Contribution of a Nurse Clinician to Office Practice Productivity: Comparison of Two Solo Primary Care Practices
by Geraldine Holmes, George Livingston, and Elizabeth Mills A comparison of two solo primary care practices with similar patient populations reveals a significant difference in productivity. A nurse clinician was employed in the more productive practice. She independently managed 1,848 patient visits a year that would otherwise have required the time and attention of a physician. She contributed to the productivity of the physician by performing some tasks he would normally have performed during visits they managed jointly. It was primarily because of the assistance he received from the nurse clinician that the physician in practice II was 12 percent more productive than the physician in practice I. The nurse clinician and physician mwnaged 31 percent more patient visits during a standard day than the physician in practice I, or a difference of 2,856 patient visits a year. This annual difference is based on a work schedule that could be matched in other practices: an eight-hour day and a 240-day work year. Despite the widespread interest that has been evidenced in the training and utilization of physician extenders, there are relatively few published studies dealing with the impact of physician extenders on the productivity of office practices. These studies include a 1972 study by Pondy et al. [1] on the number of patient visits managed in four private practices and five institutional settings before and after the introduction of a physician assistant. In the private settings, Pondy et al. found that the patient load increased by 79 percent in a solo practice and 36 percent in a group practice after the addition of a physician assistant. In 1971 R. A. Smith et al. [2] reported on a study comparing the number of patient visits managed in nine practices employing MEDEX and a matched group of practices that did not. In a three-year study published in 1974, Research supported by the Kansas Regional Medical Program. An earlier version of this article was presented at a meeting of the National Association of Regional Medical Programs in San Diego, Sept. 24, 1975. Address communications and requests for reprints to Geraldine C. Holmes, Ph.D., University of Kansas Medical Center, 39th and Rainbow Boulevard, Kansas City, KS 66103.
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Holmes et al.
Spitzer et al. [3] studied the productivity of nurse practitioners in a group family practice setting. In these studies productivity increases attributed to the addition of a physician extender ranged from 13.5 to 62.5 percent. K. Smith et al. [4] developed a model for the utilization of a physician assistant with which he demonstrated theoretical increases of up to 74 percent in patient visits, given optimal conditions for promoting this type of productivity. One physician [5] reported that he increased his productivity by 300 to 400 percent after the introduction of several innovations, including the employment of six nurse practitioners. There have been several studies to determine the profit to the physicians who employ pediatric nurse practitioners [6-8], and one study has examined the range of profit to physicians who employ MEDEX [9]. The profit to employers in these studies ranged from $2,500 to $39,210 per year. These findings suggest increased productivity in these practices but not its extent. Because of the limited data available nationally on the productivity of physician extenders and a desire to learn more about the impact of nurse clinicians on the availability of primary care services in Kansas, a series of productivity case studies was initiated in the summer of 1974. In the case study reported here, productivity was assessed in two solophysician practices, one with only a nurse to assist the physician (practice I) and the other with a nurse clinician in addition to the registered nurse (practice II). The nurse clinician was a graduate of the nurse clinician training program at Wichita State University, which is designed to train experienced registered nurses for expanded roles in primary care settings. The program consists of a two-month didactic and clinical experience in Wichita followed by a tenmonth preceptorship with a practicing physician. The nurse clinician had passed examinations related to the tasks she performed in the practice, and she had been certified by the physician who served as her preceptor in the nurse clinician training program as proficient in clinical skills encompassed in her role. No effort was made to evaluate the quality of care provided to patients on the basis of processes or outcomes of care. However, the professionals observed were fully qualified to provide services to patients within their respective role definitions and were attempting to provide their patients the best care possible. The comparisons that will be emphasized in this article are (1) the different roles of the nurse in practice I and the nurse clinician in practice II, (2) the types of patient services each professional provides, and (3) the productivity of each practice, measured in terms of number of patient visits processed during a standard time period.
Comparability of the Practices and Patient Populations The two practices were similar in the distribution of patient problems presented and in the demographic, socioeconomic, and racial characteristics of the patient populations served. Each physician had been in private, solo
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general practice in his community for approximately 25 years. Patient demand on each practice was moderately heavy, and personnel in the practices were seldom idle. Practice I was located in a small southwestern Kansas town, and practice II was in a suburb of Kansas City. As far as could be ascertained, the only significant difference between the practices was that practice I employed only a nurse to assist the physician, whereas practice II employed both a registered nurse and a nurse clinician. Practice
Practice II
I I I PROBLEMS I 18.1 _ Respiratory 10.1 Circulatory 9 Accidents 9 Skin Mental Digestive Nervous system & sense organs 3.2 Genito-urinary 3.2 Infective & parasitic 2.4 Complications of pregnancy 2.2 Endocrine, nutritional & metabolic n Musculoskeletal Blood & blood-forming organs Malignancies Symptoms & ill-defined conditions 6. WELL-CARE REQUESTS 1.8 General examinations Limited examinations 2.2* Pre/Postnatal examinations . 11.22 Special examinations Preventive care
l I
4
4
6.1 4.4
1.8s 1.8
30 25
I
1
20
15
4.7
2.5
0 5 10 15 10 5 Percent of practice load
20 25 30
Percent distribution of problems presented and well-care requests made in each practice (percentages do not sum to 100 because of rounding error). Special examinations include insurance physicals, ICC physicals, and other types of school and work physical examinations. Preventive care consisted primarily of vaccinations.
The distribution of patient problems and well-care services managed during the data collection periods of this study are shown in the accompanying figure. The only notable differences between these distributions are the larger proportion of respiratory conditions seen in practice II and the greater number of specialized types of physical examinations performed in practice I. In practice I, 22 percent of all requests were for well-care services, 59 percent involved acute problems, and 19 percent involved chronic illness. In practice II, the distribution was 10 percent well care, 65 percent acute problems, and 25 percent chronic illness. In both practices about 55 percent of the problems
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Holmes et al.
presented were new conditions and 45 percent were previously evaluated illnesses. The patient populations served by both practices were predominantly white, middle and working class, and were evenly divided by sex. About 28 percent of the patients were less than 20 years old, 39 percent were between 20 and 49 years old, and 33 percent were over 50. Published materials provide extensive documentation of variations in primary care practices, with and without physician extenders, and these variations are accompanied by great differences in practice productivity. In published reports patient visits average from 8 min to 15 min, with a range from less than 1 min to more than 60 min. The average number of patient visits managed in private practices ranges from 20 to 50 daily. Thirty-five patient visits per day is the most frequently reported average for primary care rural solo practitioners. Since both practices in the present study were more productive than the average solo primary care practice, differences in productivity between the two practices were not likely due to physician slowness or inadequate patient flow. The two practices are similar in content to a majority of primary care practices in which the nature and distribution of patient problems have been documented (bibliography available from first author).
