Physician time-saving by employment of expanded-role

Physician time-saving byemployment of expanded-rolenurses in family practiceR. E. M. Lees, m.d., m.f.c.m., Kingston, Ont.

Summary: Registered nurses

working in five family practicesin Kingston, Ontario, were givena period of in-service trainingand supplementary formalinstruction at Queen's Universityto expand their skills and enablethem to undertake prescribedprocedures in the physicians' offices.Operational data collected fromthe five practices before and aftertraining was analysed to assessthe saving of physician timeeffected by the expansion of thenurses9 activities in providingprimary medical care. Physiciantime was saved in all cases butthe amount varied. The results are

presented and discussed inrelation to staff, physical premisesand patterns of practice of theparticipating physicians. Under themost advantageous practicecircumstances in this study, a33.7% saving in originalphysician time was obtained.The mean time-saving forthe five practices was 18.2%.

Computer simulation of family med¬ical practice has shown that the ad¬dition of one or more nurses tothe primary health care team doesnot ipso facto result in increasedpractice efficiency, economy, savingof physician time or a reduction inthe time the patient spends withinthe physician's office. The improve¬ments in practice efficiency conse¬

quent on the employment of anurse depend on a variety of in¬trinsic circumstances the ratioof physicians to nurses, the ratioof rooms to personnel employed,the duties of the nurse and the re-

R. e. m. lees, Associate Professor,Department of Community Healthand Epidemiology, Queen's University,Kingston, Ont.

Reprint requests to: Dr. R. E. M. Lees,Dept. of Community Healthand Epidemiology, Queen's University,Kingston, Ont.

sponsibility for patient care dele¬gated to her, the system of patientscheduling, and so on.1

Studies in Canada2 and theUnited Kingdom3 have indicated thatpatients are willing to accept thenurse in family practice in a roleof greater responsibility than thatwhich she has traditionally beengiven. However, the final outcomeof current controversy about herfuture role as a member of thefamily practice team will likely bedetermined by the economic ad¬vantages accruing to the health serv¬ices or the individual practice. Theseeconomic advantages may be ex¬

pressed as savings in national healthexpenditure, increased physician in¬come or reduction of physician workhours (in which case income mayremain constant but leisure time in¬crease). Provincial governments' in¬volvement in the provision of per¬sonal health services increases thedemand for primary health care .

the public demands made for serv¬ice at this level are ones over whichthe physician has little control otherthan by refusal to accept more pa¬tients into his practice. This typeof physician-imposed control on theprovision of health c*re exaggeratesthe shortage (imagined or real) offamily physicians and creates in¬creased public dissatisfaction withthe health services in general. Tomeet the demand under present sys¬tems of family practice forces a re¬duction in the quality of- care

provided to the individual patient.W. J. Troup4 has pointed out

that there is cause for concern inthe foreword to the Hastings Reportwhich states that the governmentconcern over health services isprimarily with rising costs, whereasthere is no expression of concernover the inadequacy of the deliveryof health care.5 A large section ofthe Canadian population still ex¬

periences difficulty in gaining accessto the health care system; while thisremains the case, financial concerns

must surely be secondary to theneed for improvements in the wholesystem of health services so thateveryone has an equal opportunityto obtain medical care.The system must be kept in

balance, however, and improve¬ments effected without making un¬due demands on the national treas-ury. The employment of more para¬medical personnel may permit amore equitable distribution of pri¬mary health care but will only beeconomically justified, to the satis-faction of governments at least, ifthe unit cost of patient service canbe held constant or reduced.

There are difficulties in attempt-ing to assess accurately the impactan expanded-role practice nurse canhave on a family physician's workload and in attempting to reducetime savings or increased patientservice to terms of dollars and cents.It would appear that a minimumgain from the introduction of suchassistance to a practice must be anincrease in practice income equal tothe expenditure on the nurse's salaryand facility improvement or, in thecase of a sponsored clinic, a reduc¬tion in the unit cost of patient serv¬ice.The study described below rep¬

resents an attempt to quantifychanges in the work loads of physi¬cians and nurses in five family med¬ical practices in and around King¬ston, Ontario, after the nurses hadtheir role expanded by an in-servicetraining program and were givenincreased responsibility for patientservice. The physical premises oc-

cupied by the practices varied con¬

siderably and, in the light of resultsobtained from computer simulationstudies of the effects of expanded-role nurses in a variety of practicesettings, it was expected that dif¬ferences would be observed betweenthe study practices.

