The iCOMPARE trial, for which Sanjay Desai is a lead investigator, examined outcomes from trainees with different duty hour standards. The trial was funded by the National Heart Lung Blood Institute and the ACGME, and their primary outcomes were published in a series of manuscripts in the New England Journal of Medicine. Last week, the team published new outcomes describing how little time interns spend with their patients in the hospital. The complete findings can be found in JAMA Internal Medicine. Below are thoughts from Dr. Desai, senior author of the study.
You showed interns spend only a small amount of time with patients. Can you describe this study and the findings more?
This is the largest study in medical education measuring how interns spend their time when in the hospital. We followed 80 interns for over 2,000 hours as they did their work at day and night in six different hospitals. We were interested in how much time they spent directly with patients and participating in education. We found that interns spent 87 percent of their time away from patients and half of that time interacting with electronic health records. Interns spent the most time performing indirect patient care, taking up an average of 15.9 hours of a 24-hour period—almost five times more hours than the next most common activity, direct patient care, which accounted for three hours of the day. Education was the third-highest category of intern time, attributing for 1.8 hours. These data have alarmed both professional and public stakeholders.
What are the implications of these results, particularly on burnout and training?
There are many reasons to be concerned about these findings. One of the biggest is simply the significance of what it means for our current and future physicians. How do we think about our profession if we spend almost 90 percent of our time away from the people that drew us to it? How do we recruit our students into this field if this is how they think they will spend their day?
Another concern is physician burnout. Many have hypothesized that time with patients can reduce symptoms of burnout by bringing meaning to our professional experience. In the last decade, the natural forces in academic medical centers have created more distance between us and our patients. These forces include the electronic medical records (EMR), but also other technologies, operational constraints and time constraints. Recognizing the EMR is a reality, we need to now work on how to change our interaction with it to make it less burdensome. Even more importantly, we have to be very deliberate to manage the activities of our interns to promote what inspired them to pursue medicine. That is, we have to create routine processes and expectations that keep them at the bedside. And ensure those bedside experiences are meaningful and informative. This will take a renewed focus on the physical examination, patient-centered communication and overall efficiency. It also will rely on using newer technologies, such as point-of-care ultrasound that promote bedside care, and rely on investment for resources on our teams that allow physicians to practice at the top of their license.
There is hope. This study reminds me that, with the right data, we can inform and change our practices. This study establishes a baseline for us to measure the effectiveness of our educational programming on intern time. We also must be vigilant to collect evidence to test the hypotheses related to how interns spend their time. For example, long hours and the EMR are often implicated as drivers of burnout. While this may be true, the actual influence of these on burnout needs to be objectively measured. In the United Kingdom as an example, interns work fewer hours and have less EMR burden, but are still confronting high rates of burnout. The associations of time at bedside, EMR behavior and other relevant attributes of the learning environment with the outcomes we care about for our trainees must be assessed.
This study has shown light on how the training environment has evolved. It is now our responsibility to use these data to improve the experience for all that follow. In my view, this is essential to the future of internal medicine.
ARTICLE: Assessment of Inpatient Time Allocation Among First-Year Internal Medicine Residents Using Time-Motion Observations
AUTHORS: Krisda H. Chaiyachati, Judy A. Shea, David A. Asch, Manqing Liu, Lisa M. Bellini, C. Jessica Dine, Alice L. Sternberg, Yevgeniy Gitelman, Alyssa M. Yeager, Jeremy M. Asch, Sanjay Desai
JOURNAL: JAMA Intern Med. 2019 Apr 15. doi: 10.1001/jamainternmed.2019.0095. [Epub ahead of print]
IMPORTANCE: The United States spends more than $12 billion annually on graduate medical education. Understanding how residentsbalance patient care and educational activities may provide insights into how the modern physician workforce is being trained.
OBJECTIVE: To describe how first-year internal medicine residents (interns) allocate time while working on general medicine inpatientservices.
DESIGN, SETTING AND PARTICIPANTS: Direct observational secondary analysis, including 6 US university-affiliated and community-based internal medicine programs in the mid-Atlantic region, of the Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial, a cluster-randomized trial comparing different duty-hour policies. A total of 194 weekday shifts were observed and time motion data were collected, sampled by daytime, nighttime, and call shifts in proportion to the distribution of shifts within each program from March 10 through May 31, 2016. Data were analyzed from June 1, 2016, through January 5, 2019.
MAIN OUTCOMES AND MEASURES: Mean time spent in direct and indirect patient care, education, rounds, handoffs, and miscellaneous activities within a 24-hour period and in each of four 6-hour periods (morning, afternoon, evening, and night). Time spent multitasking, simultaneously engaged in combinations of direct patient care, indirect patient care, or education, and in subcategories of indirect patient care were tracked.
RESULTS: A total of 80 interns (55% men; mean [SD] age, 28.7 [2.3] years) were observed across 194 shifts, totaling 2173 hours. A mean (SD) of 15.9 (0.7) hours of a 24-hour period (66%) was spent in indirect patient care, mostly interactions with the patient's medical record or documentation (mean [SD], 10.3 [0.7] hours; 43%). A mean (SD) of 3.0 (0.1) hours was spent in direct patient care (13%) and 1.8 (0.3) hours in education (7%). This pattern was consistent across the 4 periods of the day. Direct patient care and education frequently occurred when interns were performing indirect patient care. Multitasking with 2 or more indirect patient care activities occurred for a mean (SD) of 3.8 (0.4) hours (16%) of the day.
CONCLUSIONS AND RELEVANCE: This study's findings suggest that within these US teaching programs, interns spend more timeparticipating in indirect patient care than interacting with patients or in dedicated educational activities. These findings provide an essential baseline measure for future efforts designed to improve the workday structure and experience of internal medicine trainees, without making a judgment on the current allocation of time.
For a link to the full article, click here: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2730353?guestAccessKey=11684db4-5957-4398-9517-102b44e65410&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=041519
Link to abstract online: https://www.ncbi.nlm.nih.gov/pubmed/?term=Assessment+of+Inpatient+Time+Allocation+Among+First-Year+Internal+Medicine+Residents+Using+Time-Motion+Observations