Laurie Barclay, MD
April 25, 2013
Medical interns spend only 12% of their time examining and talking with patients, and more than 40% of their time on computer tasks, according to a time-motion study published online April 18 in the Journal of General Internal Medicine.
“One of the most important learning opportunities in residency is direct interaction with patients,” lead author Lauren Block, MD, MPH, a clinical fellow in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine in Baltimore, Maryland, said in a news release. “Spending an average of eight minutes a day with each patient just doesn’t seem like enough time to me.”
Pressures on intern time for direct patient interaction include the 2003 and 2011 Accreditation Council for Graduate Medical Education program requirements increasing resident supervision and limiting consecutive duty hours, as well as documentation needs and increased data available through electronic medical records.
“Most of us went into medicine because we love spending time with the patients,” senior author Leonard Feldman, MD, a hospitalist at the Johns Hopkins Hospital, said in the news release. “Our systems have squeezed this out of medical training.”
For 3 weeks in January 2012, the investigators observed 29 interns at 2 Johns Hopkins University internal medicine residency programs for a total of 873 hours. The main study outcome was percentage of time spent in direct patient care, defined as talking with and examining patients. Multilevel regression analysis allowed adjustment for clustering at the observer and intern levels.
Direct patient care accounted for only 12.3% of interns’ time, and computer use for 40%. Interns spent 63.6% of their time on indirect patient care, including 20% on talking to other providers; 14.7% on educational activities; and 9.3% on miscellaneous activities (5.9% on walking). Interns at both programs had similar breakdowns of time spent.
Limitations of this study include its possible lack of generalizability to other programs or specialties, use of nonmedical observers, and lack of data on the quality of intern–patient interactions.
“Shockingly Low”
In time-motion studies performed before 2003, interns spent 18% to 22% of their time at the bedside. Interns in the present study spent less time in direct patient care and sleeping and more time talking with other providers and documenting.
Although the ideal proportion of time spent on direct patient care is still unknown, 12% “seems shockingly low at face value,” Dr. Feldman said in the news release. “Interns spend almost four more times as long reviewing charts than directly engaging patients.”
Possible strategies to increase intern time with patients may include better electronic medical records and grouping an intern’s patients together on the same hospital unit to reduce time in transit.
“As residency changes, we need to find ways to preserve the patient-doctor relationship,” Dr. Block said in the release. “Getting to know patients better can improve diagnoses and care and reduce medical errors.”
Future research suggested by Dr. Block includes evaluation of patient attitudes regarding how little time they spend with interns. Only 10% of hospitalized patients know which resident physicians are responsible for their care, according to previous studies.
“It’s not an easy problem to solve,” Dr. Feldman said in the news release. “All of us think that interns spend too much time behind the computer. Maybe that’s time well spent because of all of the important information found there, but I think we can do better.”
The Osler Center for Clinical Excellence at Johns Hopkins and the Johns Hopkins Hospital Scholars Fund provided funding for this study. The study authors have disclosed no relevant financial relationships.
J Gen Intern Med. Published online April 18, 2013.
Journal of General Internal Medicine
August 2013, Volume 28, Issue 8, pp 1042-1047
ABSTRACT
BACKGROUND
The 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) common program requirements compress busy inpatient schedules and increase intern supervision. At the same time, interns wrestle with the effects of electronic medical record systems, including documentation needs and availability of an ever-increasing amount of stored patient data.
OBJECTIVE
In light of these changes, we conducted a time motion study to determine how internal medicine interns spend their time in the hospital.
DESIGN
Descriptive, observational study on inpatient ward rotations at two internal medicine residency programs at large academic medical centers in Baltimore, MD during January, 2012.
PARTICIPANTS
Twenty-nine interns at the two residency programs.
MAIN MEASURES
The primary outcome was percent of time spent in direct patient care (talking with and examining patients). Secondary outcomes included percent of time spent in indirect patient care, education, and miscellaneous activities (eating, sleeping, and walking). Results were analyzed using multilevel regression analysis adjusted for clustering at the observer and intern levels.
KEY RESULTS
Interns were observed for a total of 873 hours. Interns spent 12 % of their time in direct patient care, 64 % in indirect patient care, 15 % in educational activities, and 9 % in miscellaneous activities. Computer use occupied 40 % of interns’ time. There was no significant difference in time spent in these activities between the two sites.
CONCLUSIONS
Interns today spend a minority of their time directly caring for patients. Compared with interns in time motion studies prior to 2003, interns in our study spent less time in direct patient care and sleeping, and more time talking with other providers and documenting. Reduced work hours in the setting of increasing complexity of medical inpatients, growing volume of patient data, and increased supervision may limit the amount of time interns spend with patients.