Method

Of the five participating familyphysicians, three worked as solopractitioners from individual officeswhile two worked together from asmall clinic built three years pre¬viously to their own specifications.Apart from waiting areas the spaceallocation in the offices was as fol¬lows:

Practice A: one consulting room,

C.M.A. JOURNAL/APRIL 7, 1973/VOL. 108 871

two examination rooms and onetreatment room.Practice B: one consulting room,one examination room and onetreatment room.Practice C: one consulting room,one examination room and onetreatment room.Practice DE: two consultingrooms, three examination roomsand one treatment room.

Physicians D and E, while work¬ing closely together and sharing fa¬cilities (nurse, secretarial service,etc.) apart from their consultingrooms, maintain separate patientlists and are considered in the re¬sults both as individual physiciansand as a partnership. Prior to thestudy each practice employed anurse (practice DE employed onenurse who worked for both of thephysicians) working in the tradi¬tional fashion of a nurse in a

family physician's office.Baseline data (described below)

were collected prior to the study,after which the nurses were givenin-service training by their physicianemployers and a series of supple-mentary lecture/seminars (30 hoursof instruction) at Queen's Univer¬sity. The training was designed tomeet the following objectives: thepractice nurse would make patientreferrals to specialists, complete thehistory and parts of the clinicalsections of such standard forms asschool health assessments, advise onand perform immunizations and vac-

cinations, give all except intravenousinjections, perform venepunctures,treat minor injuries and renew

dressings, take blood pressures,syringe ears, carry out all officelaboratory procedures and collectand transmit specimens to hospitalor provincial laboratories. On themore clinical aspects of office prac¬tice she should conduct most of theroutine pre- and postnatal examina¬tions and well-baby examinations,and undertake periodic assessmentsof patients with chronic diseasessuch as hypertension, diabetes,obesity and arthritis. The nurseshould also be able to do some pa¬tient counselling in areas such as

family planning and advise on

dietary or therapeutic regimens.Within some of the practices

nurses were undertaking several ofthese tasks even at the period ofbaseline data collection but as the

study progressed all expanded thequality and quantity of their patientservice to meet these objectives.

Data were collected by a researchassistant who sat in the physician'soffice throughout the sample daysand recorded the number of pa¬tients seen by the physician, nurse,and physician and nurse together;she also recorded the time of con¬tact with each member of the staff.Phone calls handled by the physicianor nurse were noted, as were labo¬ratory tests performed on thepremises and specimens sent to out¬side laboratories. The participatingphysicians kept a log of their patientcontacts outside the office, such as

hospital and home visits, togetherwith the time spent on these ac¬tivities.Two periods of sample days, one

at the beginning of the study andone a year later, consisted of 10days of observations over a 10-weekperiod. If sample day number 1was on a Monday, number 2 wasthe Tuesday of the following week,number 3 the Wednesday of theweek after, etc, so that an extendedperiod of observation was possibleand the cumulative total includedtwo Mondays, two Tuesdays andso on to give two working weeksin all. This was done to minimizeany unusual fluctuations of activityresulting from daily or seasonal

variations in patient demand. Nursetraining was begun after the firstobservation period.Results

In none of the practices was therea noteworthy change in the totalnumber of phone calls handled bythe physician or nurse or in thenumber of laboratory investigationsconducted within the office or re¬

quested from outside laboratories.Table I illustrates changes occur¬

ring in patient volume and profes¬sional man-hours spent iri the of¬fices between the two. 10-day ob¬servation periods. Changes in man-hours of work are given as per¬centage changes between these twoperiods.

The types of professional con¬tact possible for patients seekingservice would be with the physician,with the nurse or with both. Thepercentages of patients making eachtype of contact are set forth inTable II for the first and secondobservation periods. Table IIIshows the professional-contact timechanges which patients experiencedbetween the two periods; thechanges are recorded for time incontact with the physician and forcontact with either physician ornurse.

Between the two observation

Table IChanges in patient volume and professional man-hours in office

Table IIPercentages of patients seen by practice personnel

872 C.M.A. JOURNAL/APRIL 7, 1973/VOL. 108

periods physicians D and E re¬duced the frequency of home/hos-pital visits by 92% and the timespent on such visits by 88.6%.These reductions were in fact dueto a complete cessation of hospitalinpatient and emergency departmentvisits. The frequency of home visitswas unchanged. Only physician Aincreased his frequency of, and timespent on, hospital/home visits .a 21.4% increase over his initialobservation-period time.

