A measure of a family doctor's work. Part II: drugs, time, charges, morbidity By J.A. Collyer, FCFP To estimate the part of the physician's work which involved prescription drugs, copies of all prescriptions writ¬ ten during the week of Nov. 28, 1972 were kept, with a record of the total number of patients seen during that week. The small numbers made it impos¬ sible to realistically evaluate the groups of drugs prescribed. Furthermore, no record was made of the cost of these drugs, although this is now a matter of great interest to many people. Of the total 89 prescriptions, 65 were a written during 143 office visits rate of prescriptions per office visit of and 24 were written during 68 45% telephone calls. Therefore, the overall rate of prescriptions per total patient contact was 42%. Sixty women and 29 men received prescriptions; this sex ra¬ tio differs slightly from Eimerl11 who reported 31:19. In three Canadian studies, the rate of prescriptions written, calculated against office visits, varies from 45% (present study and Sellers6) to 65% (Garson and Bury1). Another calcula¬ tion can also be made: prescription rate per year per patient at risk. Extrapolating the total prescriptions for one week (89) over a year (4628), I computed that the 2145 registered patients would receive prescriptions at a rate of 2.2 per year. This figure can be com¬ pared with other estimations: Eimerl, 2.6; Scott, 2.5; and Brotherston, 4.I.11 The present study and those by Wolfe and Badgely,2 Johnson12 and Parish13 suggest that 20 to 25% of prescriptions written in general practice are for psychotropic or analgesic drugs. This corresponds to 32% of people seen with psychiatric illness in this study. Antibiotics account for 25 to 30% and contraceptive pills 6 to 7% of prescriptions; 9 to 11 % of prescriptions written are for anti-inflammatory drugs. Overall, fewer drugs were used in this study than in others, with many more
antidepressants. Clinical experience has led me to ask if there may not be a limit to what one person should do in a day if one wishes to maintain the quality of his judgement, instincts, listening ability and physical skills, all of which deteReprint requests for the two parts to Dr. J.A. Collyer, 787 Adelaide St., London 25, Ont.
riorate with fatigue. The life expectancy of doctors does not com¬ pare favourably with that of the ordinary citizen. One wonders whether the somewhat frantic life and long work hours that one hears about have a part in this too-early loss of our doctors. For family doctors, aside from the overall workday, the length of time we spend with pa-
H
Dr. James Collyer collected data on his solo practice in London, Ont. for 1 year. His research culminated in two articles in CMAJ the first of which appeared May 17.
tients must be one measure of our qual¬ ity of care. What is too little time; what is too much? Our patients complain that doctors are in too big a rush. During August and October 1972 and January 1973 I averaged each month 18% of my working time on 32 general assessments at 45 minutes each, 33% of time on 376 office calls
with
patients
with active emotional ill¬
ness.
Table III from part I of the series compares my office visit and housecall times with those reported in other studies. The variations for office visits show the difference between 4 and 12 patients seen in each hour. The difference between the British (initial, follow-up, prenatal, well-baby) times for housecalls and my own 25 at 7 minutes each, 30.5% of time on minutes seems excessive. One explana¬ 84 psychotherapy visits at 29 minutes tion may be that, although my practice each, 6.9% of time on 22 housecalls was limited to a section of the city, it is at 25 minutes each, 3% of time on less compact than the British practices hospital deliveries at 60 minutes each I have seen. and 8.4% of time on other hospital My average time per visit is longer visits at 8 minutes each. These data than in many of the published studies provide an aggregate of 81.5% of time in Canada and shorter than in others. spent in the office, 6.9% on housecalls Question: how much is enough? The answer would appear to be this: and 11.4% at the hospital. Of particular interest is that 30% because of the nature of family prac¬ of my time was spent on psychother¬ tice, where the same patients are seen apy. I averaged a further 16.6% of in repeat visits and many people are my time each month with 84 further seen for brief times such as during patients who had psychiatric problems allergy injections, the average time but on whom I used no psychotherapy. should be between 5 and 10 minutes. Thus 46.6% of my time was spent This same average duration was reCMA JOURNAL/JUNE 7, 1975/VOL. 112 1357
corded in timed visits to consultant out¬
patient
clinics in
Nuffield
a
Hospital
1965
Trust.
study by the
physician's average time per visit appears to result from several fac¬ tors: his experience and skill, his knowl¬ edge of the patient, his dislike of neuro¬ tic patients (shortening the time), the type of problem presented and the Each
treatment undertaken.
For example, the doctor's decision either to dispose of a neurotic patient
quickly (the slamming-door syndrome) or to take 15 to 30 minutes to deal with and relieve the neurotic problem appears to be an expression of his personality and level of training. He may take 5 minutes to do a checkup and limit the examination to recording the blood pressure and listening to the heart sounds; he may spend 15 to 20 minutes for a complete physical exam; he may spend 45 minutes in a com¬ plete assessment. Which he does de¬ pends on the doctor's feelings, his pa¬ tient's wishes, the method of payment, the doctor's concern, his interest in the problem and his ability to organize and control his practice sufficiently well to be able to set time aside and be unhurried. In examples such as these, use of time is undoubtedly one of the im¬ portant factors to be measured in assessing the quality of the family doc¬ tor's practice.
