience and purposive sampling to identify physicians who were willing to complete a survey and participate in an hour-long virtual interview on Zoom. We contacted current and past colleagues and used snowball sampling to identify other participants. We contacted potential participants via e-mail/letter, phone, or text message. Prior to the interview, we obtained verbal consent. Each interview lasted 1 hour, and participants were compensated with a $100 gift card. We conducted interviews until we achieved thematic saturation at a total of 25 interviews. This was consistent with our anticipated sample size for recruitment. Our sample includes primary care physicians who work in the USA, work at least 50% Full-Time Equivalent (FTE) clinical time, have 1–20 years post-training, and work in a group practice setting, including federally qualified health centers, academic medical centers, or in private practice (see Table 1).

Table 1.

Participant Characteristics

Participant characteristics	Frequency (%); n = 25
Sex
Male	11 (44)
Female	14 (56)
Race
Black or African American	1 (4)
Asian	7 (28)
White	16 (64)
*NR	1 (4)
Ethnicity
Not Latino/Hispanic	24 (96)
Prefer not to answer	1 (4)
Age
30–39	9 (36)
40–49	7 (28)
50–59	3 (12)
60 +	2 (8)
*NR	4 (16)
Accept Medicaid patients
Yes	18 (72)
No	5 (20)
I don’t know	2 (8)
Type of residency training
Family medicine	12 (48)
Internal medicine	13 (52)
Region of practice (USA)
West, excluding California	6 (24)
California	9 (36)
South	3 (12)
Midwest	2 (8)
Northeast	4 (16)
*NR	1 (4)
Years in practice
1–5	11 (44)
6–10	3 (12)
11–15	4 (16)
16–20	2 (8)
21 +	5 (20)

^*Not reported

Analysis

We used a survey to collect baseline characteristics of participants, their perceptions of time in the clinic, and burnout. We used the Ballard Organization Temporality Scale³³ to measure experiences of time and the American Medical Association adaptation of the Mini-Z survey^34,35 to measure burnout. The Ballard Scale (see Appendix A) uses a series of words to define features of time experience and measures agreement with these. For example, time scarcity is assessed using the statement, “In my particular line of work, we usually talk about time as...”, followed by a Likert scale encompassing the terms “inadequate,” “scarce,” “not enough,” “limited,” and two reverse-coded terms: “plentiful” and “abundant.” We summarized the results of this survey using the scale’s coding guidelines and divided responses into terciles of low (1–2), neutral (3–4), or high (5–6) agreement with each composite temporal scale.

We used semi-structured interviews to add depth and context to the survey data by exploring participants’ experiences and perceptions of time as it relates to their work and well-being. One study team member (M.T.N.) conducted all clinician interviews. The interviews were audio-recorded, de-identified, and professionally transcribed by a transcription service. Members of the study team coded transcripts using Dedoose (Version 9.0.18).³⁶ We then categorized excerpts into themes through deductive and inductive thematic analysis. Two team members (M.T.N. and V.H.) independently coded five transcripts, with iterative comparison and discrepancy resolution during weekly meetings. After reaching consensus and developing a codebook, V.H. coded the 20 remaining transcripts. S.S. reviewed all transcripts.

The analysis presented here focuses on responses to one question: “Tell me about a time where you chose to take more time with a patient and that changed your management.” This framing recognizes that diagnostic errors and treatment delays are difficult to capture in existing primary care safety monitoring systems because they are underreported and hard to identify given lag time and fragmentation of care.³⁷ Asking if less time has led to error may not reveal oversights that remain unrecognized. This study uses positive near-miss examples to explore the types of hazards that often go unnoticed. Responses were analyzed within the context of the broader dataset. We identified common types of interactions and a further layer of analysis focused on the nature of the time pressures faced in these episodes.

RESULTS

Table 1 describes the demographic characteristics of study participants. The majority of participants were female, white, and aged 30–39. Most participants reported practicing in an organization that accepts Medicaid patients, and most had been practicing for 1–5 years.

Responses to select survey questions are summarized in Fig. 1. The four features of time experience are derived from the Ballard Organizational Temporality Scale. A high proportion of respondents reported experiencing time scarcity. These data are presented here to provide context for the overall experience of time pressure in the study sample which is the background for the specific qualitative examples that are the focus of our analysis.

Figure 1.

Qualities of time experience based on the ballard organizational temporality scale.

