Study Suggests Interns Spend Relatively Little On-Call Time on Patient Care or Educational Activities

BACKGROUND:
The educational environment for house staff has evolved substantially since the Accreditation Council for Graduate Medical Education (ACGME) first limited duty hours in 2003. House staff now appear to spend fewer hours in the hospital, consistent with the ACGME rules. However, there are limited data to inform our understanding of how the 2003 duty hour rules have changed the actual composition of their work. While the issue of appropriate allocation of house staff time is very important, it is not described in the literature. The aim of this prospective time-motion study was to determine how internal medicine interns (11 men and 14 women) at one VAMC spent their time on call between 5/10 and 10/10. Trained observers followed the interns during a "call" day, continuously recording the tasks performed. Tasks were categorized into six areas: clinical computer work (e.g., writing orders and notes), non-patient communication, direct patient care (work done at the bedside), downtime, transit, and teaching/learning.

FINDINGS:

• During on-call periods, internal medicine interns spent relatively small amounts of time on direct patient care and teaching/learning activities: 40% of their time (the largest proportion) was spent in clinical computer work; 30% on non-patient communication; and only 12% of their time was spent at the patient bedside.
• Downtime activities, transit, and teaching/learning accounted for 11%, 5%, and 2% of the interns' time, respectively.

LIMITATIONS:

• This study was conducted at a VAMC with 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 on the computer.
• While some time spent at the computer may involve conceptualizing and integrating information, it is not possible to capture cognitive processes in an observational study.
• Each intern was observed only one time, thus the results may reflect only the situational factors of the night he/she was observed rather than an estimate of his/her typical work pattern.
• The observation period did not cover the main educational conferences or attending rounds, therefore, many educational activities would not have been recorded.

CONCLUSIONS:
As major changes in graduate medical education are occurring, the results of this study suggest a need to proactively consider strategies to increase intern time with patients and in formal and informal teaching activities when on call.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (PPO 09-259). Dr. Fletcher is part of the Milwaukee VAMC.

Fletcher K, Visotcky A, Slagle J, Tarima S, Weinger M, and Schapira M. The Composition of Intern Work While on Call. Journal of General Internal Medicine November 2012;27(11):1432-37.