Receipts Fee for service is the basis of pay¬ physicians in Ontario. The On¬ tario Medical Association's fee schedule ment of
raeffflftmiit
ijiiijiiii^
.^^¦ir^feW
$10 for taking 2
or 3 minutes to inject joint with a corticosteroid but to charge $11.50 for 10 minutes' psy¬ chotherapy is still considered excessive. Wolfe and Badgely point out that the family doctors in their group spent 1% of their time in, but received 12% of their income from, surgical work. The fee structure means that a fam¬ ily doctor who sees a high volume of patients will earn more money. Conversely, when he takes time with pa¬ tients reflected for example in his he is charges for psychotherapy penalized by a lower income. At the time of study the insurance plan paid $24 an hour ($11.50 a half hour or part thereof) for psychotherapy; an hour's office visits (at 10 minutes each) would produce $36. The charge for psychotherapy was Rush of lifestyle may contribute to psy¬ made whenever I consciously allowed chosomatic disease epidemic. GP must patients to express emotional distress take time and income loss to treat the that was making them ill. In addition, illnesses. whenever I consciously used my skill to help the patient to acquire insight began in the 1930s as a guide and is into his behaviour or gave guidance on now accepted by the provincial govern¬ ways to overcome psychological illness, ment as the basis of payment for in¬ the service was charged to psychother¬ sured services. apy. Because of the nature of the fam¬ When the schedule was being devel¬ ily doctor's work, where he has an on¬ oped, surgery was in the forefront of going relationship with an ill patient, a medical care, and the men developing few minutes so spent may benefit the the plan had a strong surgical orienta- patient more than an hour with a tion. This bias is reflected in the fee strange doctor. Clyne18 makes this point schedule, which is heavily weighted to¬ particularly well. wards surgical procedures. More than half the schedule is devoted to such Actual earnings work; fees vary according to who does the work, his training and even the Charges for services performed were type of anesthesia and the time of day. recorded by computer for the first 6 The plan doesn't question a charge of months of the study. These data have been used to calculate a typical month's charges (Table IV). Average charge per office visit was $7.26, which at six visits to the hour (the regular appoint¬ ment booking rate) produces an aver¬ age hourly gross earning of $43.56. Six visits to the hour coincides with the 10.8 minutes per office visit reported in part I (Table III) based on stopwatch timing. The average overall charge per service is $7.03. In the year of the study, gross re¬ ceipts were $45 000 and overhead was $16 000. Taking a 222 day year and applying the 7.75 hours worked per gggfjli day, we obtain average gross hourly receipts of $26.74, of which 65%, or $17.38 are actual hourly net earnings. By comparison, Wolfe and Badgely2 reported gross receipts of $70 an hour for surgical consultation in Saskat¬ chewan in 1956. Gross receipts for all Ontario doctors in the study year aver¬ aged $70 000, according to Statistics Canada. The net income of $29 000 re¬ ported above was $5000 less than the average for that year of family physi¬ cians throughout Canada. Traditionally, family physicians, pediatricians and
1358 CMA JOURNAL/JUNE 7, 1975/VOL. 112
a
knee
.
psychiatrists
have the lowest incomes among Canadian physicians.
Morbidity as a measure Studying the doctor's work habits is one way an indirect one of measuring the quality of care. More direct is study of the illnesses of his patients. In this study, every active illness in every patient seen each day, was recorded. This contrasts to "E-book" studies where each new episode of ill¬ ness is usually recorded. I made no attempt to say which of several ill¬ nesses present was of the greatest sig¬ nificance; this often is a matter of opinion. For example, a patient with a duodenal ulcer, anxiety depression, and hypertension had recorded at each visit each illness as long as it was still active. During the study year (originally planned as the first year of an ongoing study) only the major "International Classification of Diseases" groups were punched, using the adaptation of the ICD proposed by Royal College of General Practitioners of Great Britain. All active diagnoses at all doctor-pa¬ tient meetings were recorded. Psychiatric problems accounted for most illnesses, being present in a third of all patients seen. The second largest group is allergic, endocrine, metabolic and nutritional illnesses, being present in more than 14% of patients. This was likely a result of the combination of obesity and allergic rhinitis in the "hay-fever" country of western Ontario. The third major group, prophylactic procedures, reflected the Papanicolaou
W^^i^i^'Mi^^^^^^^^M^^^^
.
otherwise they had no assistance). Their colleagues, McKerracher, Smith, Coburn et al,241 commented in a later pub¬ lication.
McFarlane25 then at McMaster re¬ corded the patients' presenting symp¬ toms and related these to morbidity. He examined the problems of defining family medicine and of recording mor¬ bidity, symptoms and their frequency. He found that respiratory illness was the the most frequent diagnosis
usual result when one measures epi¬ sodes of illness only. The relative place given to psy¬ chiatric illnesses in this study, com¬ pared to the usually reported incidence, deserves comment. It might be helpful to record the basis of the diagnosis. I diagnose psychiatric illness whenever two or more symptoms are found of
anxiety (irritability, edginess, frequent outbursts of anger, difficulty in getting to sleep) or depression (fatigue, loss of energy, feelings of sadness or depres¬ sion, thoughts of life not being worth living, wish for death, thoughts of sui¬ cide, restless sleep, early morning awakening). Of interest is the variation in per¬ centages recorded between just present¬ ing diagnosis and all active diagnoses. Crombie26 quotes C.A.H. Watts as stating that the studies to that date in Great Britain show a consistency of 6.5 to 12.7% of the episodes of illness due to psychiatric illness. Crombie him¬ self reports 7% and goes on to discuss the doctor's tendency to either encour¬ age or discourage patients to come in with such problems. In the major studies discussed earlier, Watts, Cawte and Kuenssberg27 report 1% of all illness seen in family prac¬ tice is psychosis; Shepherd, Cooper, Brown et al28 attributed 14% of all visits to "minor psychiatric illness" and
smears.
