The expertise and working hours of doctors are an important resource that should be used in the best way possible.
Since 1994, the Institute for Studies of the Medical Profession has conducted regular questionnaire surveys among a representative sample of Norwegian doctors, and therefore possesses unique data on doctors’ working hours. The study by Rosta & Aasland in this issue of the Journal of the Norwegian Medical Association (1) shows that the scope of patient-oriented work among senior consultants and specialty registrars has decreased from 61 % in 1994 to 46 % in 2014. The authors find considerable variations in hours spent across the specialties. By comparison, GPs and doctors in private practice spend around 70 % of their hours on direct patient care (1).
The study is based on self-reported data. Observations of doctors’ actual use of hours would have provided more reliable information, but would be difficult to obtain. Self-reported data probably correspond well with more objective observations in this area (2). A greater weakness of the study is that the respondents’ understanding of the concept of «patient care» varies (1). However, provided that the same question is repeated over time, there is reason to be confident that the clear trends detected in the study are real.
Rosta & Aasland point to a number of possible explanations for the reduction in hours spent on patient-oriented work: increased requirements for documentation, changes in the organisation of the health services, weaknesses in electronic systems, and increased sharing of functions and tasks among groups of health personnel. They also believe that the increase in doctor density may be significant. According to the OECD, Norway shares fourth place in the world in terms of the proportion of practising doctors per 1 000 population (3). Doctor density in the USA, by comparison, is around 60 % that of Norway (3).
A pilot study from 1961, based on observations of US specialty registrars, provides an interesting historical backdrop (4): The doctors spent approximately 15 % of their time in direct contact with patients and next of kin. Most of their working hours were devoted to communicating with other health personnel and consultations with colleagues and superiors. A more recent US study of specialty registrars in internal medicine showed that they only spent around 12 % of their working hours in direct contact with patients (5). Hospital doctors spent around 40 % of their time at the computer (5), showing that digitalisation of the health services impacts the doctors’ role, tasks and working methods (6).
The doctor’s task is to promote health and reduce suffering, but medical work is not a constant entity. Tasks change over time as a result of new technology, increased specialisation and the emergence of new occupational groups in the health services (7). They may change by virtue of horizontal substitution, when work is transferred between groups with the same length of training (such as doctors and psychologists), and vertical substitution, when work is transferred between groups with different lengths of training (such as doctors and nurses or radiographers). For example, intravenous therapy was a separate category of medical work in the degree programme from 1961 (4), whereas today we take it for granted that this type of task will be dealt with by other professional groups.
Vertical task substitution may be made «downwards» or «upwards». The average salary of Norwegian medical specialists is around 1.7 times higher than the average salary for Norwegian employees. In most European countries, such as Denmark, Finland and the Netherlands, doctors earn 2.5 – 4 times more than the average (3). Is Norwegian doctors’ working hours so inexpensive that the hospitals and municipalities do not always make optimal use of doctors? Correct use of their working hours is not only crucial for doctors’ job satisfaction, but is also important to ensure that individuals achieve sufficient clinical experience and competence. It is timely to ask: Do doctors today have sufficient practice and secretarial support to be able to make effective use of their competence? The number of hospital doctors has doubled in the last 20 years (1). Is it appropriate to continue in this direction? We need to have a discussion on task distribution and the makeup of personnel categories among Norwegian hospital staff.
The trends documented by Rosta & Aasland are most likely an expression of more profound changes in the role of doctors (8). Society and health authorities have a legitimate requirement for greater scrutiny in the use of resources and the quality of services, and this is achievable with more time spent on documentation. Increased specialisation has resulted in a greater need for clinical leadership, coordination and standardisation of treatment and patient pathways. The task of doctors is inextricably linked to medical diagnostics, treatment, and the encounter with individual patients. Doctors as a group must also deal with other important health service tasks – in various roles as «health system doctors». Doctors should be involved in leadership as well as innovation and quality assurance of the services. It is important to examine what doctors actually spend their working hours on, so that we can reflect on what doctors should spend their working hours on.