Methods Two health-care researchers collected data in each practice for 12 consecutive workdays. The method involved timing all office activities of the physicians, the nurse clinician, and the nurse and coding the data in predetermined categories. Information was also collected daily on each professional's work-related activities outside the office, based on the professional's verbal report. In addition, standard data were collected on the management and organizational aspects of each practice. Prior to the initiation of data collection, the two researchers were trained as observers and data recorders and a number of other tasks were completed. Forms were developed for recording data on the way in which professionals were spending their time, and initial forms were tested in a medical practice. The observers practiced and refined their data-collection skills as they pretested the data-collection instruments in role-playing sessions and in recording data from filmed office visits. After pretesting, forms were revised to provide for accuracy and ease of data recording and to include all relevant activities. A number of modifications in data-collection procedures were also made to deal with unanticipated events such as the simultaneous occurrence of activities (e.g., the physician providing patient education while conducting a physical examination or completing a procedure, or the physician seeing two members of the same family together). Timing of activities was initiated when the professionals first arrived in the office and continued through the entire working day. For each person
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observed, two distinct types of activities were timed and recorded: (1) direct patient contact activities that occurred during patient visits and (2) other activities that took place outside of patient visits. All services provided during face-to-face contact with an individual patient on a given day were counted as a single patient visit. Each patient visit was identified by age and sex of patient, by type of visit, and by nature of problem presented. The "type of visit" identified a visit as an initial visit for a problem, a return visit for a problem, a return visit for a procedure, or a well-care visit. Problems were coded in one of 16 general and 103 specific categories based on the Eighth Revision, International Classification of Diseases [10]. Observers obtained information about diagnoses either during or after the visit. The types of patient visit activities that were separately recorded for each professional were as follows: * Conversation. Time spent in conversation that may have served to establish rapport but that was clearly outside the category of taking health history or determining the health status of the patient. * History. Time spent in conversation that could be considered useful in determining the physical, emotional, or mental health of the patient. * Physical examination. Time spent in visual or tactile examination of the patient or in taking standard measures such as height, weight, pulse, temperature, or blood pressure. * Special tests and measures. Time spent performing tests such as visual acuity, audiometry, tonometry, throat cultures, ECG, or drawing blood. * Charting. Time spent reading or recording in the patient's chart, writing prescriptions or instructions for the patient, or reviewing laboratory or EKG results. * Procedures. Time spent in activities that had a treatment orientation such as excising growths, suturing, bandaging wounds, applying casts, administering ultrasound therapy, or giving injections. * Education and counseling. Time spent giving the patient advice, information, or instruction. * Oth-er. Time spent in any activity not classifiable elsewhere. This category included time spent preparing the patient or equipment needed for an examination or time spent consulting with a colleague. Monitored activities not connected with patient visits included patient and nonpatient telephone calls, reading charts and laboratory and x-ray results, reading office correspondence or educational material, writing in patient charts, filling out insurance forms, working on office administrative matters or writing professional papers, consulting with office staff, conversing socially with staff or patients, performing laboratory tests, preparing equipment and rooms, dispensing medication, conversing with the observer, waiting for patients or colleagues, and taking breaks. Each of these activities was coded during data-collection periods in behavior-specific categories that facilitated observation and timing. They were regrouped into functional categories in the sub-
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sequent data analyses (e.g., telephone calls, writing time, and reading time that dealt with office administration were all included in the functional time and activity category, "office administration"). In order to minimize bias and error, observers in each practice alternated in observing the physician, nurse, and/or nurse clinician. During observation periods, they periodically reviewed standardized data-collection procedures and collaborated whenever a question arose about classifying activities. The observers attempted to be as unobtrusive as possible during the course of data collection. If they were introduced to patients or otherwise involved in patient visit activities, the elapsed time was coded and recorded separately. The observers were asked, on a few occasions, to step out of the examination room for part or all of a patient visit. These visits were included in analyses concerned with the number of patients seen and the total time spent in patient visits, but they were excluded from analyses of activities occurring during patient visits. In each practice the reasons for the study and the observation methods to be employed were explained in advance to the physician, nurse, and/or nurse clinician, who participated out of concern for the objectives of the research and received no payment for their cooperation.
Results Duties of the Nurse Clinician The nurse clinician's primary responsibilities involved managing selected types of patient visits independently. She managed by herself patients with uncomplicated upper respiratory infections, monitored patients with chronic disorders such as hypertension and obesity, and performed physical examinations for well-care visits. She screened and made initial assessments of patients and collaborated with the physician in visits that were too complex for her to handle alone. She took Papanicolaou smears, removed simple growths, inserted catheters, and took throat cultures. (Interviews revealed that the nurse clinician sometimes performed pelvic examinations, sutured wounds, and removed casts, but these activities were not observed during the period of this study.) In addition, the nurse clinician handled most phone calls from patients and had the primary responsibility to phone laboratory results to patients and drug prescriptions to pharmacies. She performed some routine nursing tasks. For example, she assisted the physician during some examinations and procedures, gave injections, and performed urinalysis and hemoglobin tests. She also engaged in patient education or counseling in most patient visits in which she was involved. In visits managed alone, the nurse clinician provided all of the services required for the care of the problems presented. She consulted with the physician as necessary either during the visit or at the conclusion of the day. If the nurse clinician felt any reservation about managing a visit, she referred the patient to the physician.
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Table 1. Distribution of Patient Visit Time in Practice I Times are in minutes and are averages based on the number of visits in parentheses. Mean times with the same superscript are significantly different at p = 0.06 or better, based on a median-split chi-square test. Statistical comparisons between professionals were not made. Patient visit activity All activities ....................... Conversation ....................... History ............................ Physical examination ........ ........ Special tests ....................... Charting .......................... Procedures ......................... Patient education/counseling ..... .... Other ............................. Time with observer ......... ........
Nurse visits Physician visits IndeWith With Independent physician pendent nurse (N = 51) (N = 53) (N = 301) (N = 53)
2.80' 0.55 0 0.04 0.15 0 1.68 0.20 0.16 0.02
11.28' 0.69 0.13 0.41 0.33 0.02 8.23 0.68 0.79 0
7.84 1.09 1.29b 1.66c 0.12 0.47 0.15 2.77 0.14 0.15
9.11 1.77 0.72b 1.22c 0.27 0.04 2.36 2.03 0.38 0.32
During the observation period, the average time the nurse clinician spent with a patient was about 10 min, whether she handled the entire visit herself or referred the patient. Although the difference between the average time she spent in shared and independently managed visits was not significant, the distribution of her time within visits was different when the physician also saw the patient. In visits she managed independently, she spent a greater proportion of her time in examining the patient, performing special tests, Table 2. Distribution of Patient Visit Time in Practice 11 Times are in minutes and are averages based on the number of visits in parentheses. Mean times with the same superscript are significantly different at p = 0.06 or better, based on a median-split chi-square test. Statistical comparisons between professionals were not made. Nurse clinician visits
Patient visit activity
All activities ...................... Conversation ...................... History ........................... Physical examination ........ ....... Special tests ....................... Charting .......................... Procedures ........................ Patient education/counseling ........ Other ............................ Time with observer ................