Discussion

In the year during which the fivepractices were observed, the pres¬ence of an expanded-role practicenurse appears to have effectedchanges in the patient-service timein each case. The differences ob¬served between the two assessmentperiods were, however, not uniformand only in the instances of physi¬cians D and E were the changesconsistent enough in direction andquantity to permit the conclusionthat the practice nurse had per¬mitted substantial alterations to thepattern of office organization andpatient service. These two physi¬cians had (if their individual resultsare combined) increased their pa¬tient load by 5% while reducingtheir own time in the office by 23%and the office time (in patient con¬

tact) of themselves and their nurse

by 20%. Nevertheless, they werestill providing a mean patient-con-tact time with the physician of 6.7minutes and with all the professionalpersonnel of 10.1 minutes.

All the physicians in the studydid achieve reductions in mean con-tact-time per patient for themselvesand for all professional personnelwithin their offices. Only physicianC increased the total time spent in

his office between the two observa¬tion periods (by 15.3%) but thisextra time was not spent entirely onpatient contact; during the secondperiod he spent an extra three hourson non-patient-contact office ac¬tivities and in the additional 2 hoursand 40 minutes made physician-onlycontacts with an additional 24 pa¬tients. Between the two observa¬tion periods he halved the numberof phone calls he made, while hisnurse increased her total phone callsby an approximately equal number.Each physician altered his pat¬

tern of practice considerably afterthe role of the practice nurse was

expanded but there was no consis-tency of the alterations for the sev¬eral physicians except in the in¬stances of physicians D and E whowork closely closely together andshare the same nurse. In this casethe nurse rather than the physiciansmay well have been the determinantof the trend of pattern changes.

Hodgkin and Gillie,7 in reportingin 1968 their study of the impactof a nurse on their two-man prac¬tice in England, noted that assess¬ment of resulting physician time-savings were difficult because mostgeneral practitioners will allow theirwork to fill the working day. Inother words, Parkinson's law willapply. In Canada, where physiciansdo not have fixed numbers of pa¬tients in their practices as in Eng¬land, time saved may still be filledeither by adding to patient volumeor by engaging in extra-office med¬ical activities. Parkinson's law didapply in the study under discussion:we found the collaborating physi¬cians spending their "saved time"in increasing the time normally de¬voted to hospital or home care (A),increasing patient load and timespent within the office in non-pa-

Table mChanges in patient contact-time in office

(ibuprofen)Action: Ibuprofen has demonstrated anti-inflammatory, analgesic andantipyretic activity in special animal studies designed to specifically demon¬strate these effects. Ibuprofen has no demonstrable glucocorticoid effect.Ibuprofen has been found to be less ulceroeenic and less likely to causegastrointestinal bleeding in doses usually used than is acetylsalicylic acid.Clinical trials in man have shown the clinical activity of a dose of 1200 mgof ibuprofen daily to be similar to that of 3.6 grams of acetylsalicylic aciddaily.Indications and Clinical Uses: Ibuprofen is indicated for the treatment ofrheumatoid arthritis and osteoarthritis.Contraindications: Ibuprofen should not be used during pregnancy or inpediatric patients because its safety under these conditions has not beenestablished. Ibuprofen should not be used in patients with a history of acetyl¬salicylic acid-induced bronchospasm.Precautions: Ibuprofen should be used with caution in patients with a Justoryof gastrointestinal ulceration.Ibuprofen has been reported to be associated with toxic amblyopia. Thereforeprecautions should be taken to ensure that patients on ibuprofen therapyreport to their physicians for full ophthalmological examination if they experi¬ence any visual difficulty. Medication should be discontinued if there is anyevidence of toxic amblyopia.Adverse Reactions: The following adverse reactions have been noted in patientstreated with ibuprofen:Gastrointestinal: Nausea, vomiting, diarrhoea, constipation, dyspepsia,epigastric pain and guaiac positive stools have been noted in a few patientstreated with ibuprofen. No radiologically proven cases of ibuprofen inducedgastric or duodenal ulcers have occured.Central Nervous System: Dizziness, lightheadedness, headache, anxiety,mental confusion and depression were noted in some patients treated withibuprofen.Ophthalmological: Blurred vision was noted in some patients and rarely asensation of moving lights was observed following administration of ibuprofen.In addition there are three published cases of toxic amblyopia associated withthe use of ibuprofen. Although a definite cause effect relationship was notestablished, the attending physicians considered them to be drug related. Thecondition was characterized by reduced visual acuity and difficulty in colourdiscrimination. Defects (usually centrocaecal) were observed on visual fieldexamination. Symptoms were reversible on discontinuation of treatment.Retrospective examination of 142 patients on continuous ibuprofen therapyfor periods of one to four years failed to find similar cases of visual distur¬bances.Skin: Maculopapular rashes and generalized pruritus have been reported withibuprofen therapy. Occasional cases of oedema have also been reported.Laboratory Tests: Sporadic abnormalities of liver function tests have occurredin patients on ibuprofen therapy (SGOT. serum bilirubin and alkalinephosphatase) but no definite trend was seen indicating toxicity. Similarsporadic abnormalities of white blood count and blood urea determinationswere noted.Symptoms and treatment of overdosage: Ibuprofen at a dose of 2400 mg perday for 4 weeks was given to normal volunteers without serious side effects.In another study there was no increase in gastrointestinal blood loss asmeasured by Ca labelled R.B.C.'s in patients receiving as high as 1800 mgof ibuprofen per day for 3 weeks.One case of overdosage has been reported. A one-year-old child ingested 1200mg ibuprofen and suffered no ill effects other than being drowsy the next day.Blood levels of ibuprofen reached 711 mcg/ml, which is considerably above the90 mcg/ml previously recorded as the nighest level seen in adults after asingle oral dose of 800 mg. The S.G.P.T. level, 9 days postingestion, was 72.No specific antidote is known. Standard measures to stop further absorptionand maintain urine output should be implemented at once. The drug isexcreted rapidly and excretion is almost complete in six hours.

