Robert Wachter , MD Keynote Speakers Bureau & Speaking Fee
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Understanding Patient Safety , Second Edition is the essential book for anyone seeking to learn the core clinical, organizational, and systems issues of patient safety. This classic reference is designed to make the patient safety field understandable to medical, nursing, pharmacy, hospital administration, and other trainees, and to be the go-to book for experienced clinicians and non-clinicians alike. Time spent multitasking, simultaneously engaged in combinations of direct patient care, indirect patient care, or education, and in subcategories of indirect patient care were tracked.
A mean SD of A mean SD of 3.
This pattern was consistent across the 4 periods of the day. Direct patient care and education frequently occurred when interns were performing indirect patient care. Multitasking with 2 or more indirect patient care activities occurred for a mean SD of 3. These findings provide an essential baseline measure for future efforts designed to improve the workday structure and experience of internal medicine trainees, without making a judgment on the current allocation of time.
The workday for internal medicine residents in the United States has evolved over time. With the diffusion of the electronic health record, demands for more detailed documentation, and pressures to decrease the length of stay for common clinical conditions, 1 , 2 residents may have adapted by reducing time spent with patients and in educational activities. Because the policy groups did not differ on time spent in different activity categories, we aggregated and analyzed time-motion data across all interns from the 6 training programs to comprehensively describe how interns spent their time on general medicine inpatient services.
We then examined data from 4 periods of the day morning, afternoon, evening, and night to explore variations in how time was spent throughout the day. Finally, we quantified the proportion of time spent multitasking. Time-motion data were collected from March 10 through May 31, Six programs, 3 in each policy group, were recruited for the time-motion substudy.
The iCompare trial protocol is available in Supplement 1. The study was approved by the institutional review board at the University of Pennsylvania. All participants provided written informed consent. Time-motion study programs were located in the mid-Atlantic region to facilitate in-person training of observers and ongoing monitoring of quality across multiple programs during the observation period.
Observed shifts were limited to shifts starting on a weekday Monday-Friday and included daytime short and long shifts as defined by the training program , nighttime, and call shifts defined by the training program and typically lasting more than 14 hours. The proportion of shift types observed at each program reflected the program-specific distribution of shifts in terms of shift length and overnight schedules to capture a typical hour weekday for each program. For example, for a given general medicine rotation ranging from 2 weeks to 1 month at a specific training program, if interns spent two-thirds of their rotation working day shifts and one-third working night shifts, the ratio of day to night shifts scheduled for observation at that program approximated Programs had a variety of shift types with varying start and stop times eFigure 3 in Supplement 2.
Interns rotating on the general internal medicine inpatient service at 6 mid-Atlantic teaching programs during the time-motion study period were eligible for observation. Interns, as opposed to more senior residents, were chosen for time-motion data collection because the 2 duty-hour policies studied in the iCOMPARE trial had different rules for intern shifts and different work hours for interns, and, generally speaking, interns are the primary, patient-facing physicians for patients receiving care from resident teams in teaching hospitals.
Interns were recruited individually and in group settings eg, during teaching conferences , and in person at each program. Among the interns invited to participate, We did not record why interns chose not to participate. Data were collected by 23 observers including A. We used 2 processes to assess observation reliability. First, after training was completed, each observer recorded activities observed while watching an 8-minute video of actors performing the predefined activities.
The observer began recording activities when the intern arrived at the hospital and stopped when the intern finished their clinical duties for that shift. Shifts longer than 12 hours were typically split between 2 observers; precise split times were coordinated between observers based on their available schedule.
As a quality check, we measured expected observation time based on interns self-reporting their arrival and departure times. In total, Activities were assigned to 7 major categories Table 1 , adapted from prior time-motion trials. The not-required section activities were recorded as they occurred. The required section was purposefully incorporated to avoid unrecorded blank periods that could be interpreted as the intern not engaged in any activity or the observer forgetting to record. Three of the major categories—education, direct patient care, and indirect patient care—had subcategories.
More than 1 major or subcategory could be selected if different types of activities occurred simultaneously. For example, an intern could be recording the clinical encounter while talking to a patient. In this situation, the intern would be engaged in indirect patient care subcategory of interacting with the health record and direct patient care subcategory of patient communication. We defined multitasking as periods when simultaneous activities in one of the following combinations of major categories were observed: 1 indirect and direct patient care; 2 indirect patient care and education; 3 direct patient care and education; 4 indirect patient care, direct patient care, and education; or 5 when 2 subcategories of indirect patient care ie, interacting with the health record, communicating with team members, communicating with nonteam members, or viewing images were observed because prior studies indicated these were dominant activities in a workday.
We used a granular approach to characterize time allocation to specific activities. For each second of a hour day, we calculated the proportion of interns engaged in a specific activity by totaling the number of interns who were observed engaged in that activity and then dividing by the total number of interns who could have been observed during that period. For example, to calculate the proportion of interns spending time in direct patient care from to pm , we divided the total number of interns observed in direct patient care during that specific 1-second period by the total number of interns who were observed during that 1-second period ie, an observer was on site.
