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Doctors lack time for preventive care

As Dr. Ralph Snyderman, chief executive of the Health System, continues a campaign to advocate preventive medicine among Washington lawmakers, a new Duke study suggests that primary care physicians have no time to fulfill national preventive care measures recommended by the U.S. Preventive Services Task Force.

"This was the first study that tried to estimate the workload of physicians," said Dr. Kimberly Yarnall, primary investigator of the study and associate professor of clinical medicine.

Published in the April issue of the American Journal of Public Health, the study estimates that it takes physicians approximately 7.4 hours each day to complete the recommended guidelines. This means, in an eight hour day, only about 30 minutes would be left for critical and chronic disease care.

"As the number of recommendations by the national task force increased, I felt more and more convinced that they couldn't be done," Yarnall said. "We were surprised, however, to find out that when we added it all up, it was even less doable than we thought."

Yarnall said the average primary care physician sees between 25 to 40 patients a day and about 2,500 patients in a year. The researchers applied this annual estimate to U.S. Census figures to describe the typical number of patients a physician cares for each year. Because the study used Census statistics, it accounted not only for age and sex distribution, but also for variances such as pregnancy status and the prevalence of chronic diseases.

In the wake of such a finding, the most relevant question now is whether there are models of preventive care that are not as physician-intensive, said Susan Epstein, chief of the division of community health at the Medical Center.

"The question we've been trying to answer is, how can we effectively care for patients, without burning out the physician?"

With the aging baby-boomer generation, Yarnall anticipates the responsibilities of physicians to become more complicated if alternative models of care are not implemented.

Professor of Clinical Medicine Dr. Lloyd Michener, also involved in the study, emphasized that there is nothing that says the doctors have to do the preventive work. Rather, new strategies should include teams of physician assistants, nurse practitioners and nutritionists as well as community classes to tend to the counseling and education of preventive health care measures.

"There is no argument that these are the things we need to do, but even when we take the most conservative time measurements to estimate how much time physicians need to provide preventive health care, they just can't fit it in," Michener said. "Rather than do a less than good job for the people we are committed to do, it's time to now support the education of prevention in the community."

Michener pointed to the Duke student health education program as a model for similar educational initiatives for the U.S. public. Student health education programs, which have been in existence since the 1980s, address issues such as sexual health, alcohol and stress management.

"We really think we're a great model for the rest of the world," said Jean Hanson, assistant director of student health. "We give students information about how to live a healthy life, and if we teach them how to take care of themselves, they'll have better lives."

A current Durham program led by Yarnall, called "Just for Us," applies the team model of health care and links nurse practitioners performing house calls for routine health examinations with physicians who take care of the more complicated diagnosis and care.

Another future program involves a health clinic at the Lyon Park Community Center, which is designed to provide medical care and reinforce the idea of health care as a part of daily life, said Devdutta Sangvai, administrator of the Lyon Park health clinic. Sangvai said the key is to provide individuals with more personal care. This includes designing new models that provide patients with access to preventive health care.

"There is a lot of stuff that you need to do [in order] to do everything that is recommended by the preventive care task force," Sangvai said. "It really reflects the complexity of medicine."


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