TNT to Improve Primary Care Practice

Laura Blinkhorn, MD
Posted on May 6, 2024

In his book, “Four Thousand Weeks: Time Management for Mere Mortals,” Oliver Burkeman urges readers to “resist the allure of middling priorities.” The most dangerous distraction from our most essential goals comes less from obvious time wasting than from valuable but less worthy priorities; as a family physician, the idea resonates. The bustle of box-checking can distract from more critical patient concerns; yet many preventive health recommendations seem reasonable. How are we to determine which priorities are primary and which are middling? An article in the BMJ in 2023 proposes a tool to help answer that question: time needed to treat (TNT).

In the piece, Minna Johansson and colleagues argue that physician time with patients is a precious resource and that guideline writers and policymakers should consider and quantify the time needed for a physician to perform the process of coming to a recommendation. Such a metric could help evaluate feasibility and desirability. As an example, the authors looked at the UK’s NICE guideline that all general practitioners screen adult patients for inactivity and then, when appropriate, provide brief guidance on exercise to sedentary patients. Using estimates of an average patient panel of 2,000 adults, time to perform the questionnaires and counseling (1 to 11 minutes), and effectiveness of such an intervention, Johansson and colleagues calculated that it would take a family physician 167 minutes a year, or, in relative terms, 15% of their annual face-to-face time with patients. At a patient level, it would take a family physician 3 hours of counseling to have one patient increase their self-reported amount of exercise. Exercise counseling seems like an admirable goal; however, TNT suggests that such broad application of the goal is unrealistic.

A recent analysis in the Canadian Family Physician highlighted the TNT for different guidelines on screening to prevent fragility fractures. They contrasted the new Canadian Task Force on Preventive Health Care guideline, which recommends a risk-based, shared decision-making approach for women older than 65 years with more traditional universal bone mineral density first approaches. Over 25 years, the risk-based, woman-only, older than 65 years population would take 58 clinician hours vs. 112 hours for routine bone mineral density approach for all women older than 65 years. The calculations are complex, and the time saved is relatively modest, but they give a valuable perspective. Targeting populations and eliciting patient preferences from the beginning seems to save time without sacrificing quality.

Similar to the Choosing Wisely and Lown Right Care series, the concept of the TNT approach could further the goal of reducing time-intensive, low-value care or, in Burkeman’s words, the middling priorities. This could help physicians with the primary goal of caring for the patient in front of us. As all family physicians know, the most significant insights often emerge when we sit with our patient in unrushed silence.

Dr. Blinkhorn is the 2023-2024 AFP Jay Siwek Medical Editing Fellow.