We have applied automated random sampling to perform real-time measurements of housestaff time allocation and the value of work activities. These data support the feasibility and reliability of this approach, and also provide important insights into the daytime activities of housestaff, which may inform efforts to redesign the inpatient work of medical interns and residents.
This method of work sampling was not excessively burdensome to housestaff and provided virtually complete and mostly verifiable information on work performed during the time intervals sampled. Short completion times and high complete response rates indicate that the response burden was modest and that responses to a complex but interactive computer instrument can be efficiently obtained.19
The short elapsed times between prompts and responses confirm a close relation between the prompt and the time of actual data entry, a relation that has been uncertain in previous work-sampling studies.17, 18
The reliability of automated sampling is further indicated by the high degree of interobserver agreement between housestaff subjects and medical student observers and also the consistency of responses against an external logic check.
Although the main results may not generalize to all training programs, we believe they reflect patterns typical of the inpatient experiences of housestaff in many internal medicine residencies. These data reveal, for instance, that housestaff spend the greatest part of their day in indirect patient care, despite the fact that these activities receive the lowest ratings for educational value and lower ratings for patient care value than direct patient care. Nearly one third of interns' time is devoted to documentation and to ordering tests or obtaining test results, activities given low scores for educational value.
Though time interacting with patients received higher value ratings than indirect patient care, housestaff spend less than 15% of their time in these activities. Of time allocated to direct patient care, most is dedicated to the initial history and physical examination. It may be inferred that, over the course of a patient's hospitalization, time spent with the patient diminishes substantially.
We observe that interns allocate less time than residents to activities that simultaneously support both patient care and education. If the proportions for all activities are summed, the total for interns is 109% and for residents 129%. The difference of 20% is explained by the greater overlap between patient care (direct or indirect) and education in the work activities of residents. There thus appears to be a richer content to residents' activities compared with interns' activities.
This analysis corroborates the findings of previous time studies, which have also shown that housestaff spend little time with patients and substantial time in administrative and educational activities.13, 18
However, the explanatory power of these studies is more limited owing to their measurement of no more than two dimensions of housestaff work. These studies also dichotomize activities as education or patient care, neglecting the dual content of many activities, which enhances value to both education and patient care.
What are the implications of these results for the reform of residency training as inpatient time is increasingly constrained? If value is to be preserved while continuing to meet educational objectives and support patient care, low-value activities must be reduced or delegated and high-value activities maintained. For instance, simplifying required documentation or delegating some of these tasks to other kinds of workers might reduce time dedicated to low-value administrative tasks. Valuable time with patients might be increased by shifting indirect activities (e.g., work rounds, attending rounds) to the bedside, thereby simultaneously enhancing both patient care and education. Programs might integrate housestaff tasks with those of other disciplines to strengthen collaboration, reduce solitude, and increase efficiency.
We believe that some housestaff work could be performed by nonphysicians. For instance, nearly 40% of interns' time is allocated to documentation, testing and procedures, discharge planning, initiating consultations, and miscellaneous administrative tasks. If half of these activities were delegated to others, interns' inpatient time could be substantially reduced at no cost to the higher-value activities. This is consistent with the findings of Knickman et al., who concluded that at least 20% of housestaff activities could be done by nonphysicians.13
In our study, only 13% of activities were seen as delegable by housestaff, and most of these to other housestaff ! This may be due to housestaff's difficulty reconceptualizing their work, particularly in real time. In order to decide which activities may be delegated to nonphysicians or eliminated altogether, more systematic methods must be employed, such as total quality management or work reengineering. For either of these, time studies provide the raw data for rethinking current models of training and envisioning alternative approaches.
This study has provided our training program with the kind of detailed, multidimensional information needed to respond to the increasing constraints on inpatient time. It has increased our understanding of the work experiences of housestaff and provided insight into the value of those experiences. Further research is needed to evaluate housestaff work across types of training programs and differing systems of care, which, in turn, would inform local and national initiatives to enhance the value of training experiences. For such evaluations, automated random sampling may be the method of choice for obtaining the reliable information required to guide the redesign of house officer work.
Registration Period: September 1, 1998 – December 1, 1998
Examination Dates: August 24–25, 1999
Registration Period: July 1, 1998 – November 1, 1998
Examination Dates: April 16, 1999
Important Note: The 1999 Sports Medicine Examination is the last one for which Diplomates may qualify through a practice pathway.
For more information and application forms, please contact:
Registration Section American Board of Internal Medicine 510 Walnut Street, Suite 1700 Philadelphia, PA 19106-3699 Telephone: (800) 441-2246 or (215) 446-3500 Fax: (215) 446-3590 E-mail: request/at/abim.org