In response to the question: “Tell me about a time where you chose to take more time with a patient and that changed your management,” each physician provided one or more examples. Themes ranged from heartfelt connection, to coordinating complex transitions of care, to identifying or preventing serious harm. We identified five themes related to preventing patient harm: (1) complex social situations, (2) high-risk medication regimens requiring patient education, (3) high acuity conditions requiring immediate workup or treatment, and (4) more subtle clinical suspicions. Another significant area of concern for participants was (5) the interaction between mental and physical health, such as a patient whose physical impairment limited their ability to manage their depression with exercise. Specific illustrative examples of these five types of interactions are presented in Table 2, alongside the physician’s reflection on each case.

Table 2.

Examples of Patient Care Episodes Improved by Taking More Time Despite Time Scarcity

Patient Summary	Outcome	Physician’s Reflection
Complex or high-risk social situations
Person experiencing human trafficking, picked up because “it just seemed like something was a little bit off”	2-hour visit, person connected to behavioral health resources, and short-term safety planning completed	“…It can be really, I think, easy to – unfortunately—to not listen to those alarm signs going off in your head… It can be really easy to be like, ‘I’ve got to take care of other people and I [have] to finish my notes. I’m just going to let this be whatever she says.’”
School-aged child with benign chief complaint with new problem of poor appetite	Due to extra time because of no-shows, PCP able to identify social stressors and do home safety assessment	“I felt like I was able to get a better sense as to what was actually going on… I felt like I did a better job.”
Complex or high-risk medication regimens
An elderly new patient placed in a 15-minute slot, on “loads of haldol” from her country of origin	45-minute visit, family educated on non-pharmacological treatments, and patient referred to therapy	“I felt like I did it right. I was really mad at the setup of that visit being in that slot, but I was just like, ‘I can’t just propagate this harmful treatment.’”
Complex recently hospitalized patient not taking his medications due to GERD-related stomach pain	Over the course of frequent visits, held all medications and then slowly reintroduced them after treating GERD to increase adherence	“So, instead of just trying to put out a bunch of fires, I was just like ‘Let’s get to the root cause. Work on this abdominal pain concern so that we can get to the next level with everything.’”
High acuity
A healthy young woman seen during the COVID pandemic with 10 days of symptoms and tachycardia	Diagnosed pulmonary embolism at the cost of holding up the only COVID isolation room for most of a day	“Working her up in that [isolation] room pretty much backed me up for the whole day in COVID patients, but I think it was worth the time trying to [get] the D-dimer and getting an x-ray and all.”
OB patient with late transfer of care in third trimester and uncontrolled gestational diabetes	Identified dietary modifications that improved glucose control	“So, just little things like that where you’re like, ‘I’m frustrated today. I have no time today. Everything is crazy. Also, this woman is literally carrying another human, soon to be another human inside of her body. I should just swallow my anger, sit down and figure this out so that we can help her to have a healthy baby.’”
Patient with chronic cough and no prior medical care for 30 years seen in an urgent care setting	Extensive workup initiated to expedite care at follow-up with PCP	“So, I felt like it was important to sort of set the tone that, first of all, we care, and second of all, this is serious. It’s serious enough for me to spend the extra time. So, hopefully it’s serious enough that he’ll come back for his follow-up because I was worried he’d just go home and wait 30 more years which he, I did not think, had to spare.”
Clinical intuition and subtle red flags
65-year-old woman with a vague history of previous abnormal pap smears	Unscheduled pap smear in clinic that day that led to diagnosis of CIN3	“I think sometimes you have to go with your gut, and I think there are many instances like that that I can think of.”
Previously healthy man seen for ED follow-up after an accident	Physician noted anomaly on imaging that had not been commented on in ED assessment and this turned out to be cancer	“Which doctor do you want to see? The doctor who is on that 15-min slot and kind of goes, ‘Oh, good. Everything’s fine’… or the doctor that’s going to be thorough and… do the patient, justice? … They [clinic executives] want us to move at a certain pace that is unrealistic for good quality care.”
Interactions of mental and physical health
Young man with depression who coped by riding his bike	Learned that he’d recently been advised to stop riding for a physical reason. Took steps to clarify diagnosis behind that recommendation and discussed backup coping mechanisms	“So yes, all that stuff, I think, mattered a lot. I think if we had really crunched it into 10 min, we probably wouldn’t have done much of that. It would have been like, ‘Here’s your therapy resources. Do you want to start an SSRI? Let’s work on some coping strategies you can use in the meantime.’ That’s it; but we did the extras today and that’s felt good.”
30-something male with a paranoid psychiatric disorder whose delusions center on GI complaints	Extensive exam and reassurance to prevent the patient returning to clinic unnecessarily and subsequent harms	“Those types of patients, I really have to spend more time on; otherwise, they’ll just keep on coming back. They’ll probably see another provider when I am not available…and that provider might end up giving them medications that are not needed, not necessary, and might cause them even more harm than good.”
Long-time patient with trouble following dietary plans for weight loss	On a week where the doctor “could not rush people,” the patient disclosed a traumatic childhood experience that drove her to eat ice cream	“So now we can actually talk about that and try and figure out if there’s anything to help unravel it, but that would have never come out without me feeling like I just actually have to pay more attention to what’s happening with people. And then, like I kind of went back to status quo… because it’s very impractical to just listen to whatever people have to say.”
Elderly patient with metastatic prostate cancer	Compassionate listening instead of referrals to palliative care and oncology	“It was going to be a big life change for them is probably what I think about the most as to why I didn’t cut him off.”

