Pay-for-performance and low back pain with interaction of overwork: findings from the cross-sectional Korean working conditions survey.

Background: Pay-for-performance (PFP) is a type of incentive system where employees receive monetary rewards for meeting predefined standards. While previous research has investigated the relationship between PFP and health outcomes, the focus has primarily been on mental health. Few studies have explored the impact of PFP on specific physical symptoms like pain. Methods: Data from the Korean Working Conditions Survey (KWCS) was analyzed, encompassing 20,815 subjects with information on PFP and low back pain (LBP). The associations between types of base pay (BP) and PFP with LBP were examined using multivariate logistic regression models, taking into account a directed acyclic graph (DAG). The interaction of overtime work was further explored using stratified logistic regression models and the relative excess risk for interaction. Results: The odds ratio (OR) for individuals receiving both BP and PFP was statistically significant at 1.19 (95% CI 1.04-1.35) compared to those with BP only. However, when the DAG approach was applied and necessary correction variables were adjusted, the statistical significance indicating a relationship between PFP and LBP vanished. In scenarios without PFP and with overtime work, the OR related to LBP was significant at 1.54 (95% CI 1.35-1.75). With the presence of PFP, the OR increased to 2.02 (95% CI 1.66-2.45). Conclusion: Pay-for-performance may influence not just psychological symptoms but also LBP in workers, particularly in conjunction with overtime work. The impact of management practices related to overtime work on health outcomes warrants further emphasis in research.

Early Indicators of the Impact of Using AI in Mammography Screening for Breast Cancer.

Background Retrospective studies have suggested that using artificial intelligence (AI) may decrease the workload of radiologists while preserving mammography screening performance. Purpose To compare workload and screening performance for two cohorts of women who underwent screening before and after AI system implementation. Materials and Methods This retrospective study included 50-69-year-old women who underwent biennial mammography screening in the Capital Region of Denmark. Before AI system implementation (October 1, 2020, to November 17, 2021), all screenings involved double reading. For screenings conducted after AI system implementation (November 18, 2021, to October 17, 2022), likely normal screenings (AI examination score ≤5 before May 3, 2022, or ≤7 on or after May 3, 2022) were single read by one of 19 senior full-time breast radiologists. The remaining screenings were read by two radiologists with AI-assisted decision support. Biopsy and surgical outcomes were retrieved between October 1, 2020, and April 15, 2023, ensuring at least 180 days of follow-up. Screening metrics were compared using the χ2 test. Reading workload reduction was measured as saved screening reads. Results In total, 60 751 and 58 246 women were screened before and after AI system implementation, respectively (median age, 58 years [IQR, 54-64 years] for both cohorts), with a median screening interval before AI of 845 days (IQR, 820-878 days) and with AI of 993 days (IQR, 968-1013 days; P < .001). After AI system implementation, the recall rate decreased by 20.5% (3.09% before AI [1875 of 60 751] vs 2.46% with AI [1430 of 58 246]; P < .001), the cancer detection rate increased (0.70% [423 of 60 751] vs 0.82% [480 of 58 246]; P = .01), the false-positive rate decreased (2.39% [1452 of 60 751] vs 1.63% [950 of 58 246]; P < .001), the positive predictive value increased (22.6% [423 of 1875] vs 33.6% [480 of 1430]; P < .001), the rate of small cancers (≤1 cm) increased (36.6% [127 of 347] vs 44.9% [164 of 365]; P = .02), the rate of node-negative cancers was unchanged (76.7% [253 of 330] vs 77.8% [273 of 351]; P = .73), and the rate of invasive cancers decreased (84.9% [359 of 423] vs 79.6% [382 of 480]; P = .04). The reading workload was reduced by 33.5% (38 977 of 116 492 reads). Conclusion In a population-based mammography screening program, using AI reduced the overall workload of breast radiologists while improving screening performance. Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Lee and Friedewald in this issue.