Previous studies
The first completed morbidity study in this country20 compared the mor¬ bidity among the descendants of Irish and Welsh immigrants to Newfound¬ land with their counterparts in Ireland and Wales. Next, Ross21 detailed the illnesses in six practices and related these to the services given. The next Canadian study was that of Wolfe, Garson and Bury in Saskatoon in 1965. Fiorini,22 in Ontario, found that 29.3% of the illnesses in his practice were emotional and psychosomatic. Bartel, Waldie and Rix3 compared rural and urban practices in British Columbia and found that psychiatric illness varied between 2.4 and 7.3% and respiratory illness between 10 and 18%. In an unusual study Christ, Christ and Mainprize23 recorded their ex¬ perience over 1 year during which they tried to deal with all psychological ill¬ nesses in an isolated community in Saskatchewan (a psychiatrist visited them, from outside, every 2 weeks;
Dr.
Collyer's practice, located in the basement of a London pharmacy in the northcorner of the city, serves a mixed industrial and residential district. The patients are chiefly middleclass workers. CMA JOURNAL/JUNE 7, 1975/VOL. 112 1359
eastern
New Tofranil-SD tablets of 75mg and 150mg one dose lasts from bedtime to bedtime
Brief Prescribing infomiation Tofrenhl Geigy Antidepressant/Anti-Enuretic
indicatIons
1 Depression: Neurotic or psychotic depressions including: reactive depression, endogenous depression, involutional melancholia, senile depression, the depressive phase of manic-depressive psychosis, depression associated with organic diseases, depression associated with other psychiatric disorders .,i.e.: schizophrenia, alcoholism, mental deficiency) 2 ersisfent functional childhood enuresis
Dosage
The following dosage recommendations should be used as a guide. Depression Except in elderly patients, adolescents or children: one tablet (25 mg) three times daily initially, increased up to six tablets daily, if necessary. Dosage in excess of eight tablets (200 mg) daily is not recommended for office patients. More severe and hospitalized cases may require up to 300 mg daily. In elderly patients and adolescents: 30-40 mg daily, initially, increased by 10 mg daily to a maximum of 100 mg in the elderly. In suitable subjects, the maintenance dose may be administered in a single dose before bedtime. Enuresis For persistent, functional enuresis which has not responded to other forms of management, a therapeutic trial with Tofranil may be considered for children between 5 and 15 years old, who are not mentally defective, and in whom organic causes of enuresis have been excluded. The recommended dosage for such a trial is 10-25 mg one hour before bedtime for children 5 years or over, If there is no response, the dosage may be increased up to 50 mg, in children 12-15 years old. The trial period should be 2-4 weeks. If there is a relapse, the treatment can be repeated but the drug should not be given for more than two months without discontinuing its administration and assessing the need for further drug therapy. Because the margin of safety is lower in children, the recommended dose should not be exceeded and the minimum effective dose should be used at all times. Tofranil is not otherwise recommended in children.
Contraindications
Concurrent use of monoamine oxidase inhibitors is an absolute contraindication. Two weeks should elapse before Tofranil is prescribed for patients who have received MAOI drugs.
Precautions
Utmost caution is recommended when Tofranil is used in patients with corcnary thrombosis, angina pectoris, congestive heart failure, disorders of cardiac rate or rhythm or conduction, prostatic disorders with potential urinary retention, and glaucoma. If any patient develops fever, sore throat, and stomatitis, the drug should be discontinued and a complete differential white cell count performed. As with any drug, Tofranil should not be used during the first trimester of pregnancy unless in the opinion of the prescribing physician, the potential benefits outweigh the possible risks.
Bide effects
Most are related to its anticholinergic action, such as, xerostomia, disturbances of accommodation, tachycardia, constipation and sweating. Some cases of hypotension and changes in atrioventricular conduction time have been reported. Although rare, tremor, skin rashes and blood dyscrasias may occur.
AvaliaHity
Each coral sugar-coated round tablet branded . in white, contains 25 mg imipramine ff01 Geigy Standard. In bottles of 100 and 1,000. Also supplied in 10 mg triangular and 50 mg round, coral sugar-coated tablets branded . in white. Available in bottles of 50 and 100. Also supplied in 75 mg and 150 mg round, coral, sugarcoated tablets branded . in white. Available in bottles of 30 and 500. Full information is available on request.