We repeated this procedure for every second of a hour period for every recorded activity and then summed each second to a desired interval length, such as a 6-hour or a hour period. When the percentage of interns engaged in a particular activity is summed across a set period and divided by that interval, each second is adjusted by the number of interns available to be observed. The summed value represents the mean proportion of time spent in a particular activity across all 6 training programs.
We report the mean SD number of hours engaged in any recorded activity except work because direct and indirect patient care and their subcategories provide a more detailed description of work-related activities. We parsed our measurements based on the following 4 periods of the day: 1 morning 6 am to 12 pm , 2 afternoon 12 pm to 6 pm , 3 evening 6 pm to 12 am , and 4 night 12 am to 6 am.
Clustering within programs was reflected using multilevel mixed-effects models with restricted maximum likelihood estimations using a random intercept for each program cluster. All analyses were conducted using Stata software version A total of 80 interns from 6 mid-Atlantic teaching programs were observed for hours. Forty-four We observed a median of Among the shifts observed, Little time was spent viewing radiology images, electrocardiograms, or pathology results 0. The next most frequently observed activities were rounds 5. These observed activities were followed by educational activities 1.
The least amount of time was spent handing off patient care responsibilities 0. With a few exceptions, the amount of time spent engaged in particular activities was consistent throughout the day Table 3. Indirect patient care was the predominant activity during each of the 6-hour time periods mean [SD] range, 3. Afternoons revealed the least amount of time in direct patient care but the most in education.
During evenings and nights, marginally greater time was spent in direct patient care compared with the afternoon period, and very little time was spent in educational activities. When multitasking did occur, the combination of direct and indirect patient care mean [SD], 0.
Viewed another way, a substantial portion of the time spent in direct patient care or educational activities occurred while performing indirect patient care. Simultaneous activities in subcategories of indirect patient care were also frequent Figure , B, and eTable 2 in Supplement 2.
In particular, interacting with the medical record while communicating with medical teams was the most common, occurring a mean SD of 2. Interns are predominantly engaged in indirect patient care, with little variation over 24 hours. In contrast, little time was spent in educational activities or direct patient care. When interns were engaged in these activities, indirect patient care often co-occurred.
Internal medicine interns in our study spend a small proportion of time directly engaged with patients. We add to these studies, first, by describing what occurs in the evenings and nights, whereas prior studies have mostly observed daytime activities.
Second, we provide measures of multitasking, which few studies of training programs have included. Without a consensus definition of multitasking, we chose to report what we believe is most informative for policy makers, accreditation bodies, and educators 20 - 22 : 1 the overlap among the 3 major activities of direct patient care, indirect patient care, and education and 2 co-occurring indirect patient care activities.
The New and Improved “Understanding Patient Safety” and the Evolution of the Safety Field
How the medical community responds to these observations will be important moving forward. As trainees report high rates of burnout and depression early in their career, 23 , 24 understanding how their workday affects their health and well-being may be an important next step. Our study has several limitations. First, we limited our study to internal medicine interns.
The distributions of activities of interns in other fields, such as surgery or psychiatry, are likely to be different, although many non—internal medicine residents spend a significant portion of their first year rotating on internal medicine inpatient services. Second, our study observed interns at 6 training programs, potentially limiting its generalizability. Nevertheless, we observed 2 and a half times as many hours of intern time and included 3 times as many programs as the next largest time-motion study in the United States.
Although these rotations are arguably the defining experience of a medicine internship, medical interns spend many months in other settings. Finally, these results are descriptive. We can observe how interns spend their time and we can compare that with distributions from the past, but no established standards identify what distribution of activities is best for the educational experience of interns or the quality of care patients receive.
This analysis of time-motion data from a large cohort of interns across multiple US training programs reveals that interns spend substantial time in indirect patient care and little in face-to-face contact with patients or engagement in educational activities. Concluding that this distribution is a problem might be easy, reflecting an appealing and perhaps nostalgic view that the best way to care for patients and the best way to learn from them is with personal contact.
A more agnostic view is that even if face-to-face engagement is essential, more may not be necessary given that so much of patient care now occurs in teams, is informed by diagnostic test reports, and is mediated through the work of others. Our results suggest those realities define how medical interns spend their time, and although we cannot be sure whether that is good or bad, our findings provide an essential baseline measurement for future efforts designed to improve the workday structure and experience of internal medicine trainees.
Published Online: April 15, Correction: This article was corrected on July l, , to add the Trial Protocol and Data Sharing Statement to the supplemental content and include the necessary citations within the article. Corresponding Author: Krisda H. Author Contributions: Dr Chaiyachati had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Chaiyachati, Shea, D. Asch, Bellini, Sternberg, Yeager, J. Asch, Desai.
Critical revision of the manuscript for important intellectual content: Chaiyachati, Shea, D. No other disclosures were reported. Data Sharing Statement: See Supplement 3. Additional Information: A copy of the Association of Program Directors in Internal Medicine survey results is available from the authors on request.