September 16th, 2013

Medical Interns – Not at the Bedside, but Not to Be Blamed

If only all interns looked so happy on the job…

This past week in NEJM Journal Watch General Medicine, Abigail Zuger reviewed an article from the Journal of General Internal Medicine by Lauren Block et al. in which researchers examined how medical interns spend their time. The results from this time motion study might be concerning but are not unexpected. The investigators found that interns on inpatient rotations spend only 12% of their time in direct patient care and spend only 8 minutes daily with each patient on their inpatient services. Dr. Zuger notes this “distressing paucity” of direct patient care should cause leaders in graduate medical training to effect change in interns’ daily routines.

To those of us in training or just out of training, the reasons for less direct patient care are myriad and obvious:

  • A focus on multidisciplinary care and ever-increasing specialization results in each medical patient having a dozen or more physicians, consultants, nurses, pharmacists, case managers, social workers, and therapists directly involved in care. At this core of this legion of providers stands the intern. This novice physician must field messages, pages, and advice from all arms of the treatment team. As such, the intern spends as much time coordinating care as he or she spends relaying messages and answering “quick questions” — which are never quick and rarely are questions.
  • Patient acuity in academic centers also continues to rise. Patients on medical wards often are admitted with multiple comorbidities and in a state of disarray. Rare are the relatively straightforward admissions for uncomplicated pneumonia or CHF exacerbation. Thus, interns have to manage a number of active conditions, complex medication lists, and a barrage of patient data.
  • In addition, the Centers for Medicare and Medicaid pay us by DRGs and have also inculcated us to prevent 30-day readmissions. CMS will soon ask us to admit more patients to observation status. How do all of these shifts in payment affect a house officer? The intern has to spend all the more time ensuring safe and timely discharges. Tasks like medication reconciliations and communicating with outpatient providers suck up even more of the intern’s day at the expense of face time with the patient.
  • Finally, documentation steals many a precious minute from the day. The considerations of patient acuity and reimbursement add to the burden of documentation leading to bloated notes that take far too much time to construct.

I am probably too young to be so cynical, but I do not see a shift in these routines occurring any time soon. And without be excessively cantankerous, I feel obligated to ask, “Does the percentage of interns’ time spent in direct patient care matter?”

An smaller percentage of interns’ time spent directly interfacing with patients may not mean that patients get worse care. We don’t have any direct data that the distressing paucity of direct patient care is resulting in poor outcomes. Moreover, the very “non-patient” tasks outlined above are entirely necessary in today’s inpatient environment. For example, if a patient is started on a LMWH bridge to warfarin in the hospital, figuring out how the LMWH will be paid for and who will follow the INR post-hospitalization is as important as time spent at the patient’s bedside.

Of course, I am not suggesting that intern work is inherently rewarding or educational. Most of us embark on this career path because we value interaction with actual human beings, not because we like electronic note templates. I myself romance about the days when internists actually took the time to perform thorough histories and physicals. But if we don’t encumber the interns with all of this work, who will do it?

3 Responses to “Medical Interns – Not at the Bedside, but Not to Be Blamed”

  1. Tyler Haberle says:

    Well said. This JGIM article infuriated me. At what point in the day are interns sitting around doing less important things than sitting at the patients bedside doing worthless physical exam maneuvers and taking pieces of family history? We’d all like to spend more time with patients — in the hospital and in the clnic. The problem is the constraints the system places on trainees, and the system has decided that interns are most useful doing coordination and documention.

  2. Edward Volpintesta says:

    September 18, 2013
    NEJM Journal Watch
    Re The letter “Medical Interns-Not at the Bedside but Not to be Blamed by Paul Bergl, MD published Sept. 16:
    Dr. Bergl correctly described the many tasks that must be done when taking care of hospital patients. Each individual task is manageable but together they are strenuous exercise in multi-tasking and they take away not only time, but the energy and the emotional strength needed to talk to patients and to comfort them during the frightening experience of a hospitalization.
    But I disagree with his that the small amount of time spent with patients may not necessarily lead to poor patient outcomes warrants further discussion. This is an attitude that is easy to carry over into private practice. He should realize that the many tasks that steal his energy and time in the hospital are merely replaced with different but equally time-consuming chores in the office.
    Like residents, physicians in practice can also rationalize that rather than spending time with a patient with abdominal pain going ahead and ordering a CAT scan is justified because it may quickly lead to a diagnosis or that ordering a battery of tests on a patient with confusing symptoms because they may speed up the diagnosis. But this expeditious approach is the beginning of depersonalizing medical care.
    The authors should know that doctors in private practice also are consumed by the necessity of dealing with “indirect medical care”. Talking with insurers, pharmacies, reading reports and consultation notes, filling all sorts of forms, and discussing issues with home health care agencies represent just a few of the many “indirect” tasks that consume their time. This doesn’t include the endless stream of telephone calls from patients and the occasional office emergency like a patients who walks in having chest pain of cardiac origin or the depressed patient who needs a half hour or more of time.
    I think that the only way out of this is to reduce the workload on the individual physician. Seeing fewer patients will mean having less indirect care to deal with, whether one is in the hospital or in private practice.
    This can be accomplished by shortening the education time that doctors spend in the college/medical school years. Much of the basic science could be eliminated or limited or combined as one doctor called it into a “medical science” course. If college/medical school were combined into a six year course instead of eight years more physicians could be added to the workforce in less time than now.
    With more doctors in the workforce the individual workloads would be more manageable.
    Also better use needs to be made of advanced practice nurses. The use of advanced practice nurses is at the top of the healthcare agenda. Perhaps they too could help not only with the indirect medical care but with some of the direct care as well.
    Be all of this as it may, for all the good that medical science has accomplished it has also created ethical and practical dilemmas that require radical new ways of looking at what doctors do and what patients need.
    Edward Volpintesta MD
    Bethel, CT

    • steven Goldstein says:

      I am a 50 yo primary care physician, in Southern Indiana, and have practiced here since 1993. I was a 1st year IM resident at the University of Michigan in 1989, and so read with interest how the time interns spend in “direct patient care”, as defined by the authors,has dropped from 20% in 1989 (when I was an intern) to 12% in this study. Not surprising. I feel it is safe to say the same is true for clinicians as well.

      I am one of the last of my group (over 140 primary care physicians) who still bother to do both inpatient and outpatient medicine. The time I spend in hospital with patients is dropping in an inverse correlation with the time i spend in front of a computer clicking buttons. Once Computerized Physician Order Entry (CPOE), or as I call it, “physician ward clerk duty” comes to my community hospital, I suspect that will herald the end of my inpatient care.

      I examine patients much less than I once did in my office, as I spend an absurd amount of time performing silly, menial tasks with the computer, as we all do in clinical practice, just as I’m sure those interns do. The quality of my work is also suffering, I believe.

      The powers that be will have to decide what they want: do they want physicians examining and talking to patients or do they want us playing with computers? Would an attorney type up his own letters, or have a legal clerk do it?

      Maybe, someday, in a galaxy far far away, the computerized system will actually assist us in patient care and be efficient. Not today. further, there is virtually no evidence that emr improves patient outcomes, and I suspect it may worsen them.

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