Medex:
A Time-Motion
Study
Clifford J. Sells, M.D., and Richard S. Herdener, B.S.
From (lie University of Wwthington School of Medicine, Seattle
ABSTRACT. Six Medex working with family practitioners were followed by an observer for a total of 18 days to gain an objective profile of how Medex spent their workday.
Medex on the average spent 30% of their time with office patients and saw 38% of all office patients. Medex saw between 25% and 100% of all pediatric office patients and spent on the average 37% of their office patient time with pediatric patients. On the average, Medex saw 8 pediatric and 1 1 adult office patients per day.
Well-child examinations, the largest pediatric diagnostic category, accounted for 30% of Medex pediatric office patient time. Minor surgery accounted for the second largest portion of pediatric office patient time (21%) while respira-tory illness ranked third (11%).
In view of the increasing role family practitioners and their assistants will undoubtedly play in the provision of child health care, pediatricians are urged to work closely with family physicians in developing and implementing health care services for children. Pediatrics, 56:255, 1975,
MEDEX, TIME-MOTION STUDY, PHYSICIAN’S ASSISTANTS.
A number of innovative programs have been
initiated in recent years to train non-physician
personnel to help provide child health care
services. The majority of these programs have
focused upon the retraining of nurses to function
in a more expanded role. Silver and co-workers’ at
the University of Colorado have been in the
forefront of this movement with their pediatric
nurse practitioner program. The first physician’s
assistant program utilizing former military
corpsmen was developed by Stead at Duke
Uni-versity.2 Graduates of the Duke program work with physicians in a variety of settings providing
both primary and secondary care.3
The Medex Program, pioneered at the
Univer-sity of Washington in 1969, trains former military corpsmen, nurses, and other qualified individuals
to work with family practitioners in the delivery
of primary care.4 The Medex Program is not designed, however, specifically to deliver child
health care services but rather is designed to train
new health professionals to work with physicians
who provide primary care for patients of all ages.
Since its inception, the Medex Program at the
University of Washington has provided training
for approximately 125 individuals, most of whom
are currently assisting family practitioners who
provide primary care in rural communities. Simi-lar programs patterned after the Medex
North-west model at the University of Washington are
located in Dartmouth, the University of Utah,
Charles Drew, the University of North Dakota,
the Medical College of South Carolina, Penn
State University at Hershey, Howard University,
and the University of Hawaii Medical Schools.
Despite the rather large number of Medex
graduates, few data are available regarding the
amount, the type, or the nature of the pediatric
care delivered by these new health care
provid-ers. The purpose of this study was to examine in
detail the activities of a small number of
repre-sentative Medex graduates to obtain information regarding their activities primarily as they relate
to the provision of child health services.
(Received May 13; revision accepted for publication November 11, 1974.)
Supported in part by project No. 913 from the Maternal and Child Health Services, Bureau of Community Health Services, Health Research Administration, Departlnent of Health, Education, and Welfare.
ADDRESS FOR REPRINTS: (C.J.S.) University of Washing-ton School of Medicine (WJ-10), Seattle, Washington
98195.
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TABLE I
PROFILE OF SIX MEDEX
Medex Age Education
Previous
Service Affiliation
Date Employed
Length
Employed
(mo)
Practice
Setting Location
A 48 High school Navy 5/72 13 With solo Town of 700
practitioner
B 34 High school Air Force 9/70 35 Partnership#{176} Town of 4,000
C 31 3 years college Navy 9/70 35 Partnership#{176} Town of 4,000
D 30 3 years college Navy 1 1/72 9 With solo Town of
practitioner 10,000
E 43 High school Navy 9/70 35 With solo Town of 2,000
practitioner
F 29 1#{189}years
college
Navy 11/72 9 Migrant health Town of 6,000 center
#{176}Atwo-physician group each with his own Medex.
METHODS
Six Medex graduates working with family
prac-titioners (one physician was an internist in family
practice) in rural communities were observed by
a second-year medical student (R.S.H.) for an
average of three full working days during the
summer of 1973 (Table I). The Medex were
selected from among the 58 graduates of the first
four Medex classes. Selection was limited to the
first four classes since these Medex had completed
their training and all had been employed at least
nine months prior to the initiation of the study.
The Medex selected were all providing significant
amounts#{176} of pediatric care and were chosen so
that the major geographical regions of the state of
Washington were represented.
The method of examination of the Medex’s
activities was via a time-motion study similar to
that used by Bergman et a15 in a study of
practicing pediatricians. The Medex were
ob-served from the time of their first hospital or
office visit in the morning until they left for home
in the evening. Permission for patient observation
was secured either by the office nurse prior to the
appointment with the Medex or by the Medex
immediately before the appointment. Securing
permission required on the average less than 30
seconds and no pediatric or adult patient refused
to be observed. Continual observation and
re-cording with a stopwatch was the method used.