In the interviews, reflection on these near-miss events evoked the specter of times that actual misses may have gone unnoticed. As one physician asked, “How many things am I potentially missing because I’m trying to stay focused on what’s in front of me?” The question of how often things are missed or inappropriate care is given is “not comfortable to think about.” One physician summarized that, “Good care is slow enough to be able to pay attention.” Despite the benefits of taking additional time for the quality and safety of patient care as required, respondents noted practical difficulties and disincentives to follow up when something is “a little bit off.” These included running late for other patients and having work overflow further into personal life.

These five types of interactions and their examples draw attention to three manifestations of time scarcity, highlighting the various ways in which patient needs conflict with the structure and flow of clinical time. These are discussed in Table 3. They include time sensitive interactions, time intensive interactions, and interactions requiring time flexibility or the ability to pause and reflect or change direction.

Table 3.

Interventions to Address Forms of Time Scarcity

Form of Time Pressure	Structural Interventions	Mitigating Interventions
Time sensitive
High acuity   Transitions of care	Fund high acuity teams in primary care Reimburse care coordination Integrate EHRs Decrease insurance barriers to timely outpatient management	Hospital discharge teams/clinics Schedule buffer periods Create flex (unscheduled) provider role
Time intensive
Crying, depression, grief, or trauma   Complex/high-risk medication regimens   Psychiatric conditions or dementia   Illness complicated by emotional or social challenges	Flexible, personalized appointment scheduling Increase payment for cognitive labor Invest in training of PCPs and mental health practitioners to build capacity Reduce panel sizes Policies that address homelessness, poverty Insurance reform to decrease administrative burden	Pool panels to enable real-time adaptations (e.g., a colleague sees the next patient) Create flex (unscheduled) provider role to see other patients as needed Co-management (pharmacy, mental health, nurse educator) Group visits for education and social support Scheduling that supports access for close follow-up
Requiring time flexibility or time to pause
Clinical/diagnostic intuition   Concerning social situation   Doorknob questions*	Flexible, personalized appointment scheduling Increase payment for cognitive labor Reduce panel sizes Integrate meaningful case management/social resources	Agenda setting Schedule buffer periods Prioritize continuity in scheduling

^*Doorknob questions are a commonly described situation in which patients ask a question as the physician is leaving the visit that must then be addressed

DISCUSSION

The distinct contribution of this research is PCPs’ identification of how time scarcity creates potential for patient harm and the types of situations that pose particular risk. We developed a theoretical framework describing five types of clinical content and three temporal features of interactions, in which respondents identified situations where patient care needs exceed the time available, or pressure to move quickly risks perpetuating dangerous oversights. The cases detailed by clinicians in this study included the potential for a missed cancer diagnosis, perpetuation of harmful medications due to inadequate time for patient education, and ongoing exposure and isolation of patients in precarious social circumstances. The findings also highlighted more benign but important missed opportunities, such as when a physician and patient had discussed weight management for several years without addressing the childhood trauma driving the patient’s emotional eating.

Importantly, the cases described included near-misses avoided by an astute observation or extra labor on the part of the clinician. These individual risks and interventions are unlikely to be mitigated by population-based registries or captured by metrics currently used to define quality.^38–40 Further, the additional time (i.e., labor) invested is not sustainable on the scale necessary to provide ethical care. What frightened several respondents in this study was the ubiquitous potential for unrecognized clues or errors and their inability to deliver care consistent with their own standards due to current patient care loads.

