Letter from the Editor

Modernizing the Ambulatory Care Model to Improve Physician Efficiency

Bradley P. Knight, MD, FACC, FHRS, Editor-in-Chief

Bradley P. Knight, MD, FACC, FHRS, Editor-in-Chief

As the number of patients with implanted devices and heart rhythm disorders increases, as more patients demand prompt clinic access, and as administrators focus more on metrics such as time to third new clinic appointment, the pressure for physicians to see more outpatients is growing. Unfortunately, the current inefficient ambulatory care model has not kept up with these new expectations. This is particularly true for medical proceduralists who evaluate patients in the outpatient venue.

After years of watching clinic physicians be piled on, the American Medical Association (AMA) finally seems to be trying to tackle this issue. Christine Sinsky, MD, Vice President of Professional Satisfaction for the AMA, has been a practicing primary care physician for many years and is trying to address this problem from a physician burnout perspective.1-2 She quotes physicians who have said that clinics are becoming “unbearable” and that “the little things have become the big things.” Because empathy for physician satisfaction is unlikely to gain traction with regulators, payers, and administrators, she is also trying to make a business case for a new ambulatory care model that focuses on physician efficiency.

According to Dr. Sinsky, the number one driver of physician dissatisfaction and a major source of inefficiency is the electronic medical record (EMR). The current patient encounter is dominated by data entry and the EMR — all driven by documentation requirements, billing optimization, and coding compliance. For cost reasons, access to dictation has largely been taken away from physicians in the ambulatory care setting. Although there is little debate that the EMR has led to some improvements such as chart legibility, the unintended consequence has been an explosion of clinically irrelevant, extraneous, and redundant information resulting in twelve-page clinic notes for a young and otherwise healthy patient with palpitations. The notes obscure what is really important — the critical impression and recommendation of the physician, and communication with the referring physician. There are many fields in an EMR that are completed at the time of patient registration, including race, ethnicity, marital status, and language (and need for an interpreter), but rarely is the name and contact information of the primary care doctor and referring physician entered. A common entry in the referring field is “self” or “none entered” when the patient has many physicians who need to be kept in communication. Typing in the referring physician information is usually left to the doctor.

A study from the University of Wisconsin found that family physicians now spend 32 hours per month between the hours of 6 pm and 7 am on the EMR. Too many tasks done by physicians could be done by medical assistants. Dr. Sinsky determined that the optimal ambulatory care model is two consistent medical assistants per physician. Too much time is required for each task as a result of dropdown menus, an EMR design that does not prioritize physician time, etc. By Dr. Sinsky’s calculation, it takes 32 keystrokes to order and document a flu shot. Beyond physician dissatisfaction, patients are also not pleased. There is less face time with their doctor (one study found that only 27% of a physician’s time in clinic is devoted to face-to-face time), and the “face time” they often get is with the back of the head of the doctor, who is facing the other direction in the exam room and typing.

In what other profession is it considered a good business model for the most highly trained members of the team to be performing tasks that others with less training could do? Imagine going to your dentist and having him or her leave the room every ten seconds to get you another cup to spit in. One factor that drives this is that the physicians and medical assistants now often work for a common employer. No longer is the medical assistant accountable to the physician. Lost in this new centralized employment model is the mindset that the medical assistant is there to work directly with the patient and physician to facilitate the appointment.

Dr. Sinsky’s advice can be found at www.stepsforward.com. Paraphrased highlights include:

  1. Be bold: the delivery models of the future cannot be managed with the staffing models of the past.
  2. Less is more: develop more meaningful and manageable measures of good care.
  3. Rethink documentation: hours are being spent on documentation that adds no value. Notes have lost their primary purpose, which is clinical communication.
  4. Align with team-based care.
  5. Avoid compliance creep: federal regulations are exacerbated at the local level by overly conservative interpretation of policies.
  6. Eliminate one billion clicks per day.
  7. Develop the field of Practice Science: increase research to optimize delivery models.
  8. Incentivize administrators: use metrics that include physician satisfaction and efficiency.

Doctors are now spending more and more time in clinic, typing and documenting patient encounters rather than talking to patients. They are often rooming their own patients, manually entering data into the EMR that could be entered by medical assistants, and hunting for medical records and functional printers. These tasks are being driven by billing requirements, a lack of focus on physician efficiency by ambulatory leadership, and a lack of representation by physicians at the federal regulatory level. The solution is beyond scribes. It is making fundamental changes to the system. Following the recommendations above by Dr. Sinsky would be a good start — not only to improve physician satisfaction, but to improve patient care and access.


  1. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272-278. 
  2. Sinsky CA. Internal Medicine Grand Rounds. Northwestern University. September 27th, 2016.