#{176}Asignificant amount of pediatric care is defined as at least
25% of time devoted to pediatrics. Approximately 78% of all Medex graduates at the time of the study were spending at least 25% of their time in pediatrics.
The categories used in the study were derived
from a questionnaire, “Problems and Tasks in
Frequency Rank,” developed earlier in the Medex
program. Familiarity with the method was
accomplished through observation and timing of
several physicians in different types of practices prior to the initiation of the study.
Following the observation period, each
physi-cian and Medex were interviewed separately.
Medex were queried about their backgrounds,
their jobs, and their satisfaction with their jobs.
Physician-employers were queried regarding the
role of the Medex in their practices and the
patients’ satisfaction with Medex.
RESULTS
Method of Referral to Medex
Although the Medex studied were permitted to
see any pediatric patient (under 21), patterns of
referral varied among practices. In three
prac-tices, the Medex screened all pediatric patients
and referred those patients requiring care beyond
their expertise. In two practices patients were
selected by the clinic receptionist using physician
criteria based on Medex competence, and in one
practice patients were assigned to the Medex or
the physician depending upon who was available.
Patients could schedule appointments directly
with the Medex in all practices and were free to
see the physician rather than the Medex if they
desired.
Handling of Prescriptions and Fees
Prescriptions were handled in a variety of ways
=
C.,
0..
TABLE II
DAILY AcTIvITIEs OF MEDEX
Medex
Observ-ation
Period
(hr)
Average No. of
Office Patients per Day
Pediat- Adult iic
Average Office
Time
(mm)
.
-Pedia- Adult trics
Percent of Day
Personal
&
Miscell. With
Office
Patients
Paper-work
Hospital
rounds
Consul-tation
Tele-phone
Lab &
X-Ray Travel
A 28 5 9 10 10 35 26 20 4 3 1 9 1
B 16 7 9 7 7 50 21 11 7 2 7 0 1
C 16 8 14 8 8 41 29 12 12 1 4 0 2
D 25 4 8 20 21 22 47 13 3 5 3 4 4
E 32 12 12 6 7 45 28 10 9 3 2 1 2
F 24 10 15 10 13 39 29 21 0 6 2 0 2
Average 23.5 8 11 10 11 39 30 15 6 3 3 2 2
the six Medex’s written prescriptions were
spe-cifically countersigned by the physician. Tele-phone prescriptions by the Medex were generally
accepted by the local pharmacists, although one
physician specifically prohibited certain drugs
from being prescribed. None of the physicians
noted any problems regarding prescription writ-ing by the Medex. In no practice were fees altered if the patient was cared for by a Medex.
How Medex Spend Their Days
The average Medex in this study worked
approximately eight hours per day. Table II
depicts how the Medex spent their time, while Figure 1 portrays average time distribution of the
Medex. Thirty-eight percent of all office patients
were handled by the Medex while 52% were seen
by the physicians. Three percent were seen jointly and 7% of patients entered the office for
laboratory studies only. Depending upon the practice, Medex saw between 25% and 100% of
all pediatric patients.
An average of 8 pediatric office patients and
1 1 adult office patients were seen per day by
Medex during this study. Patient visit data for
typical summer and winter months suggested that
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25
10
26% 20% 21%
I
29% 21%
FIG. 2. Patient office time with Medex.
Pediatric Patients
H
Adilt Patients1.5
years
FIG. 3. Age distribution of pediatric patients.
1)
a-‘a
a.
=
‘a a,
=
a,
=
-a,
C-,
up to 20% more patients, however, are seen by
Medex during winter months.
The average office time per pediatric patient
was 10 minutes, while the average office time
spent per adult patient was 11 minutes.
Consid-erable variation was noted between Medex.
Medex on the average spent approximately one
third (30%) of their time with office patients. Of
the office time spent with patients, 37% (41% of
the patients) was spent with pediatric patients
and 63% (59% of the patients) with adult
patients.
Paper work accounted for 15% of the Medex’s
time. This included charting, filling out insurance
forms and camp physical examination forms, and
correspondence. Hospital rounds on the average
occupied 6% of the day. Again, marked variability
was present. Medex C spent 12% of his time with
hospital rounds while Medex F was not involved
in hospital rounds during the observation
pen-od.
The telephone played a relatively minor role in
the daily activity of the Medex. On the average,
only 3% of Medex time was spent using the
telephone. An average of 3% of Medex time was
spent consulting. This included consulting with
their physician associate, with other physicians,
with office nurses, and with other office staff. On
the average, 2% of the time was spent performing
laboratory procedures. Here the range (0 to 9) was great. Medex A spent significantly more time
than the other Medex doing laboratory
proce-dunes, as his duties included taking X-rays.
