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Work Habits of the 21st-Century Intern

Summary and Comment |
September 5, 2013

Work Habits of the 21st-Century Intern

  1. Abigail Zuger, MD

A time-motion study showed that medical interns spent far more time with their computers than with their patients.

  1. Abigail Zuger, MD

The limitations placed on house staff work hours during the past decade have required program directors to devise increasingly creative schedules and have raised intense interest in understanding exactly how house staff spend their workdays and nights. Baltimore researchers devised a time-motion study of internal medicine interns that was performed in January 2012. They used specially trained undergraduate observers to shadow a convenience sample of 29 interns in two Baltimore hospitals with different day/night coverage patterns; the observers recorded activities on hand-held devices during both day and night shifts.

Interns spent a mean 12% of their time in direct patient care (i.e., making rounds, talking to patients or family members, or doing procedures). They spent more than 60% of their time in indirect patient care (e.g., talking to other providers, reviewing charts, writing notes). Most of this indirect time (40% of the total) was spent on computers. Educational activities, such as conferences, occupied about 15% of the interns' time; walking around the hospital consumed about 5%; eating, sleeping, and socializing time was negligible (≤2%). Mean time spent admitting a patient was 17 minutes (range, 4–54 minutes), and mean time spent daily with each admitted patient was 8 minutes (range, 0–40 minutes).

Comment

The distressing paucity of time that interns spend with their patients is not a new phenomenon: Back in 1989 — before both work hour limitations and computers — a similar study showed that interns spent about 20% of their time with patients and about 40% in documentation (NEJM JW Gen Med Jun 30 1989). However, things clearly are moving in the wrong direction. These fascinating data ring completely true and should give program directors impetus to reevaluate critically the present routines of clinical training.

  • Disclosures for Abigail Zuger, MD at time of publication Editorial boards Journal Watch AIDS Clinical Care; Clinical Infectious Diseases Other New York Times medical writer

Citation(s):

Reader Comments (10)

JOHN SALMON Physician, Family Medicine/General Practice, Southmead Surgery, Farnham Common, UK

In the UK, patients are increasingly getting in the way of the computer work.

KENNETH FRIAR Physician, Hospital Medicine, Michigan (Northern and UP)

My 12 y/o son wanted to know why it was ok to "work on your iPhone" while taking care of pts when it wasn't safe to drive and use a phone? Distraction is distraction.

Léo C , MD Physician, Critical Care Medicine, University Hospital, in Chicago
Competing Interests: None

Here is something to reflect on:
Do you think that with innovative software and portable computers (laptops / tablets / iPads) we can get interns and the above to actually do the documentation / history taking / verification at the bedside while taking the time to listen / feel / examine / comfort / emphasize with their patients ?
On a different note , it has been repeatedly shown that spending quality time with patients is a better deterrent to lawsuits than extensive documentation.

John Physician, Geriatrics, VA Hospital

I used to be able to sit down in the patients room at bedside and review the chart and talk with the patient, they actually saw how much time I spent on their care and I did my progress notes and orders there in front of them. Patients were amazed at how much time it took, even if they were doing OK. Now, I have to go out and harvest information and bring it back to my hole like a prairie dog to digest it and store what is left over. I am lucky that patients can come to my office any time and I will finish current project and talk with them and then document what we agreed to do in front of them. The computer in the office exam room is a different tool that in the hospital and nursing home. Our hospital is too primitive to have a secure wireless and laptops for us to use so patients may think they are neglected as we have to spend so much time documenting. I tell them I would rather they die than fall as the paper work and meetings for a fall go on forever. Our falls in my unit are down dramatically not certain if the black humor helped.

WILLIAM RENFROE Physician, Family Medicine/General Practice, Primary Care Group Practice

This was completely predictable. The push for adoption of electronic records was based on an incomplete and poorly considered view of how medical care is delivered. It is clear that the EHR does produce some benefits but there are real costs, one of which is described by this article.
Personally I find the paperwork to be MUCH more time consuming with our EHR than it was previously. I am confident that I am doing a better job of reminding patients about aspirin use, immunizations and some other things but face-to-face patient contact time has clearly been one of the casualties of the process and I don't think we really know what long term consequences that will have.

george england, MD, MS, MG, AMG Other, Surgery, Specialized, Non available as to history in Neurological Surgery

The first principal in the History of Medicine was "Hands-on" in touch and care

Faisal Zahedi, MRCP Resident, Hospital Medicine, Royal hospital

That's correct for all of us. This is some thing which has been noted by the patient's themselves also. For medico-legal reasons and in order to improve our documentation, we end up spending more time on the computers than with the patients. Typically in an OPD encounter, it takes around 15 min to review the patient records on the computer and 5 min to ask them their complaints and 5-10 min to examine them and the rest of the time to counsel them about the management plan (which is again 5-10 min). I guess this acceptable to the patients. But the patient's don't understand that when they are sick and in addition to spending time assessing the patient and sending bloods, we also spend time documenting the episode as we might forget the details later on and they get confused that we are spending more time with the computer rather than the patient !

Boguslaw Bonczak, MD Physician, Family Medicine/General Practice, Illinois

That is very truth, I believe not just for interns. For example- documenting level 4 visit in family practice office most likely would take more time using an EMR than actually seeing patient.
But- what about nurses in hospitals? From my observations they may spent more than 70% time doing documentation.

cabrera md Physician, Family Medicine/General Practice, chicago

it woulb be great if the tatio were all the way around interns and medical students in general does not apresiate the value of patient interaction but no shame on them shame on program directors and system in general tha preffer a nicly and extense note over a patien well take care of

PHILIP SACCOCCIA JR Physician, Pathology, Medical Laboratory Service

The distressing an increasing paucity of time for direct patient interaction versus documentation is also true for physicians in practice. One good solution is to hire, train, and use scribes. Interns and residents should learn to work with scribes as an integral part of everyday practice.

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