Off the rails: a pilot study of daily clinic volatility in primary care
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Background
In primary care, rising demand and shrinking capacity produce chaotic variability during clinic days, yet this daily “schedule volatility” and its drivers are rarely measured.
Objective
To measure primary care physicians’ (PCPs’) assessments of daily schedule volatility and its contributing factors, and to identify potential electronic health record (EHR)-derived measures to proxy these constructs.
Design
Observational pilot study pairing contemporaneous end-of-day text-message (SMS) surveys with matched EHR data.
Setting
Five primary care clinics in the University of Maryland Medical System, August to December 2025.
Participants
Eight PCPs with at least 50% clinical effort.
Measurements
Daily schedule volatility (5-point Likert rating) and contributing factors, collected by SMS after clinic close; four EHR-derived outcome measures (same-day visit closure, cumulated time to chart closure, and the presence and volume of EHR work after 7pm) and 16 contributing-factor measures spanning tardiness, no-shows and cancellations, asynchronous (“InBasket”) volume, and schedule structure. PCP-rated volatility was dichotomized (top two “difficult-to-manage” categories vs. others) and compared using bivariate tests.
Results
Of 150 surveys, 105 were completed (70% response rate; median response 27 minutes). Difficult-to-manage days were uncommon (14% of days), although patient tardiness, no-shows, long-running visits, and InBasket burden were each reported on >40% of days. Difficult days involved more evening EHR work (55% vs. 19%; p=0.033), higher asynchronous volume (median 13 vs. 4 patient-message encounters; p=0.022), and higher visit volume (median 17 vs. 7; p=0.001). No-shows and same-day cancellations were not associated with volatility.
Limitations
Single-system pilot; bivariate, cross-sectional, and hypothesis-generating. Conclusion: PCPs’ experience of chaotic clinic days is measurable and appears driven more by asynchronous burden and visit volume than by patient no-shows or tardiness; evening EHR work is a promising scalable proxy.
Primary Funding Source
American Medical Association.