Análisis de la carga laboral en tiempo médico en función del grado de complejidad de las muestras y propuesta de algoritmo para la distribución equitativa del trabajo asistencial en un servicio de anatomía patológica / Analysis of the workload in medical time according to the degree of complexity of the samples and proposal of an algorithm for the equitable distribution of the workload in an anatomic pathology department

Introducción: En un servicio de anatomía patológica se analiza la carga laboral en tiempo médico en función de la complejidad de las muestras recibidas, y se valora su distribución entre los patólogos, presentado un nuevo algoritmo informático que favorece una distribución equitativa. Métodos: Siguiendo las directrices para la «Estimación de la carga de trabajo en citopatología e histopatología (tiempo médico) atendiendo al catálogo de muestras y procedimientos de la SEAP-IAP (2.ª edición)» se determinan las unidades de carga laboral (UCL) por patólogo y UCL global del servicio, la carga media laboral que soporta el servicio (factor MU), el tiempo de dedicación de cada patólogo a la actividad asistencial y el número de patólogos óptimo según la carga laboral del servicio. Resultados: Determinamos 12.197 UCL totales anuales para el patólogo jefe de servicio, así como 14.702 y 13.842 para los patólogos adjuntos, con una UCL global del servicio de 40.742. El factor MU calculado es 4,97. El jefe ha dedicado el 72,25% de su jornada a la asistencia y los adjuntos el 87,09 y 82,01%. El número de patólogos óptimo para el servicio es de 3,55. Conclusiones: Todos los resultados obtenidos demuestran la sobrecarga laboral médica, y la distribución de las UCL entre los patólogos no resulta equitativa. Se propone un algoritmo informático capaz de distribuir la carga laboral de manera equitativa, asociado al sistema de información del laboratorio, y que tenga en cuenta el tipo de muestra, su complejidad y la dedicación asistencial de cada patólogo.(AU)

Introduction: In a pathological anatomy service, the workload in medical time is analyzed based on the complexity of the samples received and its distribution among pathologists is assessed, presenting a new computer algorithm that favors an equitable distribution. Methods: Following the second edition of the Spanish guidelines for the estimation of workload in cytopathology and histopathology (medical time) according to the Spanish Pathology Society-International Academy of Pathology (SEAP-IAP) catalog of samples and procedures, we determined the workload units (UCL) per pathologist and the overall UCL of the service, the average workload of the service (MU factor), the time dedicated by each pathologist to healthcare activity and the optimal number of pathologists according to the workload of the service. Results: We determined 12 197 total annual UCL for the chief pathologist, as well as 14 702 and 13 842 UCL for associate pathologists, with an overall of 40 742 UCL for the whole service. The calculated MU factor is 4.97. The chief pathologist devoted 72.25% of his working day to healthcare activity while associate pathologists dedicated 87.09% and 82.01% of their working hours. The optimal number of pathologists for the service is found to be 3.55. Conclusions: The results demonstrate medical work overload and a non-equitable distribution of UCLs among pathologists. We propose a computer algorithm capable of distributing the workload in an equitable manner. It would be associated with the laboratory information system and take into account the type of specimen, its complexity and the dedication of each pathologist to healthcare activity.(AU)

Clinical Full-Time Equivalent in PICUs: Survey of the U.S. Pediatric Critical Care Chiefs Network, 2020-2022.

OBJECTIVES: To inform workforce planning for pediatric critical care (PCC) physicians, it is important to understand current staffing models and the spectrum of clinical responsibilities of physicians. Our objective was to describe the expected workload associated with a clinical full-time equivalent (cFTE) in PICUs across the U.S. Pediatric Critical Care Chiefs Network (PC3N). DESIGN: Cross-sectional survey. SETTING: PICUs participating in the PC3N. SUBJECTS: PICU division chiefs or designees participating in the PC3N from 2020 to 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A series of three surveys were used to capture unit characteristics and clinical responsibilities for an estimated 1.0 cFTE intensivist. Out of a total of 156 PICUs in the PC3N, the response rate was 46 (30%) to all three distributed surveys. Respondents used one of four models to describe the construction of a cFTE-total clinical hours, total clinical shifts, total weeks of service, or % full-time equivalent. Results were stratified by unit size. The model used for construction of a cFTE did not vary significantly by the total number of faculty nor the total number of beds. The median (interquartile range) of clinical responsibilities annually for a 1.0 cFTE were: total clinical hours 1750 (1483-1858), total clinical shifts 142 (129-177); total weeks of service 13.0 (11.3-16.0); and total night shifts 52 (36-60). When stratified by unit size, larger units had fewer nights or overnight hours, but covered more beds per shift. CONCLUSIONS: This survey of the PC3N (2020-2022) provides the most contemporary description of clinical responsibilities associated with a cFTE physician in PCC. A 1.0 cFTE varies depending on unit size. There is no correlation between the model used to construct a cFTE and the associated clinical responsibilities.