Geigy Dorval, Quebec H9S1B1
G-4051
another 7% to psychiatrically associated illnesses, making a total of 21%. This total, when related to total visits, reflects the increased consultation rate characteristic of patients with psychiatric illness. Fiorini" in Toronto reported that 29.3% of his diagnoses were psychiatric. Christ, Christ and Mainprize'3 reported that 14% of their practice was devoted to psychiatric illness and added "we like to stress that we did not classify peptic ulcer, asthma, and such like, as psychosomatic illness". Primrose2' described 12.7% of the people in his practice as neurotics. In the introductory chapter to his book he says, "It is generally accepted (Council of College of General Practitioners, report of working party, 1958) that approximately one third of patients seen receiving medical attention . . suffer from illnesses whose origins are psychological." However, Shepherd et al recorded their strong impression that a "small number of chronic neurotic and hypochondriacal patients register disproportionately in the doctor's mind."28 Watts,.' the dean of psychiatrically oriented family doctors, says that Ayd, an American psychiatrist, found only 9.4% (of the depressions he saw in practice) were diagnosed as such in the first instance by family doctors. Watts goes on to show that the depression recognized in the community is but the tip of a hidden iceberg. It seems reasonable to conclude that approximately 10 to 12% of the population could be classified as obviously neurotic. From these people (and the rest of us from time to time) come 10% of the new episodes of illnesses, which require 30% of the family doctor's services and 45% of his time. When one relates these findings to the greater time per visit and increased numbers of visits per episode for psychologically based illnesses and reflects on the low numbers of visits per patient per year (a consultation rate of about 2.5), 1 may have saved time by "taking time" to treat emotional illness. In summary, by spending time in psychotherapy I see these people less often because they recover and do not return as frequently. The purpose of this study was to begin to put together and use these many diverse measurements of a doctor's work. Measurement of morbidity has been far too gross to permit detailed analysis. What is possible is to relate the large diagnostic groups most commonly seen with the number of services done and time spent by the doctor. Similarly, by arbitrarily assigning a number of "skill points" to techniques I use and relating the points to the numbers of these techniques done each month, I measured the relative im-
1360 CMA JOURNAL/JUNE 7, 1975/VOL. 112
portance of my services and techniques to my practice (Table V). By my measuring stick, I calculate delivering a baby and undertaking psychotherapy require an equal amount of skill (4 skill units). Over a month psychotherapy becomes the skill family doctors most require. This study gives a suggested place to start. I hope others will be interested, and in time a broader consensus will lead to a realistic measurement of skills. Such could be reflected in practical ways, such as recognizing the doctor's skills in the fee schedule.
References 1. GARSON JZ, BuRY J: Costs and Organization of Medical Care. Saskatoon Community Clinic, 1969 2. WOLFE S, BADGELY, RF: The family doctor. Milbank Mem Fund Q 50, no. 2, 1972 3. BARTEL GG, WALDIE AC, Rix DB: Rural and urban family practice in BC - a comparison. Can Fain Physician 16: 121, 1970 4. TAYLOR JA: The working hours of a general practitioner. Can Fain Physician 14: 43, 1968 5. COLLYER JA: A family doctor's time. Can Fain Physician 15: 63, 1969 6. SELLERs EM: The influences of group and independent general practice on patient care: a comparative study in Ontario. Can Med Assoc 1 93: 147, 1965 7. Fav J, KuENsssaao EV, McCosMIca JS: Present State and Future Needs of General Practice, second ed. London, Royal College of General Practitioners, 1970 8. HOPKINS P, COoPER B: Psychiatric referral from a general practice. Br I Psychiatry 115: 1163, 1969 9. RAWNSLEY K, LOUDON JB: Factors influencing the referral of patients to psychiatrists by general practitioners. Br I Prey Soc Med 16: 174, 1962 10. WRIGHT HJ: General Practice in Southwest Engiand. London, Royal College of General Practitioners, 1968 11. EIMERL TS: Organized curiosity. I Coll Gen Pract 4: 628, 1961 12. JOHNSON RA: Computer analysis of the complete medical record, Including symptoms and treatment. J R Coll Gen Pract 22: 655, 1972 13. PARISH PA: The prescribing of psychotropic drugs in general practice. I R Coll Gen Pract 21: suppl 4: 1. 1971 14. FRY J, DILLANE JB: Too much work? Proposals based on a review of fifteen years work in practice. Lancet 2: 632, 1964 15. HASLER JC, STEWART TI: The consultation in general practice. J R Coll Gen Pract 16: 31, 1968 16. HoPKINs P: Too much work? Lancet 2: 692, 1964 17. EIMERL TS, PEARSON RJC: Tools for the job. J R Coll Gen Pract 15: 447, 1968 18. CLYNE MB: Thirty-second psychotherapy. Med World (Lond) 100: 9, Jan 1964 19. Canada. Royal Commission on Health Services. Medical manpower in Canada. Ottawa, Queen's Printer, 1964 20. Ross J: A transatlantic morbidity study. Can Fain Physician 15: 13, Sept 1969 21. Ross J: A study of morbidity in family practice. Can Fain Physician 18: 105, 1972 22. FIoRINI GT: Emotional and psychosomatic disorders in family practice. Can Fain Physician 17: 53. Mar 1971 23. CHRIST LW, CinusT E, MAINPRIZE GW: Observations on the psychiatric project at Central Butte, Saskatchewan. I Coll Gen
Pract Can 13: 35, Jan 1967 et al: General-practice psychiatry: two Canadian experiments. Lancet 2: 1005, 1965 25. MCFARLANE AH, O'CONNELL BP: Morbidity in family practice. Can Med Assoc 1 101: 259. 1969 26. CROMBIE DL: Clinical auditing. Personal communication, 1972 27. WArrs CAH, CAwTE EC, KUaNssSERG EV: Survey of mental illness in general practice. Br Med 1 2: 1351, 1964 24. MCKERRACHER DG, SMITH CM, COBURN FE,
28. SHEPHERD M, COOPER B, BROWN AC, et al: Minor mental illness in London: some as-
pects of a general practice survey. Br Med / 2: 1359, 1964 29. PRIMROSE EJR: Psychological illness: a Community Study. London,
Tavistock Publica-
tions, 1962 30. WArrs CAH: Depressive Disorders in the Community. Bristol, J. Wright, 1966
antidepressants. Clinical experience has led me to ask if there may not be a limit to what one person should do in a day if one wishes to maintain the quality of his judgement, instincts, listening ability and physical skills, all of which deteReprint requests for the two parts to Dr. J.A. Collyer, 787 Adelaide St., London 25, Ont.
