Save Time for Patients

TimeI saw an interesting item in the AMA MorningRounds recently about how much less total face-time internal medicine residents are spending with their patients [1]. In fact, according to a recent study published in the Journal of General Internal Medicine, of their limited time, they spent only “…approximately 12%, in direct contact with patients.”

The item was based on an article in the New York Times by Dr. Pauline Chen, MD on the Well Blog, For New Doctors, 8 Minutes Per Patient – Wow, 8 minutes–that’s about how much time many practicing primary care doctors get to spend with their patients. You could say that physicians-in-training are just getting exposure to real world practice.

Because the links to the study in Dr. Chen’s story were broken, I had to hunt down the article on PubMed just to get the non-open access abstract and full-text article. What are residents doing instead of sitting with their patients? They’re sitting in front of computer screens, poring over the Electronic Medical Record (EMR) to get the essential information on the patients they’re trying to care for–in the same total amount of time they had before duty hours restrictions. Studying the patient’s medical record is not a bad thing and neither is attending didactic and other learning conferences.

But hang on, isn’t humanistic patient care why most of went into medicine in the first place? How do we square the way we carve up our time with the ideals the Arnold P. Gold Foundation espouses, The Arnold P. Gold Foundation?

According to the authors of the study, “The goal of residency training is to produce competent physicians capable of practicing independently. To reach the educational milestones needed to demonstrate independence, residents must hone their skills in patient care and communication. As the ACGME common programs highlight, ‘For the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty members.’ Prior studies have found that more time spent with patients may improve patient satisfaction, patient education, and clinical outcomes, and reduce inappropriate prescribing.”

Naturally I thought of our psychiatry residents and their “milestones.” The study involved internal medicine residents, but I suspect that psychiatry trainees also have less and less time to do more and more to prove their competency.

Where have you heard that before? I had a peek at the new Accreditation Council for Graduate Medical Education (ACGME) “Milestones” program (, which is definitely complicated and reminiscent of Maintenance of Certification (MOC), and actually endorses MOC as one obviously preferred way to demonstrate a commitment to life-long learning. Have a look at page 23, under Professionalism, “Prepares for obtaining, and maintaining board certification.” And on page 27 in the Practice Based Learning module in the second footnote, “Examples include PIP module as included in the ABPN MOC process, regular and structured readings of specific evidence sources.”

That sound familiar? It should because Larry Faulkner, MD, President and CEO of ABPN (Who We Are at ABPN), is one of the members of the Advisory Group contributing to the drafting of The Psychiatry Milestone Project: A Joint Initiative of The ACGME and ABPN, as of April 2013. Don’t get me wrong; Dr. Faulkner and his staff are extremely helpful assisting ABPN diplomates navigate the wilderness of MOC, the framework for which he’s pointed out came from the American Board of Medical Specialties (ABMS).

I don’t need to tell regular readers of my blog how many physicians disagree with the regulatory board approach to life-long learning, a major criticism of which is that it takes time away from patient care.

The majority of them.

I’m not pitting the Arnold P. Gold Foundation against the ABMS, either. But I wonder if the leaders of both organizations could get together, maybe over a couple of beers, and take a little time to talk things over.

“…And we must build a culture of humanistic clinical excellence.”—Jamos the Elder
“…And we must build a culture of humanistic clinical excellence.”—Jamos the Elder

1. Block, L., et al. (2013). “In the Wake of the 2003 and 2011 Duty Hours Regulations, How Do Internal Medicine Interns Spend Their Time?” Journal of General Internal Medicine: 1-6.
The 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) common program requirements compress busy inpatient schedules and increase intern supervision. At the same time, interns wrestle with the effects of electronic medical record systems, including documentation needs and availability of an ever-increasing amount of stored patient data.

In light of these changes, we conducted a time motion study to determine how internal medicine interns spend their time in the hospital.

Descriptive, observational study on inpatient ward rotations at two internal medicine residency programs at large academic medical centers in Baltimore, MD during January, 2012.

Twenty-nine interns at the two residency programs.

The primary outcome was percent of time spent in direct patient care (talking with and examining patients). Secondary outcomes included percent of time spent in indirect patient care, education, and miscellaneous activities (eating, sleeping, and walking). Results were analyzed using multilevel regression analysis adjusted for clustering at the observer and intern levels.

Interns were observed for a total of 873 hours. Interns spent 12 % of their time in direct patient care, 64 % in indirect patient care, 15 % in educational activities, and 9 % in miscellaneous activities. Computer use occupied 40 % of interns’ time. There was no significant difference in time spent in these activities between the two sites.

Interns today spend a minority of their time directly caring for patients. Compared with interns in time motion studies prior to 2003, interns in our study spent less time in direct patient care and sleeping, and more time talking with other providers and documenting. Reduced work hours in the setting of increasing complexity of medical inpatients, growing volume of patient data, and increased supervision may limit the amount of time interns spend with patients.

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