By PAULINE W. CHEN, M.D.
At a social gathering not long ago, a colleague and I exchanged stories about residency training, fondly remembering the patients who had helped us grow both as doctors and as people.
A doctor-in-training we both knew listened intently to our conversation, but when we asked him about his experiences with patients, he looked lost and struggled for a response.
“My generation is different from yours,” he finally said, and then told us about getting “caught” sneaking back to the hospital earlier that year to talk with a couple of patients. He had already officially signed out for the night, but even going back just to say hello would count toward and push him over his 80-hour weekly work limit. Such a violation could cause his residency program to lose its accreditation.
“My generation is different because we can’t have the same relationships with patients as you did,” the young man said. “We just don’t have the time.”
His comment unnerved me then and for a long time afterward. I knew he was being honest about his own experiences, but I couldn’t believe that the same held true for all doctors-in-training. After all, most people I knew became doctors because they wanted to interact with patients.
Now a new study confirms what the young doctor told us: doctors-in-training are spending less time with patients than ever before.
How interns and residents spend their time has been of interest to academic researchers for more than 50 years, but in the late 1980s, as training programs came under increasing pressure to limit the work hours of young doctors, one study in particular raised concerns. The researchers trailed 15 doctors-in-training over five nights and found that residents spent only about 20 percent of their time with patients, with the bulk of their nights at the hospital devoted to paperwork, tasks that did not have to be done by a doctor like drawing blood and inserting intravenous catheters, and frequently interrupted attempts at sleep.
Medical educators were distressed by the findings, and over the next 20 years, residency programs and academic medical centers instituted a series of changes meant to remedy them. Hospitals hired trained nonphysician teams to draw blood and start I.V.’s. They eagerly adopted electronic medical records in order to streamline documentation.
Finally in 2003, under increasing pressure from politicians, unions and sleep experts, the Accreditation Council for Graduate Medical Education issued a mandate that limited an intern’s time at the hospital to 80 hours per week. Then two years ago, they restricted duty hours even further, requiring interns to work according to a complicated algorithm of 16-hour days at most, with mandatory naps and days off.
Now, the largest study on intern work to date, published in The Journal of General Internal Medicine, reveals that while the initiatives of the last two decades were implemented with the best of intentions, the result has been a perfect storm of unintended consequences.
Researchers from Johns Hopkins University and the University of Maryland shadowed interns at two different internal medicine training programs over the course of almost 900 hours. They recorded the time the interns spent talking with and examining patients, meeting with families, attending educational conferences, discussing treatment plans with other doctors, sleeping, eating and even walking around the hospital.
As in earlier studies, the researchers found that current interns spend the majority of their time in activities only indirectly related to patient care, like reading patient charts, writing notes, entering orders, speaking with other team members and transporting patients.
But when they calculated the amount of time spent face to face with patients, the researchers found that interns were devoting about eight minutes each day to each patient, only about 12 percent of their time.
“Medicine is such an experiential learning experience,” said Dr. Kathlyn E. Fletcher, an associate professor of medicine at the Clement J. Zablocki Veterans Administration Medical Center and at the Medical College of Wisconsin in Milwaukee, who has published extensively in this area. “It’s really astonishing that so little time is spent at the patient’s bedside.”
The dramatic decrease in time spent with patients compared with previous generations appears to be linked to new constraints young doctors now face, most notably duty hour limits and electronic medical record-keeping. The study found, for example, that interns now spend almost half their days in front of a computer screen, more than they do with patients, since most documentation must be done electronically.
As a result, efficiency has become an overriding concern. Compared with previous generations of young doctors who spent a significant percentage of time eating or trying to sleep, the interns in the current study spent only about 10 percent of their time doing so. “You can only carve up the hours in so many ways,” said Dr. Lauren Block, the lead author of the paper and a clinical fellow in the division of general internal medicine at the Johns Hopkins School of Medicine. “There’s not a lot of ‘fat’ that can still be squeezed out.”
Young doctors required to see the same number of patients in less time try to speed up their work by culling from computer records all available information about patients, their symptoms and even their physical exam before seeing them in person. When finally in a room with patients, they try to speed up their work again, but by limiting or eliminating altogether gestures like sitting down to talk, posing open-ended questions, encouraging family discussions or even fully introducing themselves.
“We have to ask ourselves if spending more time on electronic medical records than with patients is time well spent,” said Dr. Leonard S. Feldman, senior author of the study and assistant professor of medicine and pediatrics at the Johns Hopkins School of Medicine. “If you’re only spending eight minutes talking to and examining a patient, something is certainly going to be missing.”
While studies have shown that patient satisfaction and outcomes suffer, and inappropriate prescribing increases when doctors spend less time with their patients, there may be even longer-term repercussions of such hurried interactions. A young doctor’s experiences during training strongly influence how he or she treats patients once in practice. In addition, because observation of diseases and their myriad manifestations is critical to building a doctor’s clinical skills, some worry that today’s young doctors won’t have had enough interactions with patients to be able to recognize the more subtle signs and symptoms of disease or of impending emergencies when they begin practicing on their own.
While more research still needs to be done, augmenting federal support of residency training programs to increase the number of trainees, decrease resident workload and make the current restrictions on hours more flexible, could help alleviate some of the pressures young doctors now face and allow them to spend more time with patients.
“There is just no substitute for time in doctor-patient relationships,” Dr. Fletcher said. “Efficiency is important but it isn’t the end of the story.”