riorate with fatigue. The life expectancy of doctors does not com¬ pare favourably with that of the ordinary citizen. One wonders whether the somewhat frantic life and long work hours that one hears about have a part in this too-early loss of our doctors. For family doctors, aside from the overall workday, the length of time we spend with pa-
H
Dr. James Collyer collected data on his solo practice in London, Ont. for 1 year. His research culminated in two articles in CMAJ the first of which appeared May 17.
tients must be one measure of our qual¬ ity of care. What is too little time; what is too much? Our patients complain that doctors are in too big a rush. During August and October 1972 and January 1973 I averaged each month 18% of my working time on 32 general assessments at 45 minutes each, 33% of time on 376 office calls
with
patients
with active emotional ill¬
ness.
Table III from part I of the series compares my office visit and housecall times with those reported in other studies. The variations for office visits show the difference between 4 and 12 patients seen in each hour. The difference between the British (initial, follow-up, prenatal, well-baby) times for housecalls and my own 25 at 7 minutes each, 30.5% of time on minutes seems excessive. One explana¬ 84 psychotherapy visits at 29 minutes tion may be that, although my practice each, 6.9% of time on 22 housecalls was limited to a section of the city, it is at 25 minutes each, 3% of time on less compact than the British practices hospital deliveries at 60 minutes each I have seen. and 8.4% of time on other hospital My average time per visit is longer visits at 8 minutes each. These data than in many of the published studies provide an aggregate of 81.5% of time in Canada and shorter than in others. spent in the office, 6.9% on housecalls Question: how much is enough? The answer would appear to be this: and 11.4% at the hospital. Of particular interest is that 30% because of the nature of family prac¬ of my time was spent on psychother¬ tice, where the same patients are seen apy. I averaged a further 16.6% of in repeat visits and many people are my time each month with 84 further seen for brief times such as during patients who had psychiatric problems allergy injections, the average time but on whom I used no psychotherapy. should be between 5 and 10 minutes. Thus 46.6% of my time was spent This same average duration was reCMA JOURNAL/JUNE 7, 1975/VOL. 112 1357
corded in timed visits to consultant out¬
patient
clinics in
Nuffield
a
Hospital
1965
Trust.
study by the
physician's average time per visit appears to result from several fac¬ tors: his experience and skill, his knowl¬ edge of the patient, his dislike of neuro¬ tic patients (shortening the time), the type of problem presented and the Each
treatment undertaken.
For example, the doctor's decision either to dispose of a neurotic patient
quickly (the slamming-door syndrome) or to take 15 to 30 minutes to deal with and relieve the neurotic problem appears to be an expression of his personality and level of training. He may take 5 minutes to do a checkup and limit the examination to recording the blood pressure and listening to the heart sounds; he may spend 15 to 20 minutes for a complete physical exam; he may spend 45 minutes in a com¬ plete assessment. Which he does de¬ pends on the doctor's feelings, his pa¬ tient's wishes, the method of payment, the doctor's concern, his interest in the problem and his ability to organize and control his practice sufficiently well to be able to set time aside and be unhurried. In examples such as these, use of time is undoubtedly one of the im¬ portant factors to be measured in assessing the quality of the family doc¬ tor's practice.