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Inde-
pendent (N =78) 10.39 0.09 1.43"
2.30° 1.72f 1.489 0.41 2.52h 0.39 0.05
Physician visits
With
Inde-
10.18 0.10 3.23"
5.59 0.34 0.40' 1.27 0.05 0.87 0.40 2.10 0.09 0.07
physician pendent (N = 143) (N =220)
1.30'
1.12f 1.289 0.56 1.09h 1.45 0.05
With
cliniciun clnician 6.88 0.34 0.75' 1.87 0.04 0.83 0.53 2.22 0.21 0.09
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Holmes et al.
charting, and in patient education and counseling. In visits she managed with the physician, she invested more time in taking the patient's history. These differences are shown in Tables 1 and 2. A comparison of patient visits managed independently by the nurse clinician with those managed independently by the physicians in the two practices shows that she spent less time in conversation with patients than either physician, but more time in most other aspects of the patient visit. She spent about the same amount of time in performing procedures and in patient education as either physician. On the average, she invested about 21/2 min more in a visit than physician I and almost 5 min more than physician II. The nurse clinician alone managed 35 percent of all patients directed to her by the receptionist. She spent 48 percent of her workday seeing patients in the office, 15 percent handling telephone calls from patients, 9 percent charting, and 6 percent making patient-related phone calls. The remainder of her day was spent in transit and other activities. In Table 3 the division of her workday is compared to the average day of the physician in the same practice as well as the physician and nurse in practice I.
Duties of the Nurse The nurse in practice I was responsible for the performance of routine nursing tasks, bookkeeping, and office maintenance. She provided some Table 3. Composition of Workdays in the Two Practices Times are rounded to the nearest minute. To make the distributions comparable, the times are based on a projected 8-hr workday. The actual average times each professional worked in the office per full workday were: practice I nurse, 9.5 hr; practice I physician, 6.5 hr; practice II nurse clinician, 7.5 hr; practice II physician 5.8 hr. The times and percentages shown do not sum exactly to 8 hr or 100%o because of rounding error. Practice I Nurse time
Activity
All activities ................... Patient visit activities . . Phone calls with patients .. Conversation with patients .. Charting/patient records . . Patient-related phone calls .. Conversation with staff . . Office business/administration
Minutes 482 89 30 11 39 13 32 175
Laboratory tests . .2 47 Equipment/office upkeep .. . .0 Study 23 Breaks/personal business . . Transit and other Time with observer
28
.7
. ..........
14
Percent 100.1 18.5 6.3 2.3 8.1 2.6 6.7 36.4 0.4 9.7 0 4.8 1.5 2.8
Physcian
Phtyician Minutes 481 308 8 12 27 10 24 15 4 1 0 21 31 20
time Percent
Practice II Nurse Phsca clinician tie ~time tm Min- Per- Min- Perutes cent utes cent
100.0 478 100.1 479 100.1 64.2 230 47.9 268 55.9 1.6 73 15.3 39 8.2 2 2 2.5 0.4 0.3 5.7 44 9.3 15 3.1 2.1 30 6.3 26 5.4 4.9 19 4.0 26 5.5 5 1.1 32 3.2 6.7 2.5 9 1.9 0.7 12 0.2 12 2.4 3 0.6 4 4 0.9 0 0.9 5 1.1 21 4.3 4.4 6.4 30 4.2 6.3 20 2.6 14 4.2 12 3.0
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services for patients during visits to the office that did not require the attention of the physician, and she assisted the physician during examinations and procedures during some visits. She handled the billing and accounting for the practice, maintained the patient record system, directed the activities of clerical assistants, and screened telephone calls from patients. Her office maintenance duties included ordering supplies and cleaning rooms and equipment. The distribution of her time during an average day is shown in Table 3. Most of the patient visits managed alone by the nurse involved scheduled procedures such as bandage changes or injections. The nurse's role in providing patient care was similar whether she saw a patient independently or with the physician. She spent most of her time during these visits performing procedures. However, she spent more time in visits managed with the physician due to the types and numbers of procedures she performed during these visits. She took vital signs, gave injections and ultrasound treatments, drew blood, and assisted with office surgery. She also performed some laboratory tests such as urinalysis and blood hemoglobin. The distribution of the nurse's and physician's time within patient visits managed independently and jointly is shown in Table 1. Nurse Clinician vs. Nurse As indicated in the previous sections, the roles of the nurse and nurse clinician were quite different. The role of the nurse clinician was more similar to the role of the physicians in these practices. She managed types of visits and problems by herself that would otherwise have required the time and attention of a physician. In contrast, the types of problems and visits handled independently by the nurse are typically handled by office assistants. In practice II these types of problems were handled by the office nurse who worked with the nurse clinician and the physician. Since the nurse and nurse clinician were not producing the same types of services in similar types of visits, a direct comparison of the number of patients seen by each during a day is not an adequate index of their respective productivity. However, some quantitative comparisons can be made of the way in which they spent their time and the kinds of patient services each produced. The nurse spent only 19 percent of her day in direct patient contact, compared to 48 percent for the nurse clinician. Almost 75 percent of the problems handled alone by the nurse involved a scheduled procedure and no significant evaluation of the patient's problem. Only 15 percent of the problems managed alone by the nurse clinician were classified as scheduled procedures. The nurse invested an average of 2.8 min in visits managed alone, and the nurse clinician averaged 10.4 min in visits she managed independently. These differences help explain how the nurse saw almost as many patients alone per day as the nurse clinician while investing only one-fifth as much of her time in these visits. The nurse and nurse clinician spent a similar amount of time in visits involving the physician, but the distributions of the two nurses' time during
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Holmes et al.
Table 4. Average Number of Patients Served Per Day by the Nurse and Nurse Clinician Averages are based on a projected 8-hr workday. Nurse (practice 1) I)
Nurscie
Nurse clinicia (practice II)
6.1 6.3
7.7 14.3
20.0 7.9
6.3 21.6
Patient visits Managed independently ...... Managed with physician ..... Patient telephone calls Routine ................... Requiring advice ............
these shared visits were very dissimilar. The nurse spent most of her time performing procedures, whereas the nurse clinician invested only a small percentage of her time in procedures and much more in history-taking, examination of the patient, special tests, charting, and education and counseling. The nurse clinician spent twice as much time as the nurse talking with patients on the telephone. Although both averaged 28 patient telephone calls per day, the nurse clinician generally gave some type of health-related advice or Table 5. Problem Distribution for Nurse (Practice I) and Nurse Clinician (Practice 11) Total number of problems exceeds the number of visits managed (Tables 1 and 2) because two or more problems were presented in some visits.
Practice I Problems
Activity category
managed bybY nurse
Practice II
Problems managed with
Problems managed by nurse
clinician
physician
Num- Per- Num- Per- Num- Perber cent ber cent ber cent 51 100.0 71 100.0 104 100.0
. All activity categories Initial evaluations Acute disorders .0 Chronic disorders .0
Problems managed with
physician Num- Perber cent 241
100.0
0 0
25 3
35.2 4.2
32 1
30.8 1.0
114 14
47.3 5.8
0 2.0
21 4
29.6 5.6
8 28
7.7 26.9
38 40
15.8 16.6
39.2 35.3
4 0
5.6 0
15 1
14.4 1.0
0 1
0 0.4
3.9 19.6
7 7
9.9 9.9
15 4
14.4 3.8
32 2
13.3 0.8
Reevaluations
Acute disorders .0 Chronic disorders .1
Scheduled procedures
Acute disorders .20 Chronic disorders .18 Well-care requests Examinations .2 Service ................. 10
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Table 6. Average Time with Patients (in Minutes) by Physician I in All Visits and by Physician 11 and the Nurse Clinician in Shared Visits Practice II
Practice I
Activityr All ................ Conversation ............
