Burden of administrative responsibilities in primary care

Abstract

Objective

To describe family physicians’ experiences of administrative burden in practice.

Design

Qualitative study using constructivist grounded theory.

Setting

Ontario.

Participants

Family physicians.

Method

In-depth virtual interviews with family physicians practising in Ontario who completed postgraduate training between 2017 and 2022.

Main findings

A total of 36 family physicians were interviewed. Without external prompting, all participants raised the issue of administrative burden, offering specific contextual factors contributing to their administrative burden. These included volume of paperwork, inbox management, and lack of compensation for the hours of administrative tasks performed. In addition to these contextual factors, 2 main themes were identified: the first revealed the impact of administrative burden on both the time available for patient care and physicians’ well-being. This latter issue was exacerbated by deteriorating relationships with specialist colleagues, contributing to family physicians’ administrative burden and burnout. A lack of exposure to the volume of administrative duties during training added to this issue. The second theme described participants’ personal strategies (eg, creating flex time, setting boundaries) and system solutions (eg, need for compensation for administrative time, funding to increase clinic staff, and interventions by regulatory bodies) to address administrative burden.

Conclusion

Administrative burden negatively impacts physician well-being and reduces time for direct patient care. These findings highlight 2 new sources contributing to administrative burden: deteriorating relationships between family physicians and specialist colleagues and a lack of exposure to managing administrative responsibilities during medical training. Study findings provide personal strategies and system solutions to guide practitioners, policy-makers, and educators.

For more than 2 decades, administrative burden has been documented as a key challenge for family physicians (FPs).^1-6 Initially, electronic medical records (EMRs) were the most documented source of administrative burden.^7-8 Now ubiquitous in family practice,⁹ EMRs have become more multipurpose, with an inbox receiving laboratory reports, imaging results, and email, and sometimes including a patient portal.^6,10-12 Administrative tasks also include paperwork such as insurance forms and sick notes, coordinating referrals, and tests or treatments. Time spent on administrative tasks has accelerated and has been propelled by virtual care during the COVID-19 pandemic.^6,12 In 2023, the Canadian Federation of Independent Business reported that FPs are spending 18.5 million hours per year on administrative tasks, equalling 55.6 million annual patient visits,¹³ and a survey from the Ontario College of Family Physicians found that FPs were spending approximately 19.1 hours per week (40% of their time) on administrative tasks.¹⁴

Administrative burden has been linked with FP burnout—frequently noted as exhaustion.^8,15-17 This is not surprising given the substantial increase in hours devoted to administrative tasks, which diminishes time spent providing direct patient care.^17-19 This issue garnered recent media attention²⁰ and motivated several professional organizations and regulatory bodies to take action, making concrete recommendations to address this problem.^14,21,22

There is growing concern regarding the number of FPs choosing not to practise comprehensive care because of the increasing administrative burden. Recent graduates entering the practice of family medicine are navigating the challenge of administrative tasks. This paper describes family medicine graduates’ experiences with administrative tasks and their proposed coping strategies and solutions to alleviate administrative burden.

METHODS

We used a constructivist grounded theory (CGT) approach, a qualitative methodology used to study social processes, especially in health and health care.²³ CGT helps to explore and understand processes or actions emerging from data²³ that offer a deeper understanding of the phenomena under examination. This study is part of a larger project examining factors influencing why new family medicine graduates may or may not practise comprehensive care.

Participants and recruitment

We selected a purposive sample of FPs practising family medicine in Ontario who completed postgraduate training at 1 of the 6 residency programs in the province between 2017 and 2022. Those expressing interest were contacted by the research assistant (C.G.), who sent them a letter of information and consent form and set up a convenient interview time. At the completion of the interview, participants were sent an electronic gift card as compensation.

Data collection

Two authors (J.B.B., S.B.) conducted semistructured individual interviews via Western University’s (located in London, Ont) Zoom videoconferencing software from December 2022 to April 2023. Interviews lasted approximately 45 minutes each and were audiorecorded and transcribed verbatim by a professional transcription service. Our interview guide contained a range of open-ended questions with accompanying prompts to elicit participants’ ideas and perceptions about the challenges faced in their daily family practice.

Analysis

Four members of the research team (J.B.B., C.T., S.B., C.G.) conducted the analysis iteratively and concurrently with the data collection.²³ We first coded each transcript independently line by line to identify key concepts and ideas. Next, we conducted focused coding, consolidating codes and deciding which codes best reflected the data. We used constant comparison analysis to examine the data within and across the interviews.²³ In the final analysis stage, we employed theoretical coding to determine the intersections across the main themes. We then shared the themes and exemplar quotes with the entire research team for additional consolidation. We used NVivo to help organize the data. Upon reaching data sufficiency, we felt confident in our interpretation of the data.^24-26 We enhanced trustworthiness by audiorecording and transcribing the interviews verbatim, completing field notes after each interview, and conducting individual and team analysis. Throughout the data collection and analysis, we used reflexivity to consider how our disciplinary perspectives (epidemiology, social work, sociology, family medicine, health sciences) could influence the research process.^23,27,28 This study received ethics approval from the Western University Health Sciences Research Ethics Board (REB#122072).