Receipts Fee for service is the basis of pay¬ physicians in Ontario. The On¬ tario Medical Association's fee schedule ment of
raeffflftmiit
ijiiijiiii^
.^^¦ir^feW
$10 for taking 2
or 3 minutes to inject joint with a corticosteroid but to charge $11.50 for 10 minutes' psy¬ chotherapy is still considered excessive. Wolfe and Badgely point out that the family doctors in their group spent 1% of their time in, but received 12% of their income from, surgical work. The fee structure means that a fam¬ ily doctor who sees a high volume of patients will earn more money. Conversely, when he takes time with pa¬ tients reflected for example in his he is charges for psychotherapy penalized by a lower income. At the time of study the insurance plan paid $24 an hour ($11.50 a half hour or part thereof) for psychotherapy; an hour's office visits (at 10 minutes each) would produce $36. The charge for psychotherapy was Rush of lifestyle may contribute to psy¬ made whenever I consciously allowed chosomatic disease epidemic. GP must patients to express emotional distress take time and income loss to treat the that was making them ill. In addition, illnesses. whenever I consciously used my skill to help the patient to acquire insight began in the 1930s as a guide and is into his behaviour or gave guidance on now accepted by the provincial govern¬ ways to overcome psychological illness, ment as the basis of payment for in¬ the service was charged to psychother¬ sured services. apy. Because of the nature of the fam¬ When the schedule was being devel¬ ily doctor's work, where he has an on¬ oped, surgery was in the forefront of going relationship with an ill patient, a medical care, and the men developing few minutes so spent may benefit the the plan had a strong surgical orienta- patient more than an hour with a tion. This bias is reflected in the fee strange doctor. Clyne18 makes this point schedule, which is heavily weighted to¬ particularly well. wards surgical procedures. More than half the schedule is devoted to such Actual earnings work; fees vary according to who does the work, his training and even the Charges for services performed were type of anesthesia and the time of day. recorded by computer for the first 6 The plan doesn't question a charge of months of the study. These data have been used to calculate a typical month's charges (Table IV). Average charge per office visit was $7.26, which at six visits to the hour (the regular appoint¬ ment booking rate) produces an aver¬ age hourly gross earning of $43.56. Six visits to the hour coincides with the 10.8 minutes per office visit reported in part I (Table III) based on stopwatch timing. The average overall charge per service is $7.03. In the year of the study, gross re¬ ceipts were $45 000 and overhead was $16 000. Taking a 222 day year and applying the 7.75 hours worked per gggfjli day, we obtain average gross hourly receipts of $26.74, of which 65%, or $17.38 are actual hourly net earnings. By comparison, Wolfe and Badgely2 reported gross receipts of $70 an hour for surgical consultation in Saskat¬ chewan in 1956. Gross receipts for all Ontario doctors in the study year aver¬ aged $70 000, according to Statistics Canada. The net income of $29 000 re¬ ported above was $5000 less than the average for that year of family physi¬ cians throughout Canada. Traditionally, family physicians, pediatricians and
1358 CMA JOURNAL/JUNE 7, 1975/VOL. 112
a
knee
.
psychiatrists
have the lowest incomes among Canadian physicians.
Morbidity as a measure Studying the doctor's work habits is one way an indirect one of measuring the quality of care. More direct is study of the illnesses of his patients. In this study, every active illness in every patient seen each day, was recorded. This contrasts to "E-book" studies where each new episode of ill¬ ness is usually recorded. I made no attempt to say which of several ill¬ nesses present was of the greatest sig¬ nificance; this often is a matter of opinion. For example, a patient with a duodenal ulcer, anxiety depression, and hypertension had recorded at each visit each illness as long as it was still active. During the study year (originally planned as the first year of an ongoing study) only the major "International Classification of Diseases" groups were punched, using the adaptation of the ICD proposed by Royal College of General Practitioners of Great Britain. All active diagnoses at all doctor-pa¬ tient meetings were recorded. Psychiatric problems accounted for most illnesses, being present in a third of all patients seen. The second largest group is allergic, endocrine, metabolic and nutritional illnesses, being present in more than 14% of patients. This was likely a result of the combination of obesity and allergic rhinitis in the "hay-fever" country of western Ontario. The third major group, prophylactic procedures, reflected the Papanicolaou
W^^i^i^'Mi^^^^^^^^M^^^^
.
otherwise they had no assistance). Their colleagues, McKerracher, Smith, Coburn et al,241 commented in a later pub¬ lication.
McFarlane25 then at McMaster re¬ corded the patients' presenting symp¬ toms and related these to morbidity. He examined the problems of defining family medicine and of recording mor¬ bidity, symptoms and their frequency. He found that respiratory illness was the the most frequent diagnosis
usual result when one measures epi¬ sodes of illness only. The relative place given to psy¬ chiatric illnesses in this study, com¬ pared to the usually reported incidence, deserves comment. It might be helpful to record the basis of the diagnosis. I diagnose psychiatric illness whenever two or more symptoms are found of
anxiety (irritability, edginess, frequent outbursts of anger, difficulty in getting to sleep) or depression (fatigue, loss of energy, feelings of sadness or depres¬ sion, thoughts of life not being worth living, wish for death, thoughts of sui¬ cide, restless sleep, early morning awakening). Of interest is the variation in per¬ centages recorded between just present¬ ing diagnosis and all active diagnoses. Crombie26 quotes C.A.H. Watts as stating that the studies to that date in Great Britain show a consistency of 6.5 to 12.7% of the episodes of illness due to psychiatric illness. Crombie him¬ self reports 7% and goes on to discuss the doctor's tendency to either encour¬ age or discourage patients to come in with such problems. In the major studies discussed earlier, Watts, Cawte and Kuenssberg27 report 1% of all illness seen in family prac¬ tice is psychosis; Shepherd, Cooper, Brown et al28 attributed 14% of all visits to "minor psychiatric illness" and
smears.