History............... Physical examination .1....... Special tests ............ Charting.............. Procedures............. Patient education/counseling .....
Other ............... Time with observer..........
(physician)
Total
Physician
8.05 1.20 1.20 .59 0.15 0.40 0.50 2.66 0.17 0.18
17.06 0.44 3.98 3.17 1.16 2.11 1.09 3.31 1.66 0.14
6.88 0.34 0.75 1.87 0.04 0.83 0.53 2.22 0.21 0.09
Nurse Clinician 10.18 0.10 3.23 1.30 1.12 1.28 0.56 1.09 1.45 0.05
education to the caller and the nurse did not. Quantitative differences in patient services provided by the nurse and nurse clinician are shown in Tables 4 and 5. Contribution of the Nurse Clinician to the Productivity of Practice II If the only contribution of the nurse clinician to the productivity of practice II were the seve'n to eight patients she handled alone per day, she would increase the number of visits handled by the practice in a year by 1,848 (given 240 8-hr workdays per year). This patient load was managed in approximately 80 mmii per day, and it constituted 15 percent of patient visits managed in the practice as a whole (excluding routine visits in which the patient saw only the office nurse). It seems likely, however, that the time the nurse clinician spent wit-h patients she referred to t-he physician also contributed something to these patients and contributed to the productivity of the physician in these visits. Table 6 shows the average amount of time the physician and nurse clinician in practice II spent in various patient activities in shared visits and compares these times with the average times invested by physician I. This table shows that patients in practice II who saw both the nurse clinician and the physician received more professional attention than did patients seen by physician I. They received about 17 min of professional attention compared with 8 min in practice I. There was some reinforcement for physical examination findings, greater detail recorded in patient records, and reinforcement or supplement of the patient education provided by the
physician. These data also suggest that by seeing these patients first, the nurse clinician saved the physician time. She perfonned some of the history, physical examination, and other steps necessary for the management of these visits t-hat otherwise would have had to be done by the physician. Since these
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Holmes et al.
Table 7. Productivity of the Physician in Practice I and the Physician and Nurse Clinician in Practice 11 Productivity measure
Practice I
Total Total
Practice II Nurse
Pician
Physician visits
Number of patients 50.2 38.3 28.2 seen per day* .......... Number of patients 6768 9 192 12 048 seen per yeart .......... * Daily averages are based on an assumed 8-hr workday. f Annual projections are based on 240 workdays per year.
shae
visits
Sae Visits
7.7
14.3
1 848
3432
~~~~~~~clinician
visits were judged too complex for the nurse clinician to handle alone, some of the examination and other steps performed by her were repeated by the physician. But he did not repeat all of the activities of the nurse clinician and thus was able to spend less time in these visits. Productivity in the Two Practices There were a number of differences between practice I and practice II in terms of the activities of the physicians. Physician I spent 64 percent of his day with patients in the office, whereas physician II spent 56 percent of his day seeing patients. Despite the fact that physician I spent more time in direct patient contact, he saw fewer patients a day than physician II because he spent more time in conversation with patients, history taking, and patient education or counseling. Since part of the productivity of the nurse clinician and physician in practice II resulted from shared management of selected patient visits, it seems appropriate to compare their productivity as a team to the productivity of the physician in practice I. Table 7 shows the daily and annual productivity of these practice personnel. Differences in productivity for the two practices may either be calculated on the basis of all visits or on the basis of visits managed independently by the nurse clinician in practice II. When all visits are used in the calculation the projected annual difference in productivity is 2,856 patient visits, or 31 percent. When only the visits managed independently by the nurse clinician are counted, the projected difference in annual productivity is 1,848 patient visits, or 20 percent.
Discussion Concern about the productivity of different types of health care professionals is necessarily linked to concern about the quality of care provided, its acceptability, and its cost. The evidence available indicates that the nurse clinician in practice II increased the productivity of the practice without increasing costs to patients. She has been very well accepted by patients, and 32
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the quality of care patients receive has not been diminished. A recent study of 65 nurse clinicians employed in the state of Kansas, which included the nurse clinician in practice II, found that patient acceptance has rarely been a problem [11]. The charge to patients is generally the same whether the patient is seen by the physician, nurse clinician, or both. In Kansas, most nurse clinicians and their employing physicians feel that services to patients have been improved at no additional cost to the patient through the utilization of the nurse clinician.
Acknowledgments. Many individuals contributed in one way or another to this study. We would like to express special appreciation to the physicians who allowed us to spend time in their practices during the data collection phases of this study and to the nurse and nurse clinician in these practices. We would like to thank Robert W. Brown, Director of the Kansas Regional Medical Program, for his advice and assistance, and Michael Grobe, who did the computer programming for the study. REFERENCES
1. Pondy, L. R., J. M. Jones, and J. A. Braun. The Utilization and Productivity of the Duke Physician Associate. G.S.B.A. Paper No. 61. Durham, NC: Duke University, Graduate School of Business Administration, 1972. 2. Smith, R. A., J. R. Anderson, and J. T. Okimoto. Increasing physician's productivity and the hospitalization characteristics of practices using Medex: A progress report. Northwest Med 70:701 Oct. 1971. 3. Spitzer, W. O., D. L. Sackett, J. C. Sibley, R. S. Roberts, M. Gent, D. J. Kergin, B. C. Hackett, and A. Olynich. Special article: The Burlington randomized trial of the nurse practitioner. New Engl J Med 290:251 Jan. 31, 1974. 4. Smith, K., M. Miller, and F. L. Golladay. An analysis of the optimal use of inputs in the production of medical services. J Hum Resour 7:208 Spring 1972. 5. Voltmann, J. D. Jamestown medical clinic system. J Am Med Assoc 234:303 Oct. 20, 1975. 6. Schiff, D. W., C. H. Fraser, and H. L. Walters. The pediatric nurse practitioner in the office of pediatricians in private practice. Pediatrics 44:62 July 1969. 7. Smith, K. R. Health Practitioners: Efficient Utilization and the Cost of Health Care. In V. W. Lippard and E. F. Purcell (eds.), Intermediate-Level Health Practitioners, pp. 135-151. New York: Josiah Macy Jr. Foundation, 1973. 8. Yankauer, A., S. Tripp, P. Andrews, and J. Connelly. The cost of training and the income generation potential of pediatric nurse practitioners. Pediatrics 49:878 June 1972. 9. Nelson, E. C., A. R. Jacobs, K. Cordner, and K. G. Johnson. Financial impact of physician assistants on medical practice. New Engl J Med 293:527 Sept. 11, 1975. 10. Eighth Revision, International Classification of Diseases, Adapted for Use in the United States, Vol. 2. P.H.S. Pub. No. 1693. Washington, DC: U.S. Government Printing Office, 1968. 11. Holmes, G. C. and R. E. Bassett. Primary care nurse clinicians in Kansas: Working roles, motivation, problems and benefits. J Kawias Med Soc (in press).
