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    1 Comment for this article
    And they said it would get better . . .
    Kurtis Elward, Clinical Professor | VCU
    It took an intern in 1993, 2 hours to put in my late wife's chemo orders - (which I had memorized as a medical student) - and then made an error that allowed them to give her 12,000 U/hr of heparin, an order that the intern’s SAR never caught (even when he said, “gosh, she clotted off two CVLs but is easy to anti-coagulate - and I pointed out this didn’t make sense - could he check the IVAC setting. . . . ), they told us all that the new computers systems would be so much better and give us more time with patients.. . . .

    I just talked with an end of the year intern - who said it still takes 3 hours to for her to enter 2 chemo protocols. When they let the pharmacy do it, it's quicker but it doesn't account for other meds and throws off the timing of the other treatments - which some just accept because the EMR told them to do it.

    I have seen so many people in the hospital fail to believe or check on the patient and defer to the EMR's decisions, timing, error messages and limitations, instead of the patient's needs.

    To paraphrase, where your time is spent, there will your heart be also.
    Original Investigation
    April 15, 2019

    Assessment of Inpatient Time Allocation Among First-Year Internal Medicine Residents Using Time-Motion Observations

    Author Affiliations
    • 1Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
    • 2Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
    • 3Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
    • 4Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
    • 5Department of Medicine, Yale–New Haven Hospital, New Haven, Connecticut
    • 6Department of Emergency Medicine, University of Pennsylvania, Philadelphia
    • 7Department of Medicine, Johns Hopkins University, Baltimore, Maryland
    JAMA Intern Med. 2019;179(6):760-767. doi:10.1001/jamainternmed.2019.0095
    Key Points

    Question  How do current first-year internal medicine residents (interns) allocate time during inpatient training?

    Findings  In this secondary analysis of a cluster-randomized trial including 80 interns, participants spent more time caring for patients indirectly (eg, recording their work) than interacting with patients or in dedicated educational activities. Direct patient care or education frequently occurred when interns were simultaneously performing indirect patient care.

    Meaning  These findings provide a comparison with historical trends and a baseline measure for future efforts designed to improve the workday structure and experience of internal medicine trainees.


    Importance  The United States spends more than $12 billion annually on graduate medical education. Understanding how residents balance patient care and educational activities may provide insights into how the modern physician workforce is being trained.

    Objective  To describe how first-year internal medicine residents (interns) allocate time while working on general medicine inpatient services.

    Design, Setting, and Participants  Direct observational secondary analysis, including 6 US university-affiliated and community-based internal medicine programs in the mid-Atlantic region, of the Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial, a cluster-randomized trial comparing different duty-hour policies. A total of 194 weekday shifts were observed and time motion data were collected, sampled by daytime, nighttime, and call shifts in proportion to the distribution of shifts within each program from March 10 through May 31, 2016. Data were analyzed from June 1, 2016, through January 5, 2019.

    Main Outcomes and Measures  Mean time spent in direct and indirect patient care, education, rounds, handoffs, and miscellaneous activities within a 24-hour period and in each of four 6-hour periods (morning, afternoon, evening, and night). 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.

    Results  A total of 80 interns (55% men; mean [SD] age, 28.7 [2.3] years) were observed across 194 shifts, totaling 2173 hours. A mean (SD) of 15.9 (0.7) hours of a 24-hour period (66%) was spent in indirect patient care, mostly interactions with the patient’s medical record or documentation (mean [SD], 10.3 [0.7] hours; 43%). A mean (SD) of 3.0 (0.1) hours was spent in direct patient care (13%) and 1.8 (0.3) hours in education (7%). 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 3.8 (0.4) hours (16%) of the day.

    Conclusions and Relevance  This study’s findings suggest that within these US teaching programs, interns spend more time participating in indirect patient care than interacting with patients or in dedicated educational activities. 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.

    Trial Registration  ClinicalTrials.gov identifier: NCT02274818