Primary Care Physician Time Spent in Patient Care: An Observational Study Using Electronic Health Record Logs

Background: Given a marked expansion in the work of primary care in recent decades, it is critical to have an accurate understanding of the time involved in managing a primary care panel and the determinants of this time. Objective: To estimate the yearly work effort involved for primary care physicians (PCPs) in caring for a patient panel, explore how work effort varies by clinical full-time equivalent (cFTE) status, and identify patient panel factors associated with differential time expenditure. Design: Cross-sectional, observational study using electronic health record and administrative data scaled by a literature-based estimate of activities inadequately captured by these data sources. Setting: 33 clinics in the Mass General Brigham health system. Participants: 406 attending PCPs who delivered care for at least 9 months in 2021. Measurements: Total yearly time expenditure per patient and full-time PCP. Results: The median work effort for a full-time PCP was 2844.3 yearly hours (IQR, 2324.9 to 3478.9 yearly hours), or 61.8 weekly hours (IQR, 50.5 to 75.6 weekly hours), for a 1.0-cFTE physician assuming a 46-week work year. This translates to a median of 1.7 hours (IQR, 1.4 to 2.2 hours) per patient per year. Part-time PCPs spent more time per patient on average than full-time PCPs. Patient medical advice request volume and certain panel characteristics, including greater average age, medical complexity, and percentage of patients with Medicaid, were associated with greater yearly PCP time expenditure per patient. Limitation: Derivation of data from a single integrated health system and lack of information about practice structures and staff supports for PCPs. Conclusion: Primary care physicians spend a median of 62 weekly hours caring for a patient panel. Panel characteristics and patient message volume are associated with time expenditure. These findings provide valuable insights for designing sustainable primary care roles and adjusting panel size expectations. Primary Funding Source: The Physicians Foundation.

Impact of Study Hypotheses on Results From Randomized Clinical Trials: Comparison Between Standard and Noninferiority Randomized Clinical Trials

Background: In embarking on randomized clinical trials (RCTs), researchers can hypothesize that a more intensive treatment is better than a less intensive treatment (positive hypothesis) or that a less intensive treatment is similar or noninferior to a more intensive treatment (negative hypothesis). Researchers may design noninferiority RCTs (NI-RCTs) to support negative hypotheses and standard RCTs (S-RCTs) to support negative or positive hypotheses. Regardless of hypotheses, S-RCTs and NI-RCTs should produce consistent results when assessing similar participants, interventions, control, and outcomes. Objective: To compare effect estimates in S-RCTs with positive hypotheses versus NI-RCTs and in S-RCTs with negative hypotheses versus NI-RCTs. Design: Meta-research. Setting: 98 meta-analyses. Participants: 468 RCTs, including 153 NI-RCTs and 315 S-RCTs (149 positive and 166 negative hypotheses). Intervention: S-RCTs as the exposure and NI-RCTs as the control. Measurements: The ratio of effect estimates between S-RCTs and NI-RCTs in each meta-analysis was combined across meta-analyses. Results: Standard RCTs with positive hypotheses produced effect estimates 1.47 (95% CI, 1.27 to 1.70) times larger than NI-RCTs; among RCTs rated as having low risk of bias for blinding, the ratio was 1.01 (CI, 0.70 to 1.45), whereas among those rated as having high or unclear risk of bias for blinding, the ratio was 1.81 (CI, 1.41 to 2.33). Standard RCTs with negative hypotheses did not produce statistically different effect estimates from NI-RCTs (ratio, 0.93 [CI, 0.84 to 1.03]). Limitation: Findings may be limited by residual differences between S-RCTs and NI-RCTs in the same meta-analysis. Conclusion: The researchers’ hypotheses may bias the results of published RCTs, especially those with high or unclear risk of bias for blinding. The effect of researchers’ hypotheses should be assessed in systematic reviews and clinical practice guidelines when RCTs addressing the same clinical question report conflicting hypotheses. Primary Funding Source: The Shenzhen Municipal Government, Guangdong Province, China, and the Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences.