FINDINGS

We interviewed 36 participants, 27 of whom identified as female and 9 as male, reflecting all 6 family medicine residency programs in Ontario. There was some variation in ethnicity. The average age was 33 years, and participants practised in both urban and rural locations. Twenty-two were providing office-based comprehensive care and 14 were doing a hybrid model (eg, 3 days of office-based comprehensive care and 2 days in areas of interest such as palliative care or hospitalist work).

Describing administrative burden

Without external prompting, all participants raised the issue of administrative burden. They articulated specific contextual factors contributing to their administrative burden. Participants described administrative burden as both the volume of paperwork and the “never-ending workload” (P07) of managing their inbox: “Paperwork is a huge issue. Insurance forms, work notes, just there seems to be paperwork for everything. And I’ve only been working since 2018 and I’ve noticed definitely an increase in that 5-year period” (P23).

Participants strongly emphasized the lack of compensation for the many hours of administrative tasks they performed:

It’s essentially volunteering your time. And I love the reward of being able to help patients and that will never change. But it just becomes quite burdensome when every single day you’re spending 1, 2, 3 hours, after hours, working on things. (P19)

Some participants suggested the increasing administrative burden was a deterrent to practising comprehensive family medicine: “For a lot of us from what I kind of see and experience is this notion of the large amounts of unpaid administrative time is really a turnoff for folks who might otherwise consider family medicine” (P38).

In addition to these contextual factors, the analysis revealed 2 other themes: the impact of administrative burden on both the time available for patient care and the physician’s professional and personal well-being; and personal strategies and system solutions to address administrative burden.

Impact on patient care and physician well-being

A major concern repeatedly expressed by participants was how administrative work “takes away from patient care” (P18). A participant remarked that “the more time we spend doing paperwork … the less time we can spend engaging with patients” (P07).

Participants experienced administrative burden as impacting their emotional well-being and work satisfaction. “It’s my least favorite part of medicine, hands down. I do a lot of it [paperwork]. I hate it” (P17). They described feeling frustrated and overwhelmed. “The unexpected hurdles that you have to jump through just take up so much of your time and it’s frustrating” (P06). Their core motivation for becoming a family physician was diminished by the feeling that “I wasn’t trained to push paper. The more paper that you give me to do, [the more] you’re reducing clinical hours I can see patients” (P33).

Participants perceived administrative burden as contributing to burnout and declining joy in practising comprehensive care: “And it [administrative burden] contributes to burnout because you’re spending less of your time on actual patient-facing care” (P05).

Participants described feeling that their work was devalued and hence “the burnout’s more noticeable and upsetting” (P33). Many participants commented on their relationships with specialists as playing a role in administrative burden and burnout. As 1 participant explained:

There is so much punting of scut-work. They’re [specialists] telling me to do part of their work. The amount of time I waste redirecting referrals is embarrassing. I would say these are the 2 most eye-opening things that I have noticed that are definitely going to contribute to burnout. (P20)

Further to the difficulty in securing referrals for their patients, another participant noted after sending numerous referrals to specialists, “the trees wasted, staff time wasted. And then you’ll do all that and they’ll say, ‘I’m sorry but we’ll decline your referral’ … this is where the burnout happens, and [you] just want to smash your head against a wall” (P32).

Some participants noted how their lack of exposure to the volume of administrative duties in practice, during both medical school and residency, contributed to their administrative burden and potential burnout. “One of the biggest challenges I have had so far has definitely been the administrative burden that comes with inbox management and is something that as a medical student we were definitely protected from” (P06). Furthermore, during residency training, some participants noted how they did not acquire the necessary skill set to manage their inbox and felt unprepared. “The time it takes that you’re doing inbox management or filling out referrals, that is something we are not exposed to” (P15). Another participant described how, in their first year of practice, “you feel burned out when you’re learning things you haven’t learned before, like how to manage an inbox of 80 messages on a Friday afternoon. It’s not a skill set you learned in residency, unfortunately” (P01).

Personal strategies and system solutions

Participants offered strategies and solutions to address administrative burden at both personal and system levels. On a personal level, they proposed creating “flex time to catch up on things” (P16) such as administrative tasks. A participant described their approach: “Whereas some of the days I do half-day clinic, and I find that a little bit more manageable because I still go in for the full day but at least I can use my non-clinic half day to catch up on all the stuff and leave at a reasonable time” (P01). Setting boundaries was a strategy to prevent administrative burden from bleeding into personal time: “I come in early. I work through lunch, and I work through the end of the day, and anything that doesn’t get done is tomorrow. And not working evenings and weekends … has been very helpful” (P17). However, for others, the volume of the work often eroded this solution: “I have 1 day off. I find I’m still working—doing my inbox” (P36). Setting boundaries could be challenging, as 1 participant noted:

It [the inbox] owns you. I’m of the type of personality where it has to be clean. When something rolls into my inbox it doesn’t matter if I’m on my way for my family vacation, I’m looking at it and I’m calling my patient from my car. (P25)

At the system level, participants underscored the need for compensation for administrative time: “Having some sort of compensation for that work, I think definitely would help, because nobody wants to be working for free” (P15). Participants noted that the need for funding went beyond the physician to include other team members: “Put the funding where it matters. Help us get access to the resources we need and to the personnel we need” (P27). Participants emphasized the need for trained clinic staff (eg, physician assistants, nurse practitioners) to help “declutter the inbox a little bit, things that the MD doesn’t necessarily have to follow up” (P35). From the participants’ perspectives, having more clinically trained staff to triage and manage some of the administrative workload, including referrals, would allow physicians to be “available for more clinical tasks and the sustainability factor of the comprehensive practice would also increase” (P07).

Another system-level solution suggested by participants was that “governing bodies [should] set guidelines for what is appropriate to dump on family medicine and what is not, and for specialists to follow up on their own tests and write their own prescriptions” (P17). Other participants were more emphatic, recommending that regulatory bodies intervene at the system level: “There needs to be something from the Ontario Medical Association or CPSO [College of Physicians and Surgeons of Ontario] just about specialists following through with their suggestions and not getting the family doctor to do all the work” (P23).

DISCUSSION

Our research findings offer valuable insights into the perspectives of newly graduated FPs and the challenges they face in managing administrative tasks. In particular, the findings highlight 2 new sources contributing to administrative burden: the deteriorating relationships between FPs and their specialist colleagues and the lack of exposure to managing administrative responsibilities during medical school and residency training. While several of the personal strategies and system solutions proposed by our participants have been documented in the literature,^{5,10,12,29-31} our study highlights the personal responsibility assumed by many of our participants in seeking strategies to reduce the administrative burden they experience in day-to-day practice. This included creating specific times in their schedule to complete administrative tasks and setting boundaries to prevent these tasks from spilling over into what some authors have described as “pajama time.”^5,32

The amount of time spent on administrative responsibilities highlighted by our participants supports the current literature,^5,6,14,33 which includes studies indicating an increase in this burden over time.⁶ Front and centre were their deep concerns about how the volume of administrative tasks were taking away from time critically needed to provide patient care—an issue reported repeatedly in the literature.^4,12,17,34 Consistent with other publications,^15,16 participants articulated that the inability to fulfill their primary motivation for becoming a physician impacted their emotional well-being and work satisfaction. Of note, our participants were forthright in describing how the relegation of administrative tasks from specialists exacerbated the deteriorating relationships with their specialist colleagues, leaving participants feeling undervalued, a finding not present in the existing literature. This is an important finding but only reflects 1 side of the relationship and warrants further research to support the rebuilding of the family physician–specialist relationship.

Another novel finding was participants’ beliefs they were sheltered from administrative burden during their training. While participants did not specifically provide suggestions about changes to medical school or residency training, their concerns imply that early exposure, mentorship, and opportunities to develop administrative service skills are essential.

Participants did not mention the use of artificial intelligence (AI), such as scribes, as a strategy.³⁵ This lack of comment on AI may be due to the time frame in which the interviews were conducted and warrants further research.

Team-based care is frequently noted in the literature as a system-level solution to reduce the administrative burden experienced by physicians.^{5,6,10,12,30,31,36,37} While our participants viewed team-based care as the optimal solution, a more achievable approach appeared to be delegating administrative tasks to other staff.^18,19 Other system solutions articulated by participants have had uptake recently, such as improved compensation for performing administrative tasks. Beginning in 2023, several provinces, including British Columbia, Saskatchewan, Manitoba, and Nova Scotia, have instituted agreements for improving compensation for FPs.³³ In particular, British Columbia offers equal time payment for completion of administrative tasks.³⁸ Furthermore, regulatory and governing bodies have released guidelines to clarify the administrative obligations of FPs and specialists,³⁷ as well as resources to help FPs communicate with specialists when such work is inappropriately delegated.¹⁴

Limitations

Participants were recruited from 1 province (Ontario), so findings may not be generalizable to other jurisdictions. The data were collected from December 2022 to March 2023 and, since that time, some of the solutions recommended by participants have been instituted in specific Canadian provinces. However, it is too early to determine if these interventions have made a substantial difference in administrative burden. Given the focus of our broader research study on the factors that influence recent family medicine graduates’ decisions to practise comprehensive care, we may have inadvertently recruited a biased sample, with most of our participants providing some degree of comprehensive care.

Conclusion

Administrative burden negatively impacts physician well-being and reduces time for direct patient care. These findings highlight 2 new sources contributing to administrative burden: deteriorating relationships between FPs and specialist colleagues and a lack of exposure to managing administrative responsibilities during medical training. This study provides personal strategies and system solutions to guide practitioners, policy-makers, and educators.