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by Geraldine Holmes, George Livingston, and Elizabeth Mills A comparison of two solo primary care practices with similar patient populations reveals a significant difference in productivity. A nurse clinician was employed in the more productive practice. She independently managed 1,848 patient visits a year that would otherwise have required the time and attention of a physician. She contributed to the productivity of the physician by performing some tasks he would normally have performed during visits they managed jointly. It was primarily because of the assistance he received from the nurse clinician that the physician in practice II was 12 percent more productive than the physician in practice I. The nurse clinician and physician mwnaged 31 percent more patient visits during a standard day than the physician in practice I, or a difference of 2,856 patient visits a year. This annual difference is based on a work schedule that could be matched in other practices: an eight-hour day and a 240-day work year. Despite the widespread interest that has been evidenced in the training and utilization of physician extenders, there are relatively few published studies dealing with the impact of physician extenders on the productivity of office practices. These studies include a 1972 study by Pondy et al. [1] on the number of patient visits managed in four private practices and five institutional settings before and after the introduction of a physician assistant. In the private settings, Pondy et al. found that the patient load increased by 79 percent in a solo practice and 36 percent in a group practice after the addition of a physician assistant. In 1971 R. A. Smith et al. [2] reported on a study comparing the number of patient visits managed in nine practices employing MEDEX and a matched group of practices that did not. In a three-year study published in 1974, Research supported by the Kansas Regional Medical Program. An earlier version of this article was presented at a meeting of the National Association of Regional Medical Programs in San Diego, Sept. 24, 1975. Address communications and requests for reprints to Geraldine C. Holmes, Ph.D., University of Kansas Medical Center, 39th and Rainbow Boulevard, Kansas City, KS 66103.
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Holmes et al.
Spitzer et al. [3] studied the productivity of nurse practitioners in a group family practice setting. In these studies productivity increases attributed to the addition of a physician extender ranged from 13.5 to 62.5 percent. K. Smith et al. [4] developed a model for the utilization of a physician assistant with which he demonstrated theoretical increases of up to 74 percent in patient visits, given optimal conditions for promoting this type of productivity. One physician [5] reported that he increased his productivity by 300 to 400 percent after the introduction of several innovations, including the employment of six nurse practitioners. There have been several studies to determine the profit to the physicians who employ pediatric nurse practitioners [6-8], and one study has examined the range of profit to physicians who employ MEDEX [9]. The profit to employers in these studies ranged from $2,500 to $39,210 per year. These findings suggest increased productivity in these practices but not its extent. Because of the limited data available nationally on the productivity of physician extenders and a desire to learn more about the impact of nurse clinicians on the availability of primary care services in Kansas, a series of productivity case studies was initiated in the summer of 1974. In the case study reported here, productivity was assessed in two solophysician practices, one with only a nurse to assist the physician (practice I) and the other with a nurse clinician in addition to the registered nurse (practice II). The nurse clinician was a graduate of the nurse clinician training program at Wichita State University, which is designed to train experienced registered nurses for expanded roles in primary care settings. The program consists of a two-month didactic and clinical experience in Wichita followed by a tenmonth preceptorship with a practicing physician. The nurse clinician had passed examinations related to the tasks she performed in the practice, and she had been certified by the physician who served as her preceptor in the nurse clinician training program as proficient in clinical skills encompassed in her role. No effort was made to evaluate the quality of care provided to patients on the basis of processes or outcomes of care. However, the professionals observed were fully qualified to provide services to patients within their respective role definitions and were attempting to provide their patients the best care possible. The comparisons that will be emphasized in this article are (1) the different roles of the nurse in practice I and the nurse clinician in practice II, (2) the types of patient services each professional provides, and (3) the productivity of each practice, measured in terms of number of patient visits processed during a standard time period.
Comparability of the Practices and Patient Populations The two practices were similar in the distribution of patient problems presented and in the demographic, socioeconomic, and racial characteristics of the patient populations served. Each physician had been in private, solo
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general practice in his community for approximately 25 years. Patient demand on each practice was moderately heavy, and personnel in the practices were seldom idle. Practice I was located in a small southwestern Kansas town, and practice II was in a suburb of Kansas City. As far as could be ascertained, the only significant difference between the practices was that practice I employed only a nurse to assist the physician, whereas practice II employed both a registered nurse and a nurse clinician. Practice
Practice II
I I I PROBLEMS I 18.1 _ Respiratory 10.1 Circulatory 9 Accidents 9 Skin Mental Digestive Nervous system & sense organs 3.2 Genito-urinary 3.2 Infective & parasitic 2.4 Complications of pregnancy 2.2 Endocrine, nutritional & metabolic n Musculoskeletal Blood & blood-forming organs Malignancies Symptoms & ill-defined conditions 6. WELL-CARE REQUESTS 1.8 General examinations Limited examinations 2.2* Pre/Postnatal examinations . 11.22 Special examinations Preventive care
l I
4
4
6.1 4.4
1.8s 1.8
30 25
I
1
20
15
4.7
2.5
0 5 10 15 10 5 Percent of practice load
20 25 30
Percent distribution of problems presented and well-care requests made in each practice (percentages do not sum to 100 because of rounding error). Special examinations include insurance physicals, ICC physicals, and other types of school and work physical examinations. Preventive care consisted primarily of vaccinations.
The distribution of patient problems and well-care services managed during the data collection periods of this study are shown in the accompanying figure. The only notable differences between these distributions are the larger proportion of respiratory conditions seen in practice II and the greater number of specialized types of physical examinations performed in practice I. In practice I, 22 percent of all requests were for well-care services, 59 percent involved acute problems, and 19 percent involved chronic illness. In practice II, the distribution was 10 percent well care, 65 percent acute problems, and 25 percent chronic illness. In both practices about 55 percent of the problems
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Holmes et al.
presented were new conditions and 45 percent were previously evaluated illnesses. The patient populations served by both practices were predominantly white, middle and working class, and were evenly divided by sex. About 28 percent of the patients were less than 20 years old, 39 percent were between 20 and 49 years old, and 33 percent were over 50. Published materials provide extensive documentation of variations in primary care practices, with and without physician extenders, and these variations are accompanied by great differences in practice productivity. In published reports patient visits average from 8 min to 15 min, with a range from less than 1 min to more than 60 min. The average number of patient visits managed in private practices ranges from 20 to 50 daily. Thirty-five patient visits per day is the most frequently reported average for primary care rural solo practitioners. Since both practices in the present study were more productive than the average solo primary care practice, differences in productivity between the two practices were not likely due to physician slowness or inadequate patient flow. The two practices are similar in content to a majority of primary care practices in which the nature and distribution of patient problems have been documented (bibliography available from first author).
