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The new iCOMPARE trial results show that first-year residents, or interns, spend nearly five times more time on indirect care of patients than on face-to-face care. Most of this time – 10 hours a day – was spent on electronic medical records.
The study of Krisda H. Chaiyachati, MD, MPH, MSHP, Assistant Professor of Medicine at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and her colleagues was published online April 15 JAMA Internal Medicine.
iCOMPARE is the largest study to date to analyze how trainees spend their days working. It includes 2.5 times more hours and three times more residency programs than a previous study.
"Our study can help residency program managers to take stock of what their trainees are doing and to determine if the time and processes are adequate to train the doctors we need for tomorrow," Chaiyachati said in a statement. Press.
The time spent by residents