Where does the day go?

Time with patients is sacrificed for time spent documenting care and talking with other clinicians.

Whether they love or hate work-hour regulations, people in medicine know how much time interns spend at work in a week. But even the new docs themselves may have difficulty quantifying exactly how they spend those 80 hours.

To solve this mystery, researchers from Johns Hopkins University and the University of Maryland in Baltimore had undergraduate students trail 29 interns rotating on internal medicine wards. They measured how much time the interns spent talking to and examining patients, working on computers, and participating in education, among other activities.

According to results published in the April Journal of General Internal Medicine, the interns studied in January 2012 spent 40% of their time on computers and only 12% directly caring for patients. Compared to some of their peers prior to 2003, they spent less time sleeping on the job, but also less time with patients and more time documenting care and talking to other clinicians.

ACP Hospitalist recently had a wide-ranging discussion of these findings and their implications for duty hours, electronic medical records and the future of general internal medicine with two of the study's coauthors.

Lenny Feldman, MD, FACP, is program director of the internal medicine-pediatrics residency, and Lauren Block, MD, MPH, is a fellow in general internal medicine, both at Johns Hopkins.

Q: What motivated you to look at how interns spend their time?

A: Dr. Block: In internal medicine, three years [in residency] is all you get to learn the skills you need for the rest of your career. We had the sense that the amount of time that [interns] got to actually spend learning from patients and faculty at the bedside was being squeezed by all the other demands on their time. We thought we could compare to studies that have been done in the past, which would let us see how things are changing.

Q: What did you find?

A: Dr. Block: What we found was continuation of a trend which really started with the first of these studies in the 1960s and 1970s and continued every decade thereafter. Each time, people find that less and less time is being spent by residents with patients. We don't answer the question of why this is the case, but we can say conclusively that 12% is the amount that residents are able to spend at the bedside with patients. Although we don't know the ideal amount of time, our research team has the sense that 12% is probably too little.

Q: What else did you learn from this study?

A: Dr. Block: Residents on average, with the current work-hour limitations in place, spend about 15 hours per day in the hospital, and 12% means that they spend less than two hours with patients. And they spend at least six hours sitting in front of the computer. That doesn't include when they're on rounds looking through their iPad, or when they're at the patient's bedside writing a note as they talk to the patient. That's at least six hours a day that are spent face-to-face with the computer. That seems like a lot to us.

When we looked at the time per day that a resident spent with each patient, it came to an average of eight minutes per patient per day. From a patient perspective, it doesn't seem like much time to spend with the doctor that's coordinating all of your care.

Dr. Feldman: Two-thirds of [interns'] daily work life is the coordination of care—talking with other providers, writing orders, writing notes, and looking through the chart. That's now where our residents spend the majority of their time in an inpatient setting.

There have been a lot of changes in the last decade, particularly around duty hours, but also significantly around the use of electronic medical records (EMRs). What's actually happening in residency education with our interns, in this new era of EMR and duty-hours restrictions? We've created this system, essentially a grand experiment, without really having thought about what the unintended consequences are. We do lots of studies of all sorts of education interventions, yet some of the largest ones that we've done, we're just studying them post hoc.

Q: What response would you like to see to your study?

A: Dr. Feldman: Although it's hard to avoid, we don't really want to place a value judgment on what we found. What we want is for [leaders in medical education] to decide “Is this what we actually want from our residency training programs?” If not, we need to take control and start evaluating how we can improve residency education, instead of reflexively reacting to the regulations and the EMRs that are thrust upon us.

We presented this data at the Association of Program Directors in Internal Medicine spring meeting, and we had 60 program directors show up to the workshop and the debate was fascinating. My guess if that if you asked almost every program director in the country, they would say that 12% in direct patient care is not how they think interns should be spending their time. It begs the next question of “How do we fix this?” We have some ideas.

Dr. Block: Our hope is that this provides an opportunity for interventions to help residents get more out of their training [and] spend more time with their patients. Or at least…as new regulations and demands affect residents, [keep] an eye to the fact that everything has an impact on the amount of time residents are able to spend with patients. One aspect of this we didn't look at is how much work is taking place at home. We may be seeing just the tip of the iceberg in documentation.

Q: What would you like to see residency programs try?

A: Dr. Feldman: Possibly, [residents] see fewer patients. I think that increasingly that's what residency programs, especially on the inpatient side, are moving towards. Many of us are coming to the conclusion that the only way our residents can have more time with patients is if we find a way to decrease the number of patients they're taking care of overall. Then that begs the question, are they going to be prepared for care of patients when they finish residency?

I think many hospitalists believe that the EMR has made it more difficult to care for a larger census of patients, and it's going to be interesting to see what happens as EMRs continue to roll out. I think our capacity to care for patients will continue to dwindle.

Dr. Block: All of this may be another among many reasons that doctors in training often choose not to go into careers in primary care and general medicine, including hospital medicine. We all know about pay differentials and the number of cases, but I think the documentation, and the way that limits your ability to spend time with patients, is another reason that it's increasingly difficult to be a good primary care doctor and general medicine clinician.

Q: Do you see any other potential solutions to these challenges?

A: Dr. Block: Reorganizing resident teams to have fewer patients. Organizing teams in such a way that less walking needs to be done between units, and more efficient communication between [other clinicians]. Designing some of these EMRs to work better for clinicians.

Dr. Feldman: EMRs still tend to store each piece of data in a separate document. As you continue to click and open and try to search through and find them all, it seems like the data never ends. Now we have all this data, but it's not synthesized for us. We need an EMR to synthesize the data to actually make it easier to care for patients and not harder.

Dr. Block: One of the other questions we wanted to look at is whether residents were doing things [to improve patients' experiences], like sitting down, like introducing themselves. That's the project that we're working on right now, looking at these patient-centered communication behaviors.

Dr. Feldman: I think these are the ideas that can make a difference: geographic cohorting, thinking about whether duty hours and other regulations are optimal, making sure that when we do interact with patients that the quality is the best that it can be, and improving the EMR's synthesizing of data. I think those are probably the keys for making sure we can turn this around, if we all think it needs to be.