Travel time averaged 2%. Since all practices
observed were in small communities and
distances between offices and hospitals were
small, travel occupied a relatively small amount
of time. Personal and miscellaneous activities
formed the largest single category and accounted
for the remaining 39% of Medex time.
Time With Patients
accounted for 21% Overall this category
18% of the Medex
Diagnostic Categories
Table III
DIAGNOSTIC CATEGORIES OF OFFICE PATIENTS OF SIX MEDEX
Ra nk by % Time
All Patients
% Time
All Patients
% Patient Load
Category
Pediatric Patients
Adult Patients
Pediatric Patients
Adult Patients
Pediatric Patients
Adult Patients
All Patients
Well-care 1 10 3 30 4 13 26 4 13
Indepen-dent
minor
sur-2 2 1 21 15 18 16 14 15
gery
Respiratory 3 4 5 11 9 9 12 10 11
Orthopedics 4 1 2 9 19 16 10 16 14
Derma-tologv
5 6 6 6 6 6 7 8 6
ENT 6 12 10 5 3 4 7 4 6
Ill-defined syndromes
7 14 12 5 1 2 3 1 2
‘CU. 8 3 4 4 14 10 7 11 9
Allergy 9 8 7 4 5 5 6 8 7
C.I. 10 7 9 2 5 4 3 5 4
Cardiovas-cular
- 5 8 - 7 4 - 7 4
Endocrine - 9 11 - 4 3 - 5 4
Psychiatric-emotional
- 1 1 13 - 3 2 - 2 1
Other - - - 3 5 4 3 5 4
the introduction, physical examination,
proce-dunes, and discussion. The history was generally
obtained during the introduction and physical examination. Figure 2 compares pediatric and
adult patient time spent with the Medex. There
was little variation with respect to time
distnibu-tion between Medex.
Table III depicts the major pediatric and adult
diagnostic categories by rank order according to
percent of time and compares the order with
percent of patient load. Patients presenting
several complaints were considered under the
major category unless a significant amount of
time was spent with the secondary category. In
the latter case, separate times were kept for each.
Well-child examinations, the largest pediatric
category, accounted for 30% of the Medex
pediatric time and 13% of overall patient care
time. Minor surgery (suturing lacerations,
mci-sions and drainages, cyst and wart removals,
assisting physicians with excisions and biopsies,
etc.) was the second largest category and
of Medex pediatric time.
ranked first, accounting for
office patient care time.
Respiratory illness ranked third and involved 11%
of the Medex pediatric time and 9% overall.
Orthopedics ranked fourth and accounted for 9%
of all pediatric patient time but 19% of the adult
patient time and ranked second overall. The
relatively little time spent with respiratory illness
probably in part at least reflects the seasonal
character of the observation period.
Age Spectrum of Patients
Forty-one percent of patients seen by Medex
were under 21 years of age. Figure 3 portrays the
age distribution of the pediatric patients seen by
Medex. Thirty-two percent of children seen were
less than 6 years of age. The largest segment of
pediatric patients seen by Medex was the 12- to
21-year age group, accounting for nearly 40% of
pediatric patients seen. All Medex saw patients of
all ages. Although the number of children seen by
most Medex in any particular age category was
small, no significant differences were apparent
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between the individual Medex. No particular age
group required a disproportionate amount of
Medex time.
Medex Interviews
All Medex enjoyed the amount of time devoted
to pediatrics and two of the Medex expressed a
desire to spend more time with pediatric patients.
One Medex preferred pediatrics as a specialty if
given the choice. All felt that there was a role for
Medex in the clinical specialties as well as in
family medicine. The Medex generally felt that
their pediatric training was adequate, although
most desired additional pediatric training. None
of the Medex felt that the presence of an observer
interfered with or altered his usual practice activities.
Physician’s Interviews
Physician-employers were unanimous in their
support of the Medex program. They noted
virtually 100% acceptance of the Medex as a
member of their health care team by patients.
One physician, however, noted considerable
professional jealousy directed toward physicians
with Medex by some physicians without Medex.
The physicians generally preferred that the
Medex perform well-child examinations, see
chil-dren with upper respiratory tract disease, and
care for normal newborns, while the physician
himself preferred to see hospitalized children,
“very sick” children, and “complicated”
prob-lems.
Two physicians felt that their Medex helped
relieve them of some of the routine pediatric
activities, while the other physicians interviewed felt that this was not a problem due to the variety
in their practice. Although the physicians
gener-ally felt the Medex training in pediatrics was
good, they suggested more emphasis might be
placed on well-child care, on growth and
devel-opment, and on routine newborn care.
COMMENTS
The time-motion study was an attempt to gain
an objective profile of how Medex spend their
days. Although the sample was small, the six
Medex studied are felt to be representative of
typical Medex. Despite seeing an average of 18
office patients per day, the average Medex spent
only 30% of his time with office patients. There
was, however, considerable variability between
Medex. Medex D spent 47% of his time seeing
patients and devoted considerably more time to
each patient than other Medex studied. This was
due in part to a considerable orthopedic workload
in this particular practice and in part to decreased
patient load expectations by his employer, thus
allowing more time per patient.
