#KeyLIMEPodcast 115: Wasting time? And Resident Duty Hours.

Hey?  What are you doing right now?  Ok now?  How about now?  Sure… but right now… what are you doing?

I don’t think this is how time-motion studies work… would it not be off-putting if someone with a clipboard and a white coat followed you around all day?  The Key Literature in Medical Education podcast jumps into the world of time-motion studies this week.  The context for the research is the impact of the ACGME resident duty hour restrictions on day-to-day clinical work.

In episode 113 we talked about the influence of these administrative changes on patient outcomes. Now we can dig a bit deeper and figure out what happens minute to minute in the life of a resident.

On to the show! (i.e. the podcast is here.).  Or if you want to wade (not jump) in, check out the abstract below.

– Jonathan

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KeyLIME Session 115 – Article under review:

Listen to the podcast

View/download the abstract here.

Leafloor CW, Lochnan HA, Code C, Keely EJ, Rothwell DM, Forster AJ, Huang AR Time-motion studies of internal medicine residents’ duty hours: a systematic review and meta-analysis. Adv Med Educ Pract. 2015. 17(6):621-9

Reviewer: Jason Frank (@drjfrank)

Background

Resident duty hours (RDH) is a frequent topic in the KeyLIME podcast. Loyal listeners will recognize the decades-long debates, the hardened positions of various advocates, and more recently, the emergence of evidence to finally guide policy and educational decision-making. (You can find some previous episodes of KeyLIME on RDH here: #62 and #76) See the Canadian task force review of the recent lit at www.residentdutyhours.ca). Previous reviews have covered the impact of changes to RDH (especially in the US), the rationale for changes, how loathed many changes are, and what impact they have had. Hint: it’s not patient safety. More recently, a national RCT of RDH changes was published in the NEJM to great fanfare (see KeyLIME episode #113, where we were disappointed in the study).

Linda found today’s paper in a journal that I had not previously heard of, and it addresses an important aspect of the RDH discourse: “what exactly do residents spend their precious time on?” Linda knows I have an interest in the obscure sub-genre of observational research called “time and motion studies”, which basically record what a population does in a given time period.

Purpose

Leafloor et al, from the Ottawa Hospital [disclosure: I work at the Ottawa Hospital, but it is a big institution and did not know anything about this paper before reading it]. The authors set out to do an overview of time and motion studies of residents in Internal Medicine. They paid particular attention to changes related to US (ACGME) RDH policies.

Type of Paper

Systematic review

Key Points on Methods

The authors searched 4 English databases from 1941 to 2013, looking for time and motion studies, internal medicine related disciplines, and duty hour related terms. They included only those that involved only direct observations. All other methods were excluded (they even tried out one published method, found it unreliable, so excluded it). They developed a taxonomy of 9 daily activities using a “modified Delphi method”, then didn’t use it to classify the data from papers. They used 5 categories instead: patient care, communication, transit, education, & personal/other. They pooled the data and performed descriptive stats.

Key Outcomes

The search found 468 records from the search that yielded 8 includes. Residents per study ranged from 2-35, total observation time was a mean of 388 hours. The overall results were that a typical on-call shift involved 41.8% of time spent in patient care, 19.7% personal/other, 18.1% communication, 13.8% education, and 6.6% transit. Post ACGME policy changes, the % were not statistically significant. Notably, education time decreased by ~6% and communication time increased by about the same.


Key Conclusions

 The authors conclude…

The authors conclude that time and motion studies provide useful insights into Internal Medicine resident activities. They also found a lack of standardization of terms, taxonomies, or methodologies in meded studies.

Spare Keys – other take home points for clinician educators

  1. Time and motion studies are a powerful sub-genre of observational research to apply to medical education problems.
  2. Reviews of a diverse group of studies can be very influential–but authors really need to pay attention to their methods to make the work defensible and comprehensive.
  3. Systematic reviews can be great resident research projects, and highly publishable.

Shout out

My colleague at the Royal College, Tanya Horsley, is a world-renowned systematic review methodologist. Look up her name when you are embarking on one of these reviews and you will find some great methods papers to model your approach on.

Access KeyLIME podcast archives here