You’ve been there, you know life as an resident is busy – but how exactly are they spending their time… and, has it changed with today’s technological advances? Jason’s paper selection is a American time and motion study which examined how first-year residents spent their time while working on a general internal medicine ward. Check it out here.
————————————————————————–
KeyLIME Session 224
Reference
Chaiyachati et al., Assessment of Inpatient Time Allocation Among First-Year Internal Medicine Residents Using Time-Motion Observations JAMA Intern Med. 2019 Apr 15.
Reviewer
Jason R. Frank (@drjfrank)
Background
I once saw #meded historian Kenneth M. Ludmerer speak at a plenary for ACGME about his time as an intern physician. My memory of the details of this talk are fuzzy, but I recall him suggesting that he and his 1950s colleagues would be on call together, admitting maybe five patients who would spend approximately a month as an inpatient. (He called this something like “the era of abundance”). The audience fell about the place, as they considered the work of a contemporary internal medicine service and the nature of resident physician workload.
Is this just pure nostalgia? Why should we care? Enter the authors of today’s paper: Chaiyachati & co from UPenn, Hopkins & Yale, who provide a contemporary take on what interns really do. (Notably, this group includes one of our all-time favourite #meded authors and ICRE keynote in health economist David A. Asch)
Purpose
The authors set out to describe how contemporary first-year residents spend their time while working on a general internal medicine ward in the US.
They note that the US spends >$12B per year on GME, so we should know what residents do…Not sure those two topics are directly connected.
Key Points on the Methods
This is a secondary analysis of the iCOMPARE cluster RCT of 2 duty hours approaches. We reviewed that elaborate, interesting but flawed NEJM paper for the Podcast back in episode 165.
This is a time-and-motion study. The authors selected six US university affiliated and community-based hospitals that had interns working on general medicine wards in 2016. They hired 23 observers, trained them, and created a tablet-based tracking form. Inter-rater reliability was addressed through training videos (kappa=0.67), and having two observers for 10% of shifts (kappa=0.74)
Over 3 months, they conducted 1:1 observations of 194 workdays (Monday to Friday), which included a prorated number of days, evenings, and call nights. No weekends were sampled. Observers recorded time spent on the following six types of activities:
- direct patient care
- indirect patient care (e.g. typing orders into an electronic medical record)
- rounds
- handoffs
- teaching,
- multitasking, and
- miscellaneous (including eating, sleeping, washroom breaks).
Notably, getting coffee and discussing Netflix were excluded from observation.
Key Outcomes
So, what did the interns do? They watched 80 interns (45% female; mean age 28.7, 47.5% Caucasian) across 194 shifts, 2173 hours. As a fraction of a 24-hour period, an intern in this study did the following:
- 15.9 hours (66%) in indirect patient care, of which 10.3 hours (43%) was in working in an electronic medical record,
- 3.0 hours in direct patient care (13%), and
- 1.8 hours in education (7%).
Multitasking two or more activities occurred for 3.8 hours (16%) of the day. Within the indirect patient care, the interns were:
- interacting with the patient’s medical record,
- communicating with the care team
- communicating with others about patients,
- reviewing tests, and
The patterns were stable across all time periods around the clock.
Key Conclusions
The authors conclude that direct patient care has declined over time, from 25% in the 1990s, to 9-12% by 2010. They also note the prominent role of multitasking throughout the day.
Spare Keys – other take home points for clinician educators
- This is a classic example of sub-genre of #meded: the time-and-motion study. This approach is resource-intensive, but can be useful to describe what people really do in a given context.
- FYI – it took about 3 years from data collection to completion of analysis. That may encourage some KeyLIMErs that it is not to late to dust off that file and get your papers out!
- We need to be careful extrapolating from any setting (e.g. internal medicine wards) to all of residency education in the US.
- It is interesting to consider the time spent away from the bedside. Is this the right amount? How would we decide? What about senior trainees?
- Will electronic medical records destroy #meded? Multitasking (what Jon calls rapid task switching) seems to be a strategy to deal with the amount of time spent on EMRs…
Access KeyLIME podcast archives here