We conducted a time-motion study to determine how interns in 2010 spent their time while on call. We demonstrated that the majority of interns’ time was spent in indirect patient care, usually in the form of clinical documentation tasks performed at a computer. Only a small proportion of their time was spent at the bedside of patients, and even less was spent in overt educational activities.
Interns spent the greatest proportion of their time in front of a computer. This is consistent with a recent review of inpatient work studies that found approximately 50 % of inpatient physician time is spent in indirect patient care.16
Our study was conducted at a VA, which has an integrated electronic medical record. Therefore, the large fraction of time spent at the computer may be partially driven by the fact that order entry, test results, chart review and all documentation occur at the computer. At hospitals with less well-developed electronic medical records, other clinical administrative and documentation tasks (e.g., searching for paper charts, handwriting notes) likely consume at least a comparable amount of interns’ time. While these documentation tasks are often maligned as busy work, it is possible that interns are also thinking and integrating information while in front of the computer. It is difficult to capture cognitive work in an observational study, but we hypothesize that at least some of the cognitive work that occurs during the admission process occurs while notes and orders are being written.
In a conceptual model of house staff time allocation, this time on clinical computer work could
fall into the category of independent education related to patient care, or into non-educational patient care. Our data does not allow us to know how much computer work would qualify as non-educational patient care time. In the past, “scut work” was the epitome of non-educational patient care. Examples included activities such as placing IVs or drawing blood.17
In our study, no intern time was spent on these tasks.
Time at the bedside is an important aspect of the experiential learning that occurs during residency.18
In our study, interns spent on average only 12 % of their time with patients. Other studies corroborate that direct patient care consumes less time than indirect patient care.16
In the only comparable US study since 2003, a single internal medicine intern was observed, and that individual spent 20 % of their time at the bedside.19
It is notable that we began our observations in the afternoons, after normal rounds would be over, but we were able to capture the time during which most admitting and cross-cover occurred. Presumably, if we had observed the interns for an entire 24 hour period, we would have captured their morning visits to patients, and any subsequent visits with supervising residents or attendings on rounds.
The ideal amount of time at the bedside for internal medicine house staff is not defined in the literature. We believe that the on-call period is a time when bedside work should be prominent, given that the admitting history and physical require more time than daily follow-up visits. With the VA EMR, it is possible that the past medical and social histories on new patients are obtained from the computer rather than from the patients, which could shorten the bedside interactions considerably, partially explaining our finding.
Only 20 minutes (2 %) per call night were spent in overt educational activities, and only 14 minutes on clinical reading. In the 2003 review by Boex, et al., 15 % of resident time was estimated to be spent in teaching/learning activities.2
Because we focused on the on-call period, we did not capture teaching from attending rounds or planned educational sessions, such as our daily noon conferences. In addition, it is possible that some educational activities were not categorized as such by our research assistants, because they were not overtly education (e.g., an intern asking a resident for advice on antibiotic therapy may not have been coded as education). However, we gave the research assistants definitions about teaching/learning activities to increase the chance that they would correctly identify them.
Time spent on call is a substantial proportion of overall house staff experience, and this time includes opportunities for both independent learning and formal teaching during patient care. Most of the formal teaching will occur during attending rounds and noon conferences. However, the on-call period is rife with opportunities for direct supervision of interns by more senior residents, but this supervision does not appear to be happening frequently. It is possible that as the shift lengths of house staff become further compressed with progressive limitations of duty hours, the opportunity for such direct supervision may be waning.
The results of our study should be considered in the context of its limitations. First, the results from one VA hospital may not generalize to other non-VA programs. However, many teaching programs include VA rotations, and the call structure at our VA utilizes a fairly standard schedule. Second, we observed each intern only one time, which means that the results for each intern may only reflect the situational factors of the night he/she was observed, rather than an estimate of his/her typical work pattern. We chose to do this to limit the burden on individual interns, and also to increase the generalizability of the study. Third, the observation period in this study did not cover the main educational conferences or attending rounds; therefore, many educational activities would not have been recorded by our observers. Time spent on teaching/learning would have increased by at least an hour (based solely on the noon conferences), and possibly by more, depending on how much teaching would have occurred on attending rounds. Finally, we did not calculate inter-rater reliability for the observations.
How house staff spend their time on call has been studied periodically over time.17,20–22
Even so, it is important to revisit their work distribution, as major changes in the graduate medical education system are occurring. Our results suggest a need to proactively consider strategies to increase intern time spent with patients and in formal and informal teaching activities when on call. It is only by knowing this information that the medical education community can maximize the house staff clinical experience in the newest era of duty hour reform.