Calibrated to drive: Measuring self-assessed driving ability and perceived workload after prolonged sitting and sleep restriction.

Self-assessed driving ability may differ from actual driving performance, leading to poor calibration (i.e., differences between self-assessed driving ability and actual performance), increased risk of accidents and unsafe driving behaviour. Factors such as sleep restriction and sedentary behaviour can impact driver workload, which influences driver calibration. This study aims to investigate how sleep restriction and prolonged sitting impact driver workload and driver calibration to identify strategies that can lead to safer and better calibrated drivers. Participants (n = 84, mean age = 23.5 ± 4.8, 49 % female) undertook a 7-day laboratory study and were randomly allocated to a condition: sitting 9-h sleep opportunity (Sit9), breaking up sitting 9-h sleep opportunity (Break9), sitting 5-h sleep opportunity (Sit5) and breaking up sitting 5-h sleep opportunity (Break5). Break9 and Break5 conditions completed 3-min of light-intensity walking on a treadmill every 30 min between 09:00-17:00 h, while participants in Sit9 and Sit5 conditions remained seated. Each participant completed a 20-min simulated commute in the morning and afternoon each day and completed subjective assessments of driving ability and perceived workload before and after each commute. Objective driving performance was assessed using a driving simulator measuring speed and lane performance metrics. Driver calibration was analysed using a single component and 3-component Brier Score. Correlational matrices were conducted as an exploratory analysis to understand the strength and direction of the relationship between subjective and objective driving outcomes. Analyses revealed participants in Sit9 and Break9 were significantly better calibrated for lane variability, lane position and safe zone-lane parameters at both time points (p < 0.0001) compared to Sit5 and Break5. Break5 participants were better calibrated for safe zone-speed and combined safe zone parameters (p < 0.0001) and speed variability at both time points (p = 0.005) compared to all other conditions. Analyses revealed lower perceived workload scores at both time points for Sit9 and Break9 participants compared to Sit5 and Break5 (p = <0.001). Breaking up sitting during the day may reduce calibration errors compared to sitting during the day for speed keeping parameters. Future studies should investigate if different physical activity frequency and intensity can reduce calibration errors, and better align a driver's self-assessment with their actual performance.

Chapitre 1. La charge professionnelle du télétravailleur.

The organization of work through the remote practice of professional activity maintains a strong link with the notion of workload, given the implications that can be generated in terms of duration, work intensification and therefore overload for the teleworker. The legal mobilization of this notion is developing with the very expansion of the practice of telecommuting. Under the banner of the employer’s general safety obligation, case law and legislation are likely to evolve (by reinforcing the obligation to control and monitor workloads), as is the case with the « forfait en jours » system, another flexible work organization method.

An examination of the usefulness of a quantitative appraisal method in nursing human resource management in primary hospital operating rooms: An example of integrated collaborative scheduling.

In recent years, China medical and health services have made great development. However, the management of nursing human resources in operating room of primary hospitals still faces a series of challenges. In the nursing work of operating room, high-quality nursing human resource management is important for improving the efficiency of operating room and ensuring the safety of patients. From January 2022 to December 2022, comprehensive collaborative scheduling and quantitative scoring evaluation methods were carried out in our hospital, and relevant data were collected. The flexible scheduling combined quantitative scoring performance appraisal system and the traditional scheduling plus average distribution performance appraisal system were statistically analyzed and compared in terms of annual surgical cases, annual overtime hours, annual back work hours, annual compensatory rest hours, and average daily working hours. This study was based on 30 medical staff (27 females and 3 males) in the operating room of a primary hospital. The annual operation volume increased by 387 cases compared with before, and the attitudes of patients to the service attitude and preoperative waiting time were significantly improved, reaching more than 95%. In addition, in the survey of surgeons, it was found that their satisfaction with preoperative preparation and operation time was significantly higher than that of the traditional scheduling method, and reached more than 95%. In the survey of nursing staff, it was found that the satisfaction with the traditional scheduling method was about 80%, and the satisfaction directly reached 100% after the comprehensive collaborative scheduling system. Based on the above survey, the satisfaction of nurses, doctors and patients with the new comprehensive collaborative scheduling system has improved compared with before. After the implementation of the comprehensive collaborative scheduling system, the annual surgical volume has increased significantly, and the average daily working hours of nursing staff have decreased. Comprehensive collaborative scheduling is an effective method of nursing human resource management in operating room, which can effectively improve the work efficiency of nurses and the satisfaction of patients, doctors and nurses. In practice, this method needs to be continuously explored and refined to adapt to different application scenarios and requirements.