Personal and miscellaneous activities (time
between patients, lunch, coffee breaks, talking to
the observer, visiting with nurses, etc.), the largest
single category occupying 39% of the Medex’s
time on the average, deserves comment.
Physi-cians and Medex alike felt the rather high
percentage of time spent by Medex with personal
and miscellaneous activities was at least in part
directly related to decreased patient visits during the summer.
The fact that an average of 41% of the Medex’s
patients are children confirms our assumption
that a significant amount of pediatric care is
provided by Medex. The independence of the
Medex in caring for patients is suggested by the
relatively small amount of time (3%) spent
consulting with physicians or seeing patients with
physicians (3%). It is interesting to note that little
time was spent using the telephone, since
pediatric care traditionally has relied heavily
upon the telephone.
Well-child care, not surprisingly, occupied the
largest portion of the Medex’s pediatric office
patient time (30%). The high percentage of
pediatric minor surgery time (21%) probably
reflects the Medex’s previous background and
experience. That virtually no time was spent with
pediatric emotional and behavioral problems is an
interesting finding. Since very little adult patient
time also was spent by Medex with emotionally
based problems, it is apparent patients do not
look to, or at least receive, significant assistance
from Medex in this important area.
The fact that most of the Medex desired
additional pediatric training is not surprising in
view of the rather limited backgrounds in
pediat-rics of most Medex generally, and the intensive
but brief formal pediatric experience provided in
the Medex program. Neither is it surprising that
patients overwhelmingly accept the Medex, since
patient acceptance of physician’s assistants has
been well documented.6
CONCLUSIONS
The data from this study suggest that Medex
perform some of the same tasks that pediatric
nurse practitioners perform but that major
differ-ences exist. As has been documented, Medex
spend little time on the telephone and apparently
almost no time with emotional and behavioral
problems. PNPs, on the other hand, generally
supervi-sion, counseling, and caring for children with
minor illnesses. Medex spent considerable time
with minor surgery and orthopedic problems
while PNPs devote little, if any, time to these
problems.
Pediatricians have been in the forefront in
developing PNP programs to assist practicing
pediatricians in the provision of child health care.
Large segments of our pediatric population,
however, are not cared for by pediatricians but
rather by family physicians. Medex, one type of
physician’s assistant, are currently assisting family
physicians in the provision of primary medical
care for both children and adults. If present
trends continue, family physicians and their
assistants may play an even greater role in
providing health care to children in the future. As
child health specialists, pediatricians have the
opportunity and the responsibility to work with
family physicians and their assistants, as well as
with pediatricians, in developing and
imple-menting optimum health care services for
chil-dren.
REFERENCES
1. Silver, H. K., Ford, L. C., and Stearly, S. G.: A program to increase health care for children: The pediatric
nurse practitioner program. Pediatrics, 39:756, 1967.
2. Stead, E. A., Jr.: A new approach to the doctor shortage. Resident Physician, 13:84, 1967.
3. Stead, E. A., Jr.: The Duke plan for physician assistants. Med. Times, 95:40, 1967.
4. Smith, R. A.: Medex. JAMA, 211:1843, 1970.
5. Bergman, A. B., Dassel, S. W., and Wedgwood, R. J.:
Time-motion study of practicing pediatricians.
Pediatrics, 38:254, 1966.
6. Smith, R. A., Bassett, C. R., Carnick, A. M., Vath, E. V.:
Freeman, W. L., and Dunn, C. F.: A strategy for
health manpower: Reflections on an experience called Medex. JAMA, 217:1362, 1971.
7. Patterson, P. K., Bergman, A. B., and Wedgwood, R. J.:
Parent reaction to the concept of pediatric
assist-ants. Pediatrics, 44:69, 1969.
8. Schiff, D. W., Frazer, C. H., and Walters, H. L.: The pediatric nurse practitioner in the office of pedia-tnicians in private practice. Pediatrics, 44:62,
1969.
ACKNOWLEDGMENT
We would like to acknowledge Dr. David Lawrence,
Medex Director, and his staff for their assistance in this study and the six physicians and their Medex who participated in the study. We would also like to thank Dr. Steve Dassel for his assistance in planning the study and Dr. Abe Bergman for his critical review of the manuscript.
EVALUATION OF HEALTH SERVICES
“. . . one of the dangers, then, of too rigorous an examination of medicine,
requiring proof beyond a reasonable doubt, is that ‘caring’ might be lost in the
‘house cleaning.’”
R. CARLSON,
The End of Medicine
(New York, Wiley, 1975)
(Noted by R.
J.
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