Lyme Disease

Lyme disease, caused by Borrelia burgdorferi, is the most common vector-borne disease in the United States, and the range of its tick vector continues to expand. Most Lyme disease cases are diagnosed with the onset of the erythema migrans rashes, which can be single or multiple and vary from a homogeneous erythema to bull’s-eye patterns. Serologic antibody testing is of low sensitivity at onset but becomes highly sensitive after a few weeks. Early dissemination may lead to neurologic and cardiac complications. Mono- or oligoarticular arthritis may develop in untreated patients. Antibiotic treatment is highly effective, but approximately 10% of treated patients experience persistent symptoms.

Don’t Wait: Palliative Care Referrals Can Be Life-Changing

Projected Effects of Proposed Cuts in Federal Medicaid Expenditures on Medicaid Enrollment, Uninsurance, Health Care, and Health

In January 2025, the Republican majority in the House of Representatives’ Budget Committee offered a list of possible spending reductions to offset revenue losses from proposed tax cuts. In May, the Committee advanced a bill incorporating several reductions on the list. The Committee estimated that the 6 largest potential Medicaid cuts (for example, work requirements for some Medicaid enrollees) would each reduce the federal government’s Medicaid outlays by at least $100 billion over 10 years. On the basis of the Committee’s estimates of savings; Congressional Budget Office analyses; and peer-reviewed studies of the coverage, financial, and health impacts of past Medicaid expansions and contractions, the authors project the likely effects of each option and of the House bill advanced by the Budget Committee in May. Each option individually would reduce federal Medicaid outlays by between $100 billion and $900 billion over a decade, increase the ranks of the uninsured by between 600 000 and 3 900 000 and the annual number of persons forgoing needed medical care by 129 060 to 838 890, and result in 651 to 12 626 medically preventable deaths annually. Enactment of the House bill advanced in May would increase the number of uninsured persons by 7.6 million and the number of deaths by 16 642 annually, according to a mid-range estimate. These figures exclude harms from lowering provider payments and shrinking benefits, as well as possible repercussions from states increasing taxes or shifting expenditures from other needs to make up for shortfalls in federal Medicaid funding. Policy makers should weigh the likely health and financial harms to patients and providers of reducing Medicaid expenditures against the desirability of tax reductions, which would accrue mostly to wealthy Americans.

Does the Patient Want TV?

Gout

Gout is characterized by deposition of monosodium urate (MSU) crystals in or around joints, tendons, bursae, and other tissues, resulting in painful recurrent flares and tissue damage. Gout is the most common form of inflammatory arthritis, with a prevalence of 5.1% in the United States, affecting 12.1 million adults. When urate levels exceed the limit of solubility (6.8 mg/dL [400 μmol/L]), MSU crystals may form or grow. Gout flares are the result of inflammatory responses to MSU crystals. The primary method to prevent and reduce gout flares, tophi, chronic inflammatory arthritis, and joint damage is to reduce urate levels below the saturation threshold. The pathophysiology of gout is well understood, and inexpensive and effective therapies are available. However, outcomes for patients with gout remain poorly optimized.

Care of Bereaved Persons: A Systematic Review: Annals of Internal Medicine: Vol 179, No 4

Background: Bereavement after the death of someone close is universal, and clinicians may be uncertain if or what interventions may be beneficial. Purpose: To synthesize effects of health care interventions for bereaved children and adults. Data Sources: Eight databases were searched from inception in September 2025, supplemented with screening reviews, guidelines, federal register entries, and expert input. Study Selection: Dual independent reviewers selected randomized controlled trials (RCTs) comparing interventions for bereaved or soon-to-be bereaved persons with usual care, no intervention, or an alternative intervention. Data Extraction: Outcomes were evaluated using the abstractor-checker model. Risk of bias was assessed; random-effects meta-analysis was used for effect estimates; multiple effect modifiers were explored; and applicability, generalizability, and strength of evidence (SoE) were determined. Data Synthesis: A total of 169 RCTs reported in 303 publications evaluated psychotherapy; expert-facilitated support groups; pharmacotherapy; peer support; self-help interventions; writing, music, and art therapy; enhanced provider contact; and integrative medicine for bereaved persons. Risk of bias was substantial, and only 15 RCTs included children. There was moderate SoE that individual psychotherapy improves grief disorder, grief, and depression symptoms and low SoE that expert-facilitated support groups and enhanced contact with health care providers may improve depression symptoms. Other interventions showed conflicting results, indicated no benefit, or had insufficient SoE. Limitations: Research focused on grief in adults, study populations were complex, and the review may have missed culturally specific interventions. Conclusion: Psychotherapy can improve key outcomes in bereaved adults, and expert-facilitated support groups and enhanced provider contact may also provide benefits. Evidence for other bereavement interventions, approaches for children, and outcomes beyond general grief or grieving, grief disorder, and depression symptoms is limited. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42023466057)

