#KeyLIMEPodcast 224: Time, Motion, and Residency (or Death by EMR)

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.

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KeyLIME Session 224

Listen to the podcast.

Reference

New KeyLIME Podcast Episode Image

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

  1. There are many, many threats to validity in this paper: the case quality is uncontrolled and unreported, the participants are self-described and presumably extremely variable, the participants are 80% still trainees, the measure of “diagnostic accuracy” and “group accuracy” are potentially flawed, etc.
  2. Beware #meded headlines that sound too good to be true: they probably are.
  3. This is still a clever way to do #meded research from existing databases.
  4. Hear us all clinician-educators: there is still a major need for more research on diagnosis.

Spare Keys – other take home points for clinician educators

  1. 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.
  2. 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!
  3. We need to be careful extrapolating from any setting (e.g. internal medicine wards) to all of residency education in the US.
  4. 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?
  5. 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…

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