In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?

Abstract

Background: 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.

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

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

Participants: Twenty-nine interns at the two residency programs.

Main measures: 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.

Key results: 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.

Conclusions: 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.

Figure 1.

Weekday call schedule, site 1 and 2. At Site 1, call/post is an overnight admitting shift, beginning at 8 pm and ending at 12 pm the following day. Long is a daytime admitting shift beginning at 7 am and ending at 9 pm. Coverage is a daytime shift beginning at 7 am and ending at 9 pm. Clinic is a daytime shift split between the hospital and outpatient clinic that was not observed during this study. Weekend schedules are similar, but vary somewhat to allow interns days off. At Site 2, on-call is a daytime admitting shift beginning at 7 am and ending at 9 pm. Pre-call, short-call, and post-call are daytime shifts beginning at 7 am and ending at 6 pm. Nights is an overnight admitting rotation beginning at 9 pm and ending at 9 am the following day. Weekend schedules are similar, but vary somewhat to allow interns days off.