There is potential for both structural interventions to address time scarcity and improved care processes to mitigate its varied manifestations. Some suggestions are presented in Table 3. Reduced patient panel size would increase time available per patient.⁴¹ This necessitates intensive investment in the workforce given the current provider shortages.³ Empowering patients to prepare for their visits and interactive agenda setting can help ensure that patient needs are prioritized.⁴² Collaborative team-based care with nurses, pharmacists, mental health clinicians, or social workers may allow for some forms of time intensive care to be shared through warm handoffs.⁴³ Scheduling practices such as building in buffer time, same-day access, or having a flex provider (i.e., a provider who can see patients when their colleagues are running behind) could allow for greater flexibility when time sensitive or intensive issues arise.¹¹ While decreased visit volume may raise cost concerns, it is possible that adequately exploring patient issues early may save time and resources later by reducing repeat appointments or the fragmented and redundant care that results from patients searching for a resolution. Creating schedules that allow for safer care may improve PCP satisfaction and retention, in turn improving continuity which is proven to improve care quality.^5,7

Interventions that mitigate time pressure through task shifting without altering the fundamental structure of care are necessary but not sufficient. In the modeling study cited previously, even with robust co-management with nurses, pharmacists, and dieticians, a PCP’s role in the care of a panel of 1500 would take 9.3 hours per day.¹⁵ Clearly, a more fundamental restructuring of our systems of care is urgently needed. We must remember that time scarcity is not a natural, inevitable reality but structured by policies and practices that can be changed.

Given its basis in interview and survey data, this study is limited by social desirability and recall bias. Data collection took place during a time in which patient care was impacted by the COVID-19 pandemic but did not focus on this period. A limitation of our convenience sampling strategy is potential selection bias, volunteer bias, and underrepresentation. Our sample of physicians was relatively young compared to the average PCP, but this also allowed us to better understand issues affecting a new generation of doctors and our future workforce. Although not designed for generalizability and premised on a small sample, we expect similar issues to arise across primary care settings. Socioeconomic factors and language barriers, which are inequitably distributed across clinical settings, likely have significant impact on the specific manifestations of the themes explored in this analysis.^44,45 We suggest that future research further explore the social determinants of health as they relate to time scarcity.

The cases described in these examples presume positive outcomes based on physician report but are not readily measurable, nor can they be captured by quality metrics. This study did not attempt to prove or quantify the harms and costs implicated in these scenarios. However, this investigation identifies opportunities for future research, quantitative and qualitative, to explore the adverse effects of the existing structure of time in primary care on the well-being of both patients and providers, including instances of avoidable patient harm and provider distress. Additional directions for future research include identifying optimal patient panel and scheduling practices; follow-up studies of the impact of such changes on access to care, quality of care, and workforce retention; broader surveys of adverse and near-miss events in primary care settings; and quantifying the downstream costs of delayed or fragmented care due to barriers to comprehensive primary care.

CONCLUSION

It has long been recognized that US primary care is characterized by time scarcity. This paper illuminates the invisible, unpaid, and unsustainable work that physicians are doing to support patient safety and care quality. Considering a physician shortage and burnout crisis, reliance on individual mitigation of systemic time scarcity threatens patient safety. We have highlighted the implications of time scarcity for patient safety and outlined possible responses. Addressing time scarcity in primary care through work design and payment reform has the potential to enhance patient safety and, in turn, reduce PCPs’ moral injury and intention to reduce hours or exit practice. Importantly, time scarcity is not inevitable. Change is possible and urgent.

Supplementary Information

Below is the link to the electronic supplementary material.

Funding

Dr. Sarkar holds current research funding from the National Cancer Institute of the National Institutes of Health, California Healthcare Foundation, the Patient-Centered Outcomes Research Institute, and the Agency for Healthcare Research and Quality. She has received prior grant funding from the Gordon and Betty Moore Foundation, the Blue Shield of California Foundation, HopeLab, the US Food and Drug Administration, and the Commonwealth Fund. She received gift funding from The Doctors Company Foundation. She holds contract funding from InquisitHealth and RecoverX. Dr. Sarkar serves as a scientific/expert advisor for nonprofit organizations HealthTech 4 Medicaid (volunteer) and for HopeLab (volunteer). She is a member of the American Medical Association’s Equity and Innovation Advisory Group (honoraria) and is on the Board of Directors of the Collaborative for Accountability and Improvement (volunteer). She is an advisor for Waymark (shares) and for Ceteri Capital I GP, LLC (shares). She has been a clinical advisor for Omada Health (honoraria), and an advisory board member for Doximity (honoraria, stock). Salary support for Dr. Michelle-Linh Nguyen was provided by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS). Dr. Aoife McDermott was a 2022–23 Commonwealth Fund Harkness Fellow in Health Care Policy and Practice. The views presented here are those of the authors and should not be attributed to the Commonwealth Fund or its directors, officers, or staff.

Data Availability

The dataset analyzed for this study can be made available upon reasonable request to the corresponding author.

Declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.