How Would You Manage This Patient With Recent-Onset Atrial Fibrillation? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Atrial fibrillation (AF) is the most common arrhythmia. Risk factors for AF include obstructive sleep apnea, physical inactivity, obesity, cigarette use, and alcohol misuse. Atrial fibrillation substantially increases the risk for stroke and is associated with higher rates of mortality than for individuals without AF. Strategies to prevent these risk factors and to optimize those that already exist reduce the risk for subsequent AF. Physicians play an important role in proposing strategies to reduce the risk for AF among patients. Decision making regarding management of AF is often complex and requires consideration of symptoms, burden of AF (the percentage of time in AF), comorbid conditions that increase stroke risk, and the risk for bleeding. In particular, novel risk scoring systems to predict stroke risk, and consideration of factors beyond those in these tools, refine the ability to identify patients with AF who are most likely to benefit from anticoagulation to reduce stroke risk. Early use of catheter ablation of AF in selected patients improves symptoms and reduces the potential for progression from intermittent to persistent AF. A 2023 collaborative guideline from the American College of Cardiology, American Heart Association, American College of Chest Physicians, and the Heart Rhythm Society addressed multiple aspects of care of patients with AF. Here, a general cardiologist and a cardiac electrophysiologist discuss recommendations derived from this guideline and how to apply them to the care of a particular patient.

Exposure to Computed Tomography Before Pregnancy and Risk for Pregnancy Loss and Congenital Anomalies: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 178, No 11

Background: Animal studies show ovarian follicle damage and mutagenesis after ionizing radiation exposure. Computed tomography (CT) imaging is commonly done outside pregnancy, but risks to future pregnancy are unknown. Objective: To evaluate the risk for spontaneous pregnancy loss and congenital anomalies in offspring of women exposed to CT ionizing radiation before conception. Design: Population-based observational study. Setting: Ontario, Canada. Participants: 5 142 339 recognized pregnancies and 3 451 968 live births identified between 1992 and 2023. Measurements: The exposure was the cumulative number of CT scans up to 4 weeks before conception. Outcomes were spontaneous pregnancy loss (miscarriage, ectopic pregnancy, or stillbirth) among recognized pregnancies and congenital anomalies diagnosed within the first year of life among live births. Results: Mean maternal age was 29 years. Diabetes, hypertension, obesity, and smoking were more common in those exposed to CT imaging. Among recognized pregnancies, rates of spontaneous pregnancy loss were 101, 117, 130, and 142 per 1000 pregnancies with 0, 1, 2, and 3 or more preconception CT scans, respectively, and adjusted hazard ratios (aHRs) were 1.08 (95% CI, 1.07 to 1.08) for 1 CT scan, 1.14 (CI, 1.12 to 1.16) for 2 CT scans, and 1.19 (CI, 1.16 to 1.21) for 3 or more CT scans. Among live births, rates of congenital anomalies were 62, 84, 96, and 105 per 1000 births in those with 0, 1, 2, and 3 or more CT scans, and aHRs were 1.06 (CI, 1.05 to 1.08) for 1 CT scan, 1.11 (CI, 1.09 to 1.14) for 2 CT scans, and 1.15 (CI, 1.11 to 1.18) for 3 or more CT scans. The risk observed with head CT was not consistently lower than with CT of the abdomen, pelvis, or lower spine. Limitation: Incomplete ascertainment of CT exposure and underlying indication may have contributed to residual confounding. Conclusion: Exposure to preconception CT imaging may be associated with higher risks for spontaneous pregnancy loss and congenital anomalies, but causal mechanisms remain to be elucidated. Alternative imaging methods should be considered when appropriate. Primary Funding Source: Canadian Institutes of Health Research.