PHARMACOLOGYHuman: Following a single 200 mg dose of ibuprofen in humans, useful bloodlevels were demonstrable in 45 minutes and still present in six hours but atbarely detectable levels. Peak levels occurred at approximately one hour afteringestion. Levels were lower when taken in conjunction with food.Two metabolites of ibuprofen were isolated from the urine of patients whohad been dosed for one month with the drug. The metabolites were identifiedas 2-4' (2-hydroxy-2-methylpropyl) phenylpropionic acid (metabolite A) and2-4' (2-carboxypropyl) phenylpropionic acid (metabolite B). About ^ of thedose was excreted in the urine of patients as metabolite B, 1/10 as unchangedibuprofen, and 1/10 as metabolite A. The remainder of the dose could notbe identified in the urine.Effect of ibuprofen on patients taking sodium warfarin: A group of hospitalizedpatients were placed on a dosage of sodium warfarin which maintained theirprothrombin time at approximately double that of the control prothrombintime for the hospital labdratory. Five days after sodium warfarin was started,patients were placed on placebo capsules. After five days on placebo capsules(10 days after starting anticoagulant medication) 1200 mg ibuprofen per daywas administered in an identical appearing form for a further five days. Dailyhaematological examinations were performed throughout the study. Theadministration of ibuprofen to these patients had no effect on any of the bloodcoagulating factors evaluated and, in particular, no effect on the patients'prothrombin time.In another clinical study, comparing ASA and ibuprofen on a double-blindcrossover basis, one patient, by coincidence, was on sodium warfarin therapyfor medical reasons. While on the ASA portion of the study her prothrombintime rose sharply and sodium warfarin had to be discontinued. The patientat this point in the study was due to switch to ibuprofen and this changewas made. Her sodium warfarin dosage then returned to its pre-ASA levelwithout difficulty. This case is an isolated finding and more experience isneeded to confirm the effect of ibuprofen on a patient's requirement of sodiumwarfarin.Effect of ibuprofen on acetylsalicylic acid-induced gastrointestinal bleeding:A small group of patients demonstrating acetylsalicylic acid-induced gastroin¬testinal bleeding were switched directly to ibuprofen. Bleeding induced byacetylsalicylic acid was neither prolonged nor aggravated when patients wereon ibuprofen therapy.Dosage and Administration: Adults-To obtain rapid response at the start oftreatment, particularly when transferring from other anti-inflammatory therapy,Motrin should be given at a dose of two tablets three times a day (1200 mgper day) until optimum clinical response is achieved. Medication should begiven on rising in the morning, at midafternoon and at bedtime to insureadequate drug effect throughout each 24 hour period. Subsequently the dosagefor maintenance therapy may be reduced to one tablet three or four timesa day (600 to 800 mg per day) depending on the response of the patient.Children: Due to lack of clinical experience, ibuprofen is not indicated foruse in children under 12 years of age.Dosage Forms: Ibuprofen is available as 200 mg sugar coated tablets in bottlesof 100 and 1,000.Product Monograph available upon request.721 l REGISTERED TRAOEMARK: MOTRIN CE 6766.1