Weak Correlation Between Perceived and Measured Intensive Care Unit Nursing Workload: An Observational Study.

BACKGROUND: Efficient management of nursing workload in the intensive care unit (ICU) is essential for patient safety, care quality, and nurse well-being. Current ICU-specific workload assessment scores lack comprehensive coverage of nursing activities and perceived workload. PURPOSE: The purpose of this study was to assess the correlation between ICU nurses' perceived workload and the Nine Equivalents of Nursing Manpower Use Score (NEMS). METHODS: In a 45-bed adult ICU at a tertiary academic hospital, nurses' perceived shift workload (measured with an 11-point Likert scale) was correlated with the NEMS, calculated manually and electronically. RESULTS: The study included 1734 observations. The perceived workload was recorded for 77.6% of observations. A weak positive correlation was found between perceived and objectively measured workload. CONCLUSION: Findings indicate a need to consider the multifaceted nature of nursing activities and individual workload perceptions in the ICU.

The relationship between workload and exercise-induced cardiac troponin elevations is influenced by non-obstructive coronary atherosclerosis.

The relationship between exercise-induced troponin elevation and non-obstructive coronary artery disease (CAD) is unclear. This observational study assessed non-obstructive CAD's impact on exercise-induced cardiac Troponin I (cTnI) elevation in middle-aged recreational athletes. cTnI levels of 40 well-trained recreational athletes (73% males, 50 ± 9 years old) were assessed by a high-sensitive cTnI assay 24 h before, and at 3 and 24 h following two high-intensity exercises of different durations; a cardiopulmonary exercise test (CPET), and a 91-km mountain bike race. Workload was measured with power meters. Coronary computed tomography angiography was used to determine the presence or absence of non-obstructive (<50% obstruction) CAD. A total of 15 individuals had non-obstructive CAD (Atherosclerotic group), whereas 25 had no atherosclerosis (normal). There were higher post-exercise cTnI levels following the race compared with CPET, both at 3 h (77.0 (35.3-112.4) ng/L vs. 11.6 (6.4-22.5) ng/L, p < 0.001) and at 24 h (14.7 (6.7-16.3) vs. 5.0 (2.6-8.9) ng/L, p < 0.001). Absolute cTnI values did not differ among groups. Still, the association of cTnI response to power output was significantly stronger in the CAD versus Normal group both at 3 h post-exercise (Rho = 0.80, p < 0.001 vs. Rho = -0.20, p = 0.33) and 24-h post-exercise (Rho = 0.87, p < 0.001 vs. Rho = -0.13, p = 0.55). Exercise-induced cTnI elevation was strongly correlated with exercise workload in middle-aged athletes with non-obstructive CAD but not in individuals without CAD. This finding suggests that CAD influences the relationship between exercise workload and the cTnI response even without coronary artery obstruction.

Pharmacy Workload in Clinical Trial Management: A Preliminary Complexity Assessment Tool for Sponsored Oncology and Haematology Trials.

Investigational drug services need to be organised in a structured approach, especially for sites with a large number of ongoing clinical trials. The aim of this study was to develop a tool to assess the complexity of pharmacy involvement in a sponsored oncology clinical trial. Categorisation into ordinal complexity categories was used to assess the complexity of the clinical trials for consistent pharmacy grant applications. The 15 items of the tool were divided into three sections, and individual item scores were agreed upon among four pharmacists with experience in the conduct of clinical trials at two different centres. A final version of the tool, named Pharm-CAT, was approved. The pharmacists were instructed to use Pharm-CAT to assign a score to each new sponsored trial. To determine the cut-offs for the complexity categories, the scores were sorted in ascending order and the cut-offs corresponding to the first and third tertiles of the score distribution were selected. To verify the reproducibility of the results, Pharm-CAT was applied by two pharmacists independently for each trial. Pharm-CAT proved to be user-friendly. Sixty clinical trials were evaluated and a total of 120 scores were recorded. Low-complexity scores ranged from 0 to 19, medium-complexity scores ranged from 20 to 25, and high-complexity scores were 26 or higher. The average score recorded was 22.88 points. Prospective multicentre validation of Pharm-CAT is needed to confirm its applicability.