Previous studies
The first completed morbidity study in this country20 compared the mor¬ bidity among the descendants of Irish and Welsh immigrants to Newfound¬ land with their counterparts in Ireland and Wales. Next, Ross21 detailed the illnesses in six practices and related these to the services given. The next Canadian study was that of Wolfe, Garson and Bury in Saskatoon in 1965. Fiorini,22 in Ontario, found that 29.3% of the illnesses in his practice were emotional and psychosomatic. Bartel, Waldie and Rix3 compared rural and urban practices in British Columbia and found that psychiatric illness varied between 2.4 and 7.3% and respiratory illness between 10 and 18%. In an unusual study Christ, Christ and Mainprize23 recorded their ex¬ perience over 1 year during which they tried to deal with all psychological ill¬ nesses in an isolated community in Saskatchewan (a psychiatrist visited them, from outside, every 2 weeks;
Dr.
Collyer's practice, located in the basement of a London pharmacy in the northcorner of the city, serves a mixed industrial and residential district. The patients are chiefly middleclass workers. CMA JOURNAL/JUNE 7, 1975/VOL. 112 1359
eastern
New Tofranil-SD tablets of 75mg and 150mg one dose lasts from bedtime to bedtime
Brief Prescribing infomiation Tofrenhl Geigy Antidepressant/Anti-Enuretic
indicatIons
1 Depression: Neurotic or psychotic depressions including: reactive depression, endogenous depression, involutional melancholia, senile depression, the depressive phase of manic-depressive psychosis, depression associated with organic diseases, depression associated with other psychiatric disorders .,i.e.: schizophrenia, alcoholism, mental deficiency) 2 ersisfent functional childhood enuresis
Dosage
The following dosage recommendations should be used as a guide. Depression Except in elderly patients, adolescents or children: one tablet (25 mg) three times daily initially, increased up to six tablets daily, if necessary. Dosage in excess of eight tablets (200 mg) daily is not recommended for office patients. More severe and hospitalized cases may require up to 300 mg daily. In elderly patients and adolescents: 30-40 mg daily, initially, increased by 10 mg daily to a maximum of 100 mg in the elderly. In suitable subjects, the maintenance dose may be administered in a single dose before bedtime. Enuresis For persistent, functional enuresis which has not responded to other forms of management, a therapeutic trial with Tofranil may be considered for children between 5 and 15 years old, who are not mentally defective, and in whom organic causes of enuresis have been excluded. The recommended dosage for such a trial is 10-25 mg one hour before bedtime for children 5 years or over, If there is no response, the dosage may be increased up to 50 mg, in children 12-15 years old. The trial period should be 2-4 weeks. If there is a relapse, the treatment can be repeated but the drug should not be given for more than two months without discontinuing its administration and assessing the need for further drug therapy. Because the margin of safety is lower in children, the recommended dose should not be exceeded and the minimum effective dose should be used at all times. Tofranil is not otherwise recommended in children.
Contraindications
Concurrent use of monoamine oxidase inhibitors is an absolute contraindication. Two weeks should elapse before Tofranil is prescribed for patients who have received MAOI drugs.
Precautions
Utmost caution is recommended when Tofranil is used in patients with corcnary thrombosis, angina pectoris, congestive heart failure, disorders of cardiac rate or rhythm or conduction, prostatic disorders with potential urinary retention, and glaucoma. If any patient develops fever, sore throat, and stomatitis, the drug should be discontinued and a complete differential white cell count performed. As with any drug, Tofranil should not be used during the first trimester of pregnancy unless in the opinion of the prescribing physician, the potential benefits outweigh the possible risks.
Bide effects
Most are related to its anticholinergic action, such as, xerostomia, disturbances of accommodation, tachycardia, constipation and sweating. Some cases of hypotension and changes in atrioventricular conduction time have been reported. Although rare, tremor, skin rashes and blood dyscrasias may occur.
AvaliaHity
Each coral sugar-coated round tablet branded . in white, contains 25 mg imipramine ff01 Geigy Standard. In bottles of 100 and 1,000. Also supplied in 10 mg triangular and 50 mg round, coral sugar-coated tablets branded . in white. Available in bottles of 50 and 100. Also supplied in 75 mg and 150 mg round, coral, sugarcoated tablets branded . in white. Available in bottles of 30 and 500. Full information is available on request.
