Interns Spend Most Time With EMRs, Not Patients

Veronica Hackethal, MD

April 15, 2019

New results from the iCOMPARE trial show that first-year residents, or interns, spend almost five times more hours on indirect patient care than on face-to-face patient care. Most of that time — 10 hours over a 24-hour period — was spent working with electronic medical records.

The study by Krisda H. Chaiyachati, MD, MPH, MSHP, assistant professor of medicine, the Perelman School of Medicine, the University of Pennsylvania, Philadelphia, and colleagues was published online April 15 in JAMA Internal Medicine.

iCOMPARE is the largest study to date to analyze how interns spend their workdays. It includes 2.5 times as many hours and three times as many residency programs as a past study.

"Our study can help residency program leaders take stock of what their interns are doing and consider whether the time and processes are right for developing the physicians we need tomorrow," Chaiyachati said a news release.

The amount of time residents spend working has generated controversy since 2003, when the Accreditation Council of Graduate Medical Education (ACGME) began limiting residents' work hours. Residents' shifts were limited to 30 hours, and workweeks were limited to 80 hours. Residents were requierd to be given at least 1 day off every 7 days, and caps were placed on the frequency of overnight calls. Since instituting these limits, ACGME has granted some programs waivers that allow longer shifts while maintaining the 80-hour workweek cap, limits on overnight calls, and mandatory days off.

iCOMPARE is a cluster randomized trial that compared flexible-hour residency programs with standard-hour residency programs with regard to patient care as well as residency training and well-being. The study was conducted in 63 residency programs nationwide from July 2015 through June 2016.

Previously reported results from iCOMPARE suggested that several measures of patient safety, including patient death, are no different for programs with standard work hours vs those with flexible work hours. Results also suggested similar effects on resident well-being, including chronic sleep loss and excessive sleepiness.

Other results from iCOMPARE suggested that there were no significant differences in time spent on patient care for flexible-hour vs standard-hour programs, although residents in standard-hour programs reported more satisfaction with training and work-life balance.

Questions remain concerning the effects of shorter hours on the quality of physician training, particularly for interns who work the longest inpatient hours and whose learning curves are steepest.

To provide some answers, researchers undertook a substudy of the larger iCOMPARE trial. The smaller study included three flexible-hour and three standard-hour internal medicine residency programs at academic medical centers (66.7%) and community hospitals (33.3%).

The researchers used time-motion techniques to follow 80 interns throughout the day and to observe how they spent their time. The analysis included 194 shifts, or 2173 hours. The median length of shifts was 10.5 hours. The study took place during a 2.5-month period in spring 2016 and included morning, afternoon, evening, and night shifts.

For each 24-hour period, interns spent an average of 15.9 hours (66% of every 24 hours) on indirect patient care. Much of this time — 10.3 hours, or 43% of every 24-hour period — was spent working with electronic medical records and documentation.

Over a 24-hour period, interns spent only 3.0 hours (13% of their time) on direct patient care and only 1.8 hours (7% of their time) on education.

The proportion of time spent in these tasks was similar throughout the day, regardless of whether the interns worked morning, afternoon, evening, or night shifts.

Furthermore, interns frequently engaged in multitasking, which often involved combining indirect patient care with direct patient care and education. For each 24-hour period, interns combined 23% of all direct patient care and 28% of all educational activities with indirect patient care.

Spending so much time multitasking may reflect the need to pack in more and more work in less amount of time. The study cannot answer whether spending more time multitasking and less time with patients is good or bad. The results could serve as an important baseline about the current experience of residents. Training programs could use these results to implement changes that improve education and decrease trainee burnout, according to the authors.

The results raise questions as to whether these changes merely reflect a shift in medicine toward increased reliance on teamwork and computer technology or whether they reflect a deterioration of humanism in medicine, according to Christopher Moriates, MD, and F. Parker Hudson, MD, MPH, both of Dell Medical School at the University of Texas at Austin, who were invited to write a commentary on the study.

"Whether this modern snapshot of the daily lives of interns serves as a clarion call to reinvest in the humanistic aspects of medical training or simply becomes a marker on an inexorable evolution in what it means to be a physician is up to all of us and will ultimately reveal what we truly value," they wrote.

Because the study included only six internal medicine training programs, the majority of which were affiliated with universities, the results may not be generalizable to other settings. Also, the "education" category may have been too narrow to capture educational opportunities that occur throughout the day, such as during rounds.

The study was funded by the National Heart, Lung, and Blood Institute and the ACGME. One or more authors have received grants, personal fees, and/or review committee participation from one or more of the following: the National Institutes of Health, the National Heart, Lung, and Blood Institute, and the ACGME. Coauthor David A. Asch, MD, MBA, has partial ownership in VAL Health. Hudson completed medical school and residency at the University of Pennsylvania, where the iCOMPARE study was coordinated. He has no ties to the study and has not been at the University of Pennsylvania for more than 5 years.

JAMA Intern Med. Published online April 15, 2019. Full text, Commentary

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