Methods Two health-care researchers collected data in each practice for 12 consecutive workdays. The method involved timing all office activities of the physicians, the nurse clinician, and the nurse and coding the data in predetermined categories. Information was also collected daily on each professional's work-related activities outside the office, based on the professional's verbal report. In addition, standard data were collected on the management and organizational aspects of each practice. Prior to the initiation of data collection, the two researchers were trained as observers and data recorders and a number of other tasks were completed. Forms were developed for recording data on the way in which professionals were spending their time, and initial forms were tested in a medical practice. The observers practiced and refined their data-collection skills as they pretested the data-collection instruments in role-playing sessions and in recording data from filmed office visits. After pretesting, forms were revised to provide for accuracy and ease of data recording and to include all relevant activities. A number of modifications in data-collection procedures were also made to deal with unanticipated events such as the simultaneous occurrence of activities (e.g., the physician providing patient education while conducting a physical examination or completing a procedure, or the physician seeing two members of the same family together). Timing of activities was initiated when the professionals first arrived in the office and continued through the entire working day. For each person
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observed, two distinct types of activities were timed and recorded: (1) direct patient contact activities that occurred during patient visits and (2) other activities that took place outside of patient visits. All services provided during face-to-face contact with an individual patient on a given day were counted as a single patient visit. Each patient visit was identified by age and sex of patient, by type of visit, and by nature of problem presented. The "type of visit" identified a visit as an initial visit for a problem, a return visit for a problem, a return visit for a procedure, or a well-care visit. Problems were coded in one of 16 general and 103 specific categories based on the Eighth Revision, International Classification of Diseases [10]. Observers obtained information about diagnoses either during or after the visit. The types of patient visit activities that were separately recorded for each professional were as follows: * Conversation. Time spent in conversation that may have served to establish rapport but that was clearly outside the category of taking health history or determining the health status of the patient. * History. Time spent in conversation that could be considered useful in determining the physical, emotional, or mental health of the patient. * Physical examination. Time spent in visual or tactile examination of the patient or in taking standard measures such as height, weight, pulse, temperature, or blood pressure. * Special tests and measures. Time spent performing tests such as visual acuity, audiometry, tonometry, throat cultures, ECG, or drawing blood. * Charting. Time spent reading or recording in the patient's chart, writing prescriptions or instructions for the patient, or reviewing laboratory or EKG results. * Procedures. Time spent in activities that had a treatment orientation such as excising growths, suturing, bandaging wounds, applying casts, administering ultrasound therapy, or giving injections. * Education and counseling. Time spent giving the patient advice, information, or instruction. * Oth-er. Time spent in any activity not classifiable elsewhere. This category included time spent preparing the patient or equipment needed for an examination or time spent consulting with a colleague. Monitored activities not connected with patient visits included patient and nonpatient telephone calls, reading charts and laboratory and x-ray results, reading office correspondence or educational material, writing in patient charts, filling out insurance forms, working on office administrative matters or writing professional papers, consulting with office staff, conversing socially with staff or patients, performing laboratory tests, preparing equipment and rooms, dispensing medication, conversing with the observer, waiting for patients or colleagues, and taking breaks. Each of these activities was coded during data-collection periods in behavior-specific categories that facilitated observation and timing. They were regrouped into functional categories in the sub-
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Holmes et al.
sequent data analyses (e.g., telephone calls, writing time, and reading time that dealt with office administration were all included in the functional time and activity category, "office administration"). In order to minimize bias and error, observers in each practice alternated in observing the physician, nurse, and/or nurse clinician. During observation periods, they periodically reviewed standardized data-collection procedures and collaborated whenever a question arose about classifying activities. The observers attempted to be as unobtrusive as possible during the course of data collection. If they were introduced to patients or otherwise involved in patient visit activities, the elapsed time was coded and recorded separately. The observers were asked, on a few occasions, to step out of the examination room for part or all of a patient visit. These visits were included in analyses concerned with the number of patients seen and the total time spent in patient visits, but they were excluded from analyses of activities occurring during patient visits. In each practice the reasons for the study and the observation methods to be employed were explained in advance to the physician, nurse, and/or nurse clinician, who participated out of concern for the objectives of the research and received no payment for their cooperation.
Results Duties of the Nurse Clinician The nurse clinician's primary responsibilities involved managing selected types of patient visits independently. She managed by herself patients with uncomplicated upper respiratory infections, monitored patients with chronic disorders such as hypertension and obesity, and performed physical examinations for well-care visits. She screened and made initial assessments of patients and collaborated with the physician in visits that were too complex for her to handle alone. She took Papanicolaou smears, removed simple growths, inserted catheters, and took throat cultures. (Interviews revealed that the nurse clinician sometimes performed pelvic examinations, sutured wounds, and removed casts, but these activities were not observed during the period of this study.) In addition, the nurse clinician handled most phone calls from patients and had the primary responsibility to phone laboratory results to patients and drug prescriptions to pharmacies. She performed some routine nursing tasks. For example, she assisted the physician during some examinations and procedures, gave injections, and performed urinalysis and hemoglobin tests. She also engaged in patient education or counseling in most patient visits in which she was involved. In visits managed alone, the nurse clinician provided all of the services required for the care of the problems presented. She consulted with the physician as necessary either during the visit or at the conclusion of the day. If the nurse clinician felt any reservation about managing a visit, she referred the patient to the physician.
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Table 1. Distribution of Patient Visit Time in Practice I Times are in minutes and are averages based on the number of visits in parentheses. Mean times with the same superscript are significantly different at p = 0.06 or better, based on a median-split chi-square test. Statistical comparisons between professionals were not made. Patient visit activity All activities ....................... Conversation ....................... History ............................ Physical examination ........ ........ Special tests ....................... Charting .......................... Procedures ......................... Patient education/counseling ..... .... Other ............................. Time with observer ......... ........
Nurse visits Physician visits IndeWith With Independent physician pendent nurse (N = 51) (N = 53) (N = 301) (N = 53)
2.80' 0.55 0 0.04 0.15 0 1.68 0.20 0.16 0.02
11.28' 0.69 0.13 0.41 0.33 0.02 8.23 0.68 0.79 0
7.84 1.09 1.29b 1.66c 0.12 0.47 0.15 2.77 0.14 0.15
9.11 1.77 0.72b 1.22c 0.27 0.04 2.36 2.03 0.38 0.32
During the observation period, the average time the nurse clinician spent with a patient was about 10 min, whether she handled the entire visit herself or referred the patient. Although the difference between the average time she spent in shared and independently managed visits was not significant, the distribution of her time within visits was different when the physician also saw the patient. In visits she managed independently, she spent a greater proportion of her time in examining the patient, performing special tests, Table 2. Distribution of Patient Visit Time in Practice 11 Times are in minutes and are averages based on the number of visits in parentheses. Mean times with the same superscript are significantly different at p = 0.06 or better, based on a median-split chi-square test. Statistical comparisons between professionals were not made. Nurse clinician visits
Patient visit activity
All activities ...................... Conversation ...................... History ........................... Physical examination ........ ....... Special tests ....................... Charting .......................... Procedures ........................ Patient education/counseling ........ Other ............................ Time with observer ................
