Computers vs. patients

If you’re a medical intern (a new doctor in their first year of additional training after medical school), most of what you need to do your job can be pulled off a computer screen: Blood test results. Paged messages. Orders to start a medication. All but, of course, how sick a patient is. How he feels. What his rash looks like.

Researchers at Johns Hopkins University and the University of Maryland, suspecting that more and more of an intern’s time is spent in front of a computer, looked into just how today’s intern spends her working hours on an inpatient ward. They asked trained college students to shadow 29 internal medicine interns from two different Baltimore teaching hospitals and document how much time they spent talking to patients, eating lunch, reading charts, and the like – for nearly 900 hours over the course of three weeks. Their recently published results confirm a trend that old-timers nostalgically lament and that those of us in training know to be all too true: only a small percentage of our time is spent in direct patient care.

The interns in the study spent just 12% of their time with patients – on average, about 8 minutes with each patient each day. Nearly as much time (7%) was spent walking. In contrast, they spent 64% of their time in indirect patient care – for example, talking to other doctors and nurses (20% of total time) or writing patient notes. They spent a full 40% of their time in front of a computer screen – writing notes, placing orders, and reading electronic medical records. Fifteen percent of their time went to educational activities. The authors compared these findings with those of similar studies conducted before the ACGME, the regulatory board for residency programs, first limited how many hours interns could work at a time and over a given week back in 2003. In the first of these time motion studies, published in 1989,  interns spent about 20% of their time with patients and split the rest between documenting (42-45%) and sleeping and eating (up to 40%). Subsequent pre-2003 studies had similar results.

How do we explain the small but noticeable shift toward less time with patients? Today’s interns have more information to wade through in each patient’s chart. In the move toward team-based care, they spend increasing amounts of time talking to various members of the health care team: TBW (touch base with) you fill-in-the-blank (consulting doctor, physical therapist, case manager) is an inevitable item times ten on their daily to do lists. They still do their share of tasks like faxing documents that probably don’t require an MD. And, apparently, they spend a lot of time walking (I’d imagine this is less true at hospitals where teams’ patients are clustered by floor).

I don’t quite agree with the Baltimore researchers’ assumption that less direct time with patients is necessarily a strike against our ever-elusive aim of patient-centered care. After all, as I try to remind our patients (though I know firsthand how difficult it is to believe), we spend the vast majority of our time thinking about and working for them even when we aren’t in their line of sight.

But as I’ve come to appreciate more since emerging from the weeds of intern year, the time we do get to spend with patients is as illuminating as it is rewarding. As one of the junior residents overseeing a team of interns, I have the luxury of delegating some of the minutiae of patient care to the interns so that I can focus more on direct patient care – explaining test results, initiating difficult conversations about end of life goals, and getting to know patients as people. On the not-so-rare occasion when difficult exchanges with multiple different providers leave me muddled and dejected, I find clarity in sitting down with the patient in question and sorting out what matters to him or her.

During residency-wide discussions about improving our training experience, we often talk about creating more time for interns as well as more senior residents to spend with patients – for example, by presenting patient stories at the bedside whenever possible and by creating a scheduled time in the afternoons to drop by patients’ rooms. This is increasingly difficult as we try to squeeze our work into shorter and shorter resident duty hours, but well worth the effort – not only for patient care but for our growth as physicians.