Whose relative value? Work intensity similar across physician specialties

Proponents of lower payments for primary care providers argue that work requiring less mental challenge and stress should pay less. The problem with that “relative value” position, according to a recent study, is that overall work intensity actually is quite similar across medical specialties.

“Although preliminary, the findings suggest that these instruments can be used to further investigate clinical work intensity and that currently accepted assumptions of extremely differing work intensity among medical specialists may be flawed,” said lead investigator Ronnie Horner, PhD, chairman of the University of Cincinnati (UC) College of Medicine’s public health sciences department.

In a study published online by the journal Medical Care, UC researchers studied 45 family physicians, 20 general internists, 22 neurologists, and 21 surgeons in Kansas, Kentucky, Maryland, Ohio, and Virginia, using validated work intensity and stress measures. Questionnaires were completed by nonsurgical specialists immediately after a patient visit, usually the last encounter of a clinical session. Surgeons filled out the forms after a procedure that lasted at least 1 hour and involved general anesthesia, using the last operation of the day.

The NASA-Task Load Index (NASA-TLX), the Subjective Workload Assessment Technique (SWAT), and the Multiple Resources Questionnaire (MRQ) were used to measure work intensity, whereas the Dundee Stress State Questionnaire was used to measure stress. Participating physicians reported similar degrees of work intensity on the NASA-TLX and MRQ, regardless of their specialties.

Compared with the other specialties, surgeons reported significantly higher levels of task engagement, that is, concentration, on the stress measure and significantly higher intensity on physical demand but significantly lower intensity on the performance dimensions of the NASA-TLX and on time demand.

General internists reported work intensity similar to surgeons but significantly lower than family physicians and neurologists on the SWAT assessment. Family physicians reported the highest intensity on the time dimension of the SWAT, significantly higher than either general internists or surgeons.

“Similarities and differences in physician work intensity among specialties are poorly understood but have implications for quality of care, patient safety, practice organization, management, and payment,” Horner says. “A physician’s work can be assessed by the time required to complete it and by the intensity of the effort, which is central to properly valuing the services being provided. Current payment for medical services by the Centers for Medicare and Medicaid Services is largely determined by the relative value of the intensity associated with the service which may also affect the quality and efficiency of the care provided.” 

Although Horner notes that physician work intensity levels historically have been established by expert panels and surveys, he suggests that using measurement tools could produce a more accurate outcome, especially when it comes to comparing surgical activities with evaluation and management efforts.

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