Geigy Dorval, Quebec H9S1B1
G-4051
another 7% to psychiatrically associated illnesses, making a total of 21%. This total, when related to total visits, reflects the increased consultation rate characteristic of patients with psychiatric illness. Fiorini" in Toronto reported that 29.3% of his diagnoses were psychiatric. Christ, Christ and Mainprize'3 reported that 14% of their practice was devoted to psychiatric illness and added "we like to stress that we did not classify peptic ulcer, asthma, and such like, as psychosomatic illness". Primrose2' described 12.7% of the people in his practice as neurotics. In the introductory chapter to his book he says, "It is generally accepted (Council of College of General Practitioners, report of working party, 1958) that approximately one third of patients seen receiving medical attention . . suffer from illnesses whose origins are psychological." However, Shepherd et al recorded their strong impression that a "small number of chronic neurotic and hypochondriacal patients register disproportionately in the doctor's mind."28 Watts,.' the dean of psychiatrically oriented family doctors, says that Ayd, an American psychiatrist, found only 9.4% (of the depressions he saw in practice) were diagnosed as such in the first instance by family doctors. Watts goes on to show that the depression recognized in the community is but the tip of a hidden iceberg. It seems reasonable to conclude that approximately 10 to 12% of the population could be classified as obviously neurotic. From these people (and the rest of us from time to time) come 10% of the new episodes of illnesses, which require 30% of the family doctor's services and 45% of his time. When one relates these findings to the greater time per visit and increased numbers of visits per episode for psychologically based illnesses and reflects on the low numbers of visits per patient per year (a consultation rate of about 2.5), 1 may have saved time by "taking time" to treat emotional illness. In summary, by spending time in psychotherapy I see these people less often because they recover and do not return as frequently. The purpose of this study was to begin to put together and use these many diverse measurements of a doctor's work. Measurement of morbidity has been far too gross to permit detailed analysis. What is possible is to relate the large diagnostic groups most commonly seen with the number of services done and time spent by the doctor. Similarly, by arbitrarily assigning a number of "skill points" to techniques I use and relating the points to the numbers of these techniques done each month, I measured the relative im-
1360 CMA JOURNAL/JUNE 7, 1975/VOL. 112
portance of my services and techniques to my practice (Table V). By my measuring stick, I calculate delivering a baby and undertaking psychotherapy require an equal amount of skill (4 skill units). Over a month psychotherapy becomes the skill family doctors most require. This study gives a suggested place to start. I hope others will be interested, and in time a broader consensus will lead to a realistic measurement of skills. Such could be reflected in practical ways, such as recognizing the doctor's skills in the fee schedule.
References 1. GARSON JZ, BuRY J: Costs and Organization of Medical Care. Saskatoon Community Clinic, 1969 2. WOLFE S, BADGELY, RF: The family doctor. Milbank Mem Fund Q 50, no. 2, 1972 3. BARTEL GG, WALDIE AC, Rix DB: Rural and urban family practice in BC - a comparison. Can Fain Physician 16: 121, 1970 4. TAYLOR JA: The working hours of a general practitioner. Can Fain Physician 14: 43, 1968 5. COLLYER JA: A family doctor's time. Can Fain Physician 15: 63, 1969 6. SELLERs EM: The influences of group and independent general practice on patient care: a comparative study in Ontario. Can Med Assoc 1 93: 147, 1965 7. Fav J, KuENsssaao EV, McCosMIca JS: Present State and Future Needs of General Practice, second ed. London, Royal College of General Practitioners, 1970 8. HOPKINS P, COoPER B: Psychiatric referral from a general practice. Br I Psychiatry 115: 1163, 1969 9. RAWNSLEY K, LOUDON JB: Factors influencing the referral of patients to psychiatrists by general practitioners. Br I Prey Soc Med 16: 174, 1962 10. WRIGHT HJ: General Practice in Southwest Engiand. London, Royal College of General Practitioners, 1968 11. EIMERL TS: Organized curiosity. I Coll Gen Pract 4: 628, 1961 12. JOHNSON RA: Computer analysis of the complete medical record, Including symptoms and treatment. J R Coll Gen Pract 22: 655, 1972 13. PARISH PA: The prescribing of psychotropic drugs in general practice. I R Coll Gen Pract 21: suppl 4: 1. 1971 14. FRY J, DILLANE JB: Too much work? Proposals based on a review of fifteen years work in practice. Lancet 2: 632, 1964 15. HASLER JC, STEWART TI: The consultation in general practice. J R Coll Gen Pract 16: 31, 1968 16. HoPKINs P: Too much work? Lancet 2: 692, 1964 17. EIMERL TS, PEARSON RJC: Tools for the job. J R Coll Gen Pract 15: 447, 1968 18. CLYNE MB: Thirty-second psychotherapy. Med World (Lond) 100: 9, Jan 1964 19. Canada. Royal Commission on Health Services. Medical manpower in Canada. Ottawa, Queen's Printer, 1964 20. Ross J: A transatlantic morbidity study. Can Fain Physician 15: 13, Sept 1969 21. Ross J: A study of morbidity in family practice. Can Fain Physician 18: 105, 1972 22. FIoRINI GT: Emotional and psychosomatic disorders in family practice. Can Fain Physician 17: 53. Mar 1971 23. CHRIST LW, CinusT E, MAINPRIZE GW: Observations on the psychiatric project at Central Butte, Saskatchewan. I Coll Gen
Pract Can 13: 35, Jan 1967 et al: General-practice psychiatry: two Canadian experiments. Lancet 2: 1005, 1965 25. MCFARLANE AH, O'CONNELL BP: Morbidity in family practice. Can Med Assoc 1 101: 259. 1969 26. CROMBIE DL: Clinical auditing. Personal communication, 1972 27. WArrs CAH, CAwTE EC, KUaNssSERG EV: Survey of mental illness in general practice. Br Med 1 2: 1351, 1964 24. MCKERRACHER DG, SMITH CM, COBURN FE,
28. SHEPHERD M, COOPER B, BROWN AC, et al: Minor mental illness in London: some as-
pects of a general practice survey. Br Med / 2: 1359, 1964 29. PRIMROSE EJR: Psychological illness: a Community Study. London,
Tavistock Publica-
tions, 1962 30. WArrs CAH: Depressive Disorders in the Community. Bristol, J. Wright, 1966