Food and family care during the COVID-19 pandemic: A study of women's domestic workload during the first wave in Chile.

This study aimed to explore women's perceptions of domestic work related to food and family care during the first wave of the COVID-19 pandemic in Chile and its association with sociodemographic and health variables. We conducted a cross-sectional, analytical, non-probabilistic study. A sample of 2047 women answered an online self-report survey that included a Likert scale about the perception of domestic work associated with food. The survey also included an open comment section. The survey was available between May and June 2020, during the first wave of the COVID-19 pandemic and when most of the country had some degree of mobility restriction. 70.2% of participants perceived their domestic work as "regular"; being younger, having a higher educational level, caring for children or the elderly, and having worse self-perception of mental and general health status increased the chances of having a lower perception of the burden of these tasks. In comments, women declared how heavy the domestic work was, the challenges of being together with their families and of paid job requirements, and how family demands from them increased. Most women felt that their domestic work was heavier during this pandemic period: some groups of women could be at risk of being more affected by this extra workload at home. The importance of interventions and public policies with a gender perspective becomes relevant, considering the role of women in the home and the necessity to generate a social change regarding the domestic burden associated with gender.

Small Patients but a Heavy Lift: Workload and Burnout of Advanced Practice Providers and Physicians in a Level IV Neonatal Intensive Care Unit.

OBJECTIVE: This study explored the association between workload and the level of burnout reported by clinicians in our neonatal intensive care unit (NICU). A qualitative analysis was used to identify specific factors that contributed to workload and modulated clinician workload in the NICU. STUDY DESIGN: We conducted a study utilizing postshift surveys to explore workload of 42 NICU advanced practice providers and physicians over a 6-month period. We used multinomial logistic regression models to determine associations between workload and burnout. We used a descriptive qualitative design with an inductive thematic analysis to analyze qualitative data. RESULTS: Clinicians reported feelings of burnout on nearly half of their shifts (44%), and higher levels of workload during a shift were associated with report of a burnout symptom. Our study identified 7 themes related to workload in the NICU. Two themes focused on contributors to workload, 3 themes focused on modulators of workload, and the final 2 themes represented mixed experiences of clinicians' workload. CONCLUSION: We found an association between burnout and increased workload. Clinicians in our study described common contributors to workload and actions to reduce workload. Decreasing workload and burnout along with improving clinician well-being requires a multifaceted approach on unit and systems levels.

Insights from end-of-career general practitioners on changing working conditions and generational differences: considerations for future strategies.

The landscape of general practice has experienced notable transformations in recent decades, profoundly influencing the working conditions of general practitioners (GPs). This study aimed to examine the most salient changes affecting GPs' daily practices. Through semi-structured qualitative interviews with 15 end-of-career GPs, the study explored how these changes affected work organization, equipment, working hours, work-life balance, job satisfaction, training, patient relationships, and reputation. The interviews revealed that these changes were perceived as barriers, opportunities, or a complex interplay of both for general practice. While the interviewed GPs valued technological advancements and reported positive developments in working conditions, challenges included a gradual reduction in the range of tasks, growing administrative burdens, and less practical training for young physicians. Other changes, such as new doctor-patient dynamics, the transition from single to group practice, and differing professional expectations of the younger generation, were seen as both challenging and strengthening for general practice. By combining these factors and trade-offs observed by end-of-career GPs in our study over the past few decades with general societal changes, we provide ideas for the design of future framework conditions in general practice that might enhance the attractiveness of the profession. These insights offer key considerations that can guide future strategies for general practice and medical education.

Optimizing Human-Robot Teaming Performance through Q-Learning-Based Task Load Adjustment and Physiological Data Analysis.