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Inde-
pendent (N =78) 10.39 0.09 1.43"
2.30° 1.72f 1.489 0.41 2.52h 0.39 0.05
Physician visits
With
Inde-
10.18 0.10 3.23"
5.59 0.34 0.40' 1.27 0.05 0.87 0.40 2.10 0.09 0.07
physician pendent (N = 143) (N =220)
1.30'
1.12f 1.289 0.56 1.09h 1.45 0.05
With
cliniciun clnician 6.88 0.34 0.75' 1.87 0.04 0.83 0.53 2.22 0.21 0.09
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Holmes et al.
charting, and in patient education and counseling. In visits she managed with the physician, she invested more time in taking the patient's history. These differences are shown in Tables 1 and 2. A comparison of patient visits managed independently by the nurse clinician with those managed independently by the physicians in the two practices shows that she spent less time in conversation with patients than either physician, but more time in most other aspects of the patient visit. She spent about the same amount of time in performing procedures and in patient education as either physician. On the average, she invested about 21/2 min more in a visit than physician I and almost 5 min more than physician II. The nurse clinician alone managed 35 percent of all patients directed to her by the receptionist. She spent 48 percent of her workday seeing patients in the office, 15 percent handling telephone calls from patients, 9 percent charting, and 6 percent making patient-related phone calls. The remainder of her day was spent in transit and other activities. In Table 3 the division of her workday is compared to the average day of the physician in the same practice as well as the physician and nurse in practice I.
Duties of the Nurse The nurse in practice I was responsible for the performance of routine nursing tasks, bookkeeping, and office maintenance. She provided some Table 3. Composition of Workdays in the Two Practices Times are rounded to the nearest minute. To make the distributions comparable, the times are based on a projected 8-hr workday. The actual average times each professional worked in the office per full workday were: practice I nurse, 9.5 hr; practice I physician, 6.5 hr; practice II nurse clinician, 7.5 hr; practice II physician 5.8 hr. The times and percentages shown do not sum exactly to 8 hr or 100%o because of rounding error. Practice I Nurse time
Activity
All activities ................... Patient visit activities . . Phone calls with patients .. Conversation with patients .. Charting/patient records . . Patient-related phone calls .. Conversation with staff . . Office business/administration
Minutes 482 89 30 11 39 13 32 175
Laboratory tests . .2 47 Equipment/office upkeep .. . .0 Study 23 Breaks/personal business . . Transit and other Time with observer
28
.7
. ..........
14
Percent 100.1 18.5 6.3 2.3 8.1 2.6 6.7 36.4 0.4 9.7 0 4.8 1.5 2.8
Physcian
Phtyician Minutes 481 308 8 12 27 10 24 15 4 1 0 21 31 20
time Percent
Practice II Nurse Phsca clinician tie ~time tm Min- Per- Min- Perutes cent utes cent
100.0 478 100.1 479 100.1 64.2 230 47.9 268 55.9 1.6 73 15.3 39 8.2 2 2 2.5 0.4 0.3 5.7 44 9.3 15 3.1 2.1 30 6.3 26 5.4 4.9 19 4.0 26 5.5 5 1.1 32 3.2 6.7 2.5 9 1.9 0.7 12 0.2 12 2.4 3 0.6 4 4 0.9 0 0.9 5 1.1 21 4.3 4.4 6.4 30 4.2 6.3 20 2.6 14 4.2 12 3.0
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services for patients during visits to the office that did not require the attention of the physician, and she assisted the physician during examinations and procedures during some visits. She handled the billing and accounting for the practice, maintained the patient record system, directed the activities of clerical assistants, and screened telephone calls from patients. Her office maintenance duties included ordering supplies and cleaning rooms and equipment. The distribution of her time during an average day is shown in Table 3. Most of the patient visits managed alone by the nurse involved scheduled procedures such as bandage changes or injections. The nurse's role in providing patient care was similar whether she saw a patient independently or with the physician. She spent most of her time during these visits performing procedures. However, she spent more time in visits managed with the physician due to the types and numbers of procedures she performed during these visits. She took vital signs, gave injections and ultrasound treatments, drew blood, and assisted with office surgery. She also performed some laboratory tests such as urinalysis and blood hemoglobin. The distribution of the nurse's and physician's time within patient visits managed independently and jointly is shown in Table 1. Nurse Clinician vs. Nurse As indicated in the previous sections, the roles of the nurse and nurse clinician were quite different. The role of the nurse clinician was more similar to the role of the physicians in these practices. She managed types of visits and problems by herself that would otherwise have required the time and attention of a physician. In contrast, the types of problems and visits handled independently by the nurse are typically handled by office assistants. In practice II these types of problems were handled by the office nurse who worked with the nurse clinician and the physician. Since the nurse and nurse clinician were not producing the same types of services in similar types of visits, a direct comparison of the number of patients seen by each during a day is not an adequate index of their respective productivity. However, some quantitative comparisons can be made of the way in which they spent their time and the kinds of patient services each produced. The nurse spent only 19 percent of her day in direct patient contact, compared to 48 percent for the nurse clinician. Almost 75 percent of the problems handled alone by the nurse involved a scheduled procedure and no significant evaluation of the patient's problem. Only 15 percent of the problems managed alone by the nurse clinician were classified as scheduled procedures. The nurse invested an average of 2.8 min in visits managed alone, and the nurse clinician averaged 10.4 min in visits she managed independently. These differences help explain how the nurse saw almost as many patients alone per day as the nurse clinician while investing only one-fifth as much of her time in these visits. The nurse and nurse clinician spent a similar amount of time in visits involving the physician, but the distributions of the two nurses' time during
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Holmes et al.
Table 4. Average Number of Patients Served Per Day by the Nurse and Nurse Clinician Averages are based on a projected 8-hr workday. Nurse (practice 1) I)
Nurscie
Nurse clinicia (practice II)
6.1 6.3
7.7 14.3
20.0 7.9
6.3 21.6
Patient visits Managed independently ...... Managed with physician ..... Patient telephone calls Routine ................... Requiring advice ............
these shared visits were very dissimilar. The nurse spent most of her time performing procedures, whereas the nurse clinician invested only a small percentage of her time in procedures and much more in history-taking, examination of the patient, special tests, charting, and education and counseling. The nurse clinician spent twice as much time as the nurse talking with patients on the telephone. Although both averaged 28 patient telephone calls per day, the nurse clinician generally gave some type of health-related advice or Table 5. Problem Distribution for Nurse (Practice I) and Nurse Clinician (Practice 11) Total number of problems exceeds the number of visits managed (Tables 1 and 2) because two or more problems were presented in some visits.
Practice I Problems
Activity category
managed bybY nurse
Practice II
Problems managed with
Problems managed by nurse
clinician
physician
Num- Per- Num- Per- Num- Perber cent ber cent ber cent 51 100.0 71 100.0 104 100.0
. All activity categories Initial evaluations Acute disorders .0 Chronic disorders .0
Problems managed with
physician Num- Perber cent 241
100.0
0 0
25 3
35.2 4.2
32 1
30.8 1.0
114 14
47.3 5.8
0 2.0
21 4
29.6 5.6
8 28
7.7 26.9
38 40
15.8 16.6
39.2 35.3
4 0
5.6 0
15 1
14.4 1.0
0 1
0 0.4
3.9 19.6
7 7
9.9 9.9
15 4
14.4 3.8
32 2
13.3 0.8
Reevaluations
Acute disorders .0 Chronic disorders .1
Scheduled procedures
Acute disorders .20 Chronic disorders .18 Well-care requests Examinations .2 Service ................. 10
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Table 6. Average Time with Patients (in Minutes) by Physician I in All Visits and by Physician 11 and the Nurse Clinician in Shared Visits Practice II
Practice I
Activityr All ................ Conversation ............
