After-hours primary care has long been seen as a necessary evil among providers in the field. However, as burnout among physicians reached an “epidemic level,” Penn Primary Care was compelled to seek a better way.
“In primary care now, there’s such a focus on ‘work overload,’ both in terms of more challenging patients and this whole asynchronous in-basket world that we have to manage, that after-hours calls feel like adding insult to injury,” says Jeffrey Millstein, MD, Regional Medical Director of Bucks County and New Jersey for Penn Primary Care.
Dr. Millstein and his colleague, Jeffrey Tokazewski, MD, Medical Director of Penn Medicine OnDemand and Associate Medical Director of Clinical Informatics for Penn Primary Care and Penn Specialty Practices, recently highlighted a promising new alternative to after-hours care that’s gradually being implemented at Penn Primary Care practices.
When those offices now close for the day, a clinician with Penn Medicine OnDemand, a 24/7/365 “telehealth solution,” as Dr. Tokazewski describes it, fields calls overnight and over weekends, rather than a designated on-call physician from the practice. The caller is then given the opportunity to meet virtually with the OnDemand clinician.
The on-call physician is typically contacted only when the OnDemand clinician can’t resolve the matter. Such instances can include an abnormal lab result or a prescription clarification.
“It has cut my calls significantly,” Dr. Tokazewski says. “I hardly ever get calls during the week. And a lot of weekends when I’m on call, I get zero calls, and some, I get maybe one.”
Dr. Tokazewski projects that all Penn Primary Care practices will be enrolled in this after-hours care program by the end of June 2025. He says they’re also discussing ways to eliminate the need for an on-call physician altogether and expects such a plan to be in place by the end of June 2025.
Many different kinds of solutions
The after-hours care program is far from the only measure Penn Primary Care is deploying to shape a better work-life balance for its providers. These efforts generally fall into one of two categories, fundamental and complementary, with the former addressing core operations and the latter, benefits.
Beyond the after-hours care program, the fundamental changes include the addition of a half-day to physicians’ weekly schedules where they can catch up on administrative tasks, in or out of the office; an increasingly flexible schedule in which physicians can start their weekly late shift later in the day; and caps on patient panels.
Workflows have been redesigned at each practice so that responsibilities, wherever possible, fall more evenly across the office’s staff, rather than largely on the physicians and advanced practice providers. For example, nurses now triage most patients. They’re also responding to patients’ voicemails and following up with patients.
“It really does take a village to do really good primary care these days,” Dr. Millstein says.
Electronic medical records have been a significant source of frustration and even burnout for physicians across all fields. To offset this effect, every new Penn Primary Care provider is now onboarded by a group of electronic medical record experts. Those experts are also available to all providers for ongoing assistance.
At Penn Medicine Lancaster General Health Primary Care, new providers receive similar training that extends through their first four weeks, says John C. Wood, MD, MBA, FAAFP, Executive Medical Director of Primary Care and Population Health for Penn Medicine Lancaster General Health. This training is part of a larger, 90-day, competency-based onboarding program for Lancaster General Health Primary Care providers.
Dr. Wood says the electronic medical record interface has also been streamlined, enabling Lancaster General Health Primary Care providers to order routine tests and vaccinations with a single click.
An artificial intelligence-assisted dictation and chart review are being tested among both Penn Primary Care and Lancaster General Health Primary Care providers.
Increasing clinical staffing is also a priority for both entities. Dr. Wood says Lancaster General Health Primary Care is adding 18 physicians.
The two organizations are aiming to attract candidates (and enhance the careers of its existing providers) by upgrading a number of benefits, including increasing salaries, vacation time, paid leave, and mental health coverage, as well as providing access to Penn COBALT, a health and wellness platform created for Penn Medicine faculty and staff.
Preserving clinicians’ autonomy
In acknowledging that all of the above is too new to pinpoint an effect, Dr. Millstein says, “I think what probably helps the most is just knowing the health system is taking these things seriously, that we really care about provider wellbeing, and we’re looking for ways to support it.”
This level of engagement, he says, stems in large part from having practicing clinicians in leadership roles. For example, Joseph Teel, MD, the newly appointed Chief of Regional Primary Care for Penn Medicine, was part of a group that recently earned a Clifton Faculty Wellness Award from the Perelman School of Medicine at the University of Pennsylvania for “developing new models for in-basket management.”
These strategies, Dr. Teel says, will be part of “some very large-scale changes to really reduce the amount of after-hours work for all our clinicians in primary care” in the coming year.
Facilitating flexibility will be the focus of the next innovations aimed at improving work-life balance for Penn Primary Care physicians, he says.
“We need to make sure that we’re preserving our clinicians’ autonomy,” Dr. Teel says. “And so, we’re making changes to allow for more flexibility in clinical work schedules. This may include allowing them to work fewer hours per week or even part-time.”