Hospital interns spend just 12 percent of duty time examining or talking with patients, far less than they spend on paperwork and computer time. Indeed, the study found interns’ availability for bedside interaction only modestly exceeds the time—7 percent of their workday—they spend walking from place to place. “One of the most important learning opportunities in residency is direct interaction with patients,” says Lauren Block, a clinical fellow at the Johns Hopkins University School of Medicine and leader of the study. “Spending an average of eight minutes a day with each patient just doesn’t seem like enough time to me.” The study, published online in the Journal of General Internal Medicine, followed first-year residents at Baltimore’s two large academic medical centers. Compared with similar time-tracking studies done before 2003, when hospitals were first required to limit consecutive working hours for trainees, interns now spend significantly less time in direct contact with patients, the researchers found. Changes to the 2003 rules limited interns to no more than 30 consecutive hours on duty; further restrictions in 2011 now allow them to work only 16 hours in a row. “Most of us went into medicine because we love spending time with the patients. Our systems have squeezed this out of medical training,” says Leonard Feldman, the study’s senior author and a hospitalist. Observation of first-year residents The researchers sent trained observers to follow 29 internal medicine interns—doctors in their first year out of medical school—at Johns Hopkins and the University of Maryland Medical Center for three weeks during January 2012, for a total of 873 hours. The observers used an iPod app to record what the interns were doing every minute of their shifts. If they were multi-tasking, the observers were told to count the activity most closely related to direct patient care. The researchers found that interns spent 12 percent of their time talking with and examining patients; 64 percent on indirect patient care, such as placing orders, researching patient history, and filling out electronic paperwork; 15 percent on educational activities, such as medical rounds; and 9 percent on miscellaneous activities. ‘Shockingly low’ The researchers acknowledge that it’s unclear what proportion of time spent at the bedside is ideal or whether the interns make up the time lost with patients later in three-year residencies. But 12 percent, Feldman says, seems “shockingly low at face value.” “Interns spend almost four more times as long reviewing charts than directly engaging patients,” he says. Studies in 1989 and 1993 found that interns also spent more time documenting than seeing patients, but were able to spend between 18 and 22 percent of their time at the bedside. In those studies, however, researchers found that a large chunk of time was spent sleeping at the hospital, something rarely seen today. Reduced intern work hours were designed to lessen trainee fatigue and improve patient safety. Feldman says questions raised by the new study aren’t just about whether the patients are getting enough time with their doctors, but also whether the time spent with patients is enough to give interns the experience they need to practice excellent medicine. With fewer hours spent in the hospital, protocols need to be put in place to ensure that vital parts of training aren’t lost, the researchers say. Doctor who? “As residency changes, we need to find ways to preserve the patient-doctor relationship,” Block says. “Getting to know patients better can improve diagnoses and care and reduce medical errors.” The researchers say better electronic medical records may help reduce time spent combing through patient histories on the computer. Another improvement could be made by grouping an intern’s patients together on the same hospital unit so the intern doesn’t have to race from floor to floor to see patients, wasting time in transit. Block says she would like to know how patients feel about how little time they see with interns, who generally are charged with overseeing many aspects of their care. Studies have shown that only 10 percent of hospitalized patients know who their resident doctors are. “It’s not an easy problem to solve,” Feldman says. “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 and the Johns Hopkins Hospitalist Scholars Fund supported the research. Source