History............... Physical examination .1....... Special tests ............ Charting.............. Procedures............. Patient education/counseling .....
Other ............... Time with observer..........
(physician)
Total
Physician
8.05 1.20 1.20 .59 0.15 0.40 0.50 2.66 0.17 0.18
17.06 0.44 3.98 3.17 1.16 2.11 1.09 3.31 1.66 0.14
6.88 0.34 0.75 1.87 0.04 0.83 0.53 2.22 0.21 0.09
Nurse Clinician 10.18 0.10 3.23 1.30 1.12 1.28 0.56 1.09 1.45 0.05
education to the caller and the nurse did not. Quantitative differences in patient services provided by the nurse and nurse clinician are shown in Tables 4 and 5. Contribution of the Nurse Clinician to the Productivity of Practice II If the only contribution of the nurse clinician to the productivity of practice II were the seve'n to eight patients she handled alone per day, she would increase the number of visits handled by the practice in a year by 1,848 (given 240 8-hr workdays per year). This patient load was managed in approximately 80 mmii per day, and it constituted 15 percent of patient visits managed in the practice as a whole (excluding routine visits in which the patient saw only the office nurse). It seems likely, however, that the time the nurse clinician spent wit-h patients she referred to t-he physician also contributed something to these patients and contributed to the productivity of the physician in these visits. Table 6 shows the average amount of time the physician and nurse clinician in practice II spent in various patient activities in shared visits and compares these times with the average times invested by physician I. This table shows that patients in practice II who saw both the nurse clinician and the physician received more professional attention than did patients seen by physician I. They received about 17 min of professional attention compared with 8 min in practice I. There was some reinforcement for physical examination findings, greater detail recorded in patient records, and reinforcement or supplement of the patient education provided by the
physician. These data also suggest that by seeing these patients first, the nurse clinician saved the physician time. She perfonned some of the history, physical examination, and other steps necessary for the management of these visits t-hat otherwise would have had to be done by the physician. Since these
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Holmes et al.
Table 7. Productivity of the Physician in Practice I and the Physician and Nurse Clinician in Practice 11 Productivity measure
Practice I
Total Total
Practice II Nurse
Pician
Physician visits
Number of patients 50.2 38.3 28.2 seen per day* .......... Number of patients 6768 9 192 12 048 seen per yeart .......... * Daily averages are based on an assumed 8-hr workday. f Annual projections are based on 240 workdays per year.
shae
visits
Sae Visits
7.7
14.3
1 848
3432
~~~~~~~clinician
visits were judged too complex for the nurse clinician to handle alone, some of the examination and other steps performed by her were repeated by the physician. But he did not repeat all of the activities of the nurse clinician and thus was able to spend less time in these visits. Productivity in the Two Practices There were a number of differences between practice I and practice II in terms of the activities of the physicians. Physician I spent 64 percent of his day with patients in the office, whereas physician II spent 56 percent of his day seeing patients. Despite the fact that physician I spent more time in direct patient contact, he saw fewer patients a day than physician II because he spent more time in conversation with patients, history taking, and patient education or counseling. Since part of the productivity of the nurse clinician and physician in practice II resulted from shared management of selected patient visits, it seems appropriate to compare their productivity as a team to the productivity of the physician in practice I. Table 7 shows the daily and annual productivity of these practice personnel. Differences in productivity for the two practices may either be calculated on the basis of all visits or on the basis of visits managed independently by the nurse clinician in practice II. When all visits are used in the calculation the projected annual difference in productivity is 2,856 patient visits, or 31 percent. When only the visits managed independently by the nurse clinician are counted, the projected difference in annual productivity is 1,848 patient visits, or 20 percent.
Discussion Concern about the productivity of different types of health care professionals is necessarily linked to concern about the quality of care provided, its acceptability, and its cost. The evidence available indicates that the nurse clinician in practice II increased the productivity of the practice without increasing costs to patients. She has been very well accepted by patients, and 32
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the quality of care patients receive has not been diminished. A recent study of 65 nurse clinicians employed in the state of Kansas, which included the nurse clinician in practice II, found that patient acceptance has rarely been a problem [11]. The charge to patients is generally the same whether the patient is seen by the physician, nurse clinician, or both. In Kansas, most nurse clinicians and their employing physicians feel that services to patients have been improved at no additional cost to the patient through the utilization of the nurse clinician.
Acknowledgments. Many individuals contributed in one way or another to this study. We would like to express special appreciation to the physicians who allowed us to spend time in their practices during the data collection phases of this study and to the nurse and nurse clinician in these practices. We would like to thank Robert W. Brown, Director of the Kansas Regional Medical Program, for his advice and assistance, and Michael Grobe, who did the computer programming for the study. REFERENCES
1. Pondy, L. R., J. M. Jones, and J. A. Braun. The Utilization and Productivity of the Duke Physician Associate. G.S.B.A. Paper No. 61. Durham, NC: Duke University, Graduate School of Business Administration, 1972. 2. Smith, R. A., J. R. Anderson, and J. T. Okimoto. Increasing physician's productivity and the hospitalization characteristics of practices using Medex: A progress report. Northwest Med 70:701 Oct. 1971. 3. Spitzer, W. O., D. L. Sackett, J. C. Sibley, R. S. Roberts, M. Gent, D. J. Kergin, B. C. Hackett, and A. Olynich. Special article: The Burlington randomized trial of the nurse practitioner. New Engl J Med 290:251 Jan. 31, 1974. 4. Smith, K., M. Miller, and F. L. Golladay. An analysis of the optimal use of inputs in the production of medical services. J Hum Resour 7:208 Spring 1972. 5. Voltmann, J. D. Jamestown medical clinic system. J Am Med Assoc 234:303 Oct. 20, 1975. 6. Schiff, D. W., C. H. Fraser, and H. L. Walters. The pediatric nurse practitioner in the office of pediatricians in private practice. Pediatrics 44:62 July 1969. 7. Smith, K. R. Health Practitioners: Efficient Utilization and the Cost of Health Care. In V. W. Lippard and E. F. Purcell (eds.), Intermediate-Level Health Practitioners, pp. 135-151. New York: Josiah Macy Jr. Foundation, 1973. 8. Yankauer, A., S. Tripp, P. Andrews, and J. Connelly. The cost of training and the income generation potential of pediatric nurse practitioners. Pediatrics 49:878 June 1972. 9. Nelson, E. C., A. R. Jacobs, K. Cordner, and K. G. Johnson. Financial impact of physician assistants on medical practice. New Engl J Med 293:527 Sept. 11, 1975. 10. Eighth Revision, International Classification of Diseases, Adapted for Use in the United States, Vol. 2. P.H.S. Pub. No. 1693. Washington, DC: U.S. Government Printing Office, 1968. 11. Holmes, G. C. and R. E. Bassett. Primary care nurse clinicians in Kansas: Working roles, motivation, problems and benefits. J Kawias Med Soc (in press).
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