Off the rails: a pilot study of daily clinic volatility in primary care

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.