THE UPJOHN COMPANY OF CANADADON MILLS. ONTARIO Vpjohn

C.M.A. JOURNAL/APRIL 7, 1973/VOL. 108 873

tient activities (B and C) or in tak¬ing outside appointments as in¬dustrial or prison medical officers(D and E). All of the physiciansetngaging in this study are alsopreceptors in Family Medicine atQueen's University, devoting sev¬eral hours weekly to teaching, andparticipate in rotational staffing ofrural clinics in outlying areas. Itis, therefore, difficult to assess theimpact of the practice nurse interms of time saved in the physi¬cian's working day but, subjectively,the physicians were unanimous infeeling that their time was betterutilized, their hours of work more

regular and their level of job satis-faction greater.

Individual variations in patternsof practice and utilization of theskills and abilities of the expanded-role nurses make it impossible togeneralize on the physician time-savings which can be effected bythe employment of a family prac¬tice nurse working at the level de¬scribed here. Patient- and work¬loads can vary from day to day andfrom week to week so that perhapsthe most effective way of assessingtime savings is on a mean patient-contact time basis. The Royal Col¬lege of General Practitioners inBritain estimates the physician time-saving, for tasks and patient loadheld constant, to be between 4 and8% when a practice nurse is em¬

ployed.8In this study it was found that the

mean time-saving for unit patient-service varied, for the physician,from 3.4 to 33.7% (mean 18.2%)and for total professional (physicianand nurse) service time from 6.5 to27.9% (mean 16.5%).

In computer simulation model-ling, differences in physician spaceavailable within the office as wellas the physician/nurse ratio were

found to affect the efficiency withwhich a nurse could be utilized.One physician and one nurse work¬ing in an area with four usablerooms appear to be a more ef¬fective team than the same teamwith two available rooms. With fiverooms available, efficiency againfails. In general, two rooms in ex¬cess of the number of personnel inthe team (up to a maximum offour) provides the most efficient al¬location of physical space for thistype of approach to primary medicalcare. In this study, excluding small

treatment rooms used by the nursefor doing dressings and giving in¬jections, only physicians D and Ehad two rooms in excess of thenumber of professional personnelworking. Since they generally oc-

cupy the office space at differenttimes, and only the consultingrooms were not shared at any time,they had an effective "two roomsin excess of personnel" situation.Physician A had one room in ex¬

cess of personnel.Despite reductions by all physi¬

cians and teams in their mean serv-

ice-time per patient, only three (A,D and E) reduced the total amountof time they spent in their offices;B's time remained unchanged buthe saw more patients, as did Cwhose time in the office actuallyincreased by a greater amount thanthe percentage increase in patientvolume (Table I).One concern over this reduction

in contact time per patient is relatedto the effect on the quality of care

dispensed. No objective third-partymeasurements of quality of care

were attempted in this study but byquestionnaires submitted to the pa¬tients at its conclusion, an impres¬sion of consumer satisfaction withcare provided by the practice nursewas obtained. In a random sampleof patients from the study prac¬tices 68.2% believed that the prac¬tice nurse was better qualified andmore experienced than family prac¬tice office nurses in general, com¬

pared with 45.8% in a control prac¬tice where nurses worked in the ex¬

panded role but did not have thetraining given to the study nurses.

Of those who had received advicefrom the practice nurses 60.8% saidthat they were very satisfied withthe advice, compared with 49.4%from the control group. Only 1%from each group stated that theyhad been dissatisfied with thenurse's advice. In the event thatthe physician was temporarily un-available 81.2% of study patients,compared with 67.0% of the con¬

trol group, stated that they wouldbe happy to attend the office andbe seen by the nurse. These dif¬ferences were all significant at theP < 0.05 level.

In obtaining the impression ofthe practice nurses by questionnaireat the end of the study all four feltsubjectively that the quality of care

given to the patients had improved

by the second observation period.They felt, however, that the physi¬cians had not delegated sufficientresponsibility to permit them to as¬sume their maximum potential as

practice nurses in the light of thetraining they had received.One would have anticipated

marked changes in the distributionof patient contacts with the physi¬cian, the nurse, or both, betweenthe first and second periods. Withincreasing delegation of responsibil¬ity one would have expected physi-cian-only contacts to decline andnurse-only contacts to increase. Thefact that this did not happen (TableII) might well be a substantiation ofthe subjective impressions of thenurses. On the other hand, the de¬sign of the study did not permit theobserver to note changes in thequality of contact between nurseand patient either in nurse-only or

nurse-and-physician contacts.

Conclusions

There can be no exact calculationof physician time-saving when an

expanded-role practice nurse is em¬

ployed but, on the basis of unitpatient-service time, all the par¬ticipating physicians did achievesome measure of saved time; itvaried considerably from practiceto practice. Physical space availablefor the team to work in appears tobe extremely important in deter¬mining the efficiency of the team-of-two approach to patient care infamily practice as does the ratio ofphysicians to nurses in the prac¬tice, provided it does not exceed1:1 in any working period.By the criterion of unit service-

time per patient this study showeda physician office-time saving of3.4 to 33.7% or from 1 hour and4 minutes to 9 hours and 3 min¬utes per week. Hodgkin and Gillie7found that in their practice, with a

physician/practice-nurse ratio of2:1, a time saving of 7 hours and30 minutes per physician per weekwas effected, i.e. 15.7% of physi¬cian time. They further claim thattheir practice was in a growth situa¬tion and had it been static the timesaving would have been 11 hoursand 15 minutes per week or 27%of physician time, very close to thelevel recorded by physicians D andE.Some of the physicians increased

874 C.M.A. JOURNAL/APRIL 7, 1973/VOL. 108

their work to accommodate the timesaved but, despite this, their sub-jective impressions were that theywere working more regular hoursand had extra leisure time. Thesefeelings probably reflect improve-ments in practice organization andapportionment of physician timewhich were made possible by dele-gation of more responsibility to thenurse. If this was true, then the fullbenefit of the introduction of a prac-tice nurse cannot be quantified bythe data collected in this study andit is doubtful whether it can be ac-curately assessed at all. These sub-jective impressions may ultimatelybe of great importance, for if theyindicate that family practice can bea more attractive vocation than iscurrently believed by medical stu-dents and young physicians, themajor benefit to the health servicesas a whole, of increased employmentof expanded-role practice nurses,may be the attraction of more physi-cians into this branch of medicine.

I wish to thank Dr. R. A. Spasoff forhis assistance during the preparationof this paper. Miss G. Thompson andMrs. I. MacDonald were responsiblefor data collection.The study was supported by De-

monstration Grant D.M. 5 from theOntario Department of Health.

ResumeL'extension du role des infirmieresen pratique familiale et l'epargnede temps pour le medecinDes infirmieres diplomees travail-lant dans cinq bureaux de genera-listes 'a Kingston, Ontario, ont eteformees durant leurs heures de ser-vices actif et ont recu une forma-tion supplementaire a Queen's Uni-versity. Cette formation etait desti-nee a augmenter leurs connaissan-ces pratiques et 'a leur permettred'appliquer les traitements prescritspar leur patron. Les donnees re-cueillies dans les cinq bureaux sus-dits avant et apres la periode deformation ont ete analysees en vued'evaluer le temps qu'epargnaientles medecins, en confiant a leursinfirmieres certaines taches primai-res qui leur incombaient jusque la.Dans tous les cas, les medecins ontgagne du temps, mais dans une me-sure variable. Les resultats de l'e-tude ont ete presentes et analysesen tenant compte des equipes encause, des lcocaux disponibles et dela nature de la pratique des mede-

cins participants. Dans les condi-tions les plus avantageuses, les me-decins ont gagne 33.7% de leurtemps par rapport a l'epoque prea-lable. Quant 'a la moyenne de tempsgagne, pour les cinq bureaux, ellea t de 18.2%.

References1. SAGAR G, MoRRow T, LEES R: Could

you use a physician's assistant inyour practice?- a computer analy-sis. 1972 (in press)

2. LEES R, ANDERSON R: Patient atti-tudes to the expanded role of thenurse in family practice. Can MedAssoc J 105: 1164, 1971

3. SMITH JW, O'DoNovAN JB: Thepractice nurse- a new look. Br MedJ IV: 673, 1970

4. TRoUP WJ: Reaction to the HastingsReport. Can Med Assoc J 107: 907,1972

5. Report on the Community HealthCentre Project Committee to theConference of Health Ministers,1972, Ottawa.

6. Royal College of General Practi-tioners Council: The Practice Nurse:furthzer development of her role ingeneral practice and its effect on thedoctor's work. London, 1968

7. HODGIN K, GILLIE C: Relieving thestrain by work study and a practicenurse in a two doctor urban practice,in Ibid

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C.M.A. JOURNAL/APRIL 7, 1973/VOL. 108 875