The transition to Industry 4.0 and 5.0 underscores the need for integrating humans into manufacturing processes, shifting the focus towards customization and personalization rather than traditional mass production. However, human performance during task execution may vary. To ensure high human-robot teaming (HRT) performance, it is crucial to predict performance without negatively affecting task execution. Therefore, to predict performance indirectly, significant factors affecting human performance, such as engagement and task load (i.e., amount of cognitive, physical, and/or sensory resources required to perform a particular task), must be considered. Hence, we propose a framework to predict and maximize the HRT performance. For the prediction of task performance during the development phase, our methodology employs features extracted from physiological data as inputs. The labels for these predictions-categorized as accurate performance or inaccurate performance due to high/low task load-are meticulously crafted using a combination of the NASA TLX questionnaire, records of human performance in quality control tasks, and the application of Q-Learning to derive task-specific weights for the task load indices. This structured approach enables the deployment of our model to exclusively rely on physiological data for predicting performance, thereby achieving an accuracy rate of 95.45% in forecasting HRT performance. To maintain optimized HRT performance, this study further introduces a method of dynamically adjusting the robot's speed in the case of low performance. This strategic adjustment is designed to effectively balance the task load, thereby enhancing the efficiency of human-robot collaboration.

The Impact of Various Cockpit Display Interfaces on Novice Pilots' Mental Workload and Situational Awareness: A Comparative Study.

Future airspace is expected to become more congested with additional in-service cargo and commercial flights. Pilots will face additional burdens in such an environment, given the increasing number of factors that they must simultaneously consider while completing their work activities. Therefore, care and attention must be paid to the mental workload (MWL) experienced by operating pilots. If left unaddressed, a state of mental overload could affect the pilot's ability to complete his or her work activities in a safe and correct manner. This study examines the impact of two different cockpit display interfaces (CDIs), the Steam Gauge panel and the G1000 Glass panel, on novice pilots' MWL and situational awareness (SA) in a flight simulator-based setting. A combination of objective (EEG and HRV) and subjective (NASA-TLX) assessments is used to assess novice pilots' cognitive states during this study. Our results indicate that the gauge design of the CDI affects novice pilots' SA and MWL, with the G1000 Glass panel being more effective in reducing the MWL and improving SA compared with the Steam Gauge panel. The results of this study have implications for the design of future flight deck interfaces and the training of future pilots.

Work & life stress experienced by professional workers during the pandemic: a gender-based analysis.

The COVID-19 pandemic impacted work and home life exacerbating pre-existing stressors and introducing new ones. These impacts were notably gendered. In this paper, we explore the different work and home life related stressors of professional workers specifically as a result of the COVID-19 pandemic through the gender-based analysis of two pan Canadian surveys: The Canadian Community Health Survey (2019, 2020, 2021) and the Healthy Professional Worker Survey (2021). Analyses revealed high rates of work stress among professional workers compared to other workers and this was particularly notable for women. Work overload emerged as the most frequently selected source of work stress, followed by digital stress, poor work relations, and uncertainty. Similar trends were noted in life stress among professional workers, particularly women. Time pressure consistently stood out as the primary source of non-work stress, caring for children and physical and mental health conditions. These findings can help to develop more targeted and appropriate workplace mental health promotion initiatives that are applicable to professional workers taking gender more fully into consideration.

The hidden work of general practitioners: An ethnography.

High quality primary care is a foundational element of effective health services. Internationally, primary care physicians (general practitioners (GPs), family doctors) are experiencing significant workload pressures. How non-patient-facing work contributes to these pressures and what constitutes this work is poorly understood and often unrecognised and undervalued by patients, policy makers, and even clinicians engaged in it. This paper examines non-patient-facing work ethnographically, informed by practice theory, the Listening Guide, and empirical ethics. Ethnographic observations (104 h), in-depth interviews (n = 16; 8 with GPs and 8 with other primary care staff) and reflexive workshops were conducted in two general practices in England. Our analysis shows that 'hidden work' was integral to direct patient care, involving diverse clinical practices such as: interpreting test results; crafting referrals; and accepting interruptions from clinical colleagues. We suggest the term 'hidden care work' more accurately reflects the care-ful nature of this work, which was laden with ambiguity and clinical uncertainty. Completing hidden care work outside of expected working hours was normalised, creating feelings of inefficiency, and exacerbating workload pressure. Pushing tasks forward into an imagined future (when conditions might allow its completion) commonly led to overspill into GPs' own time. GPs experienced tension between their desire to provide safe, continuous, 'caring' care and the desire to work a manageable day, in a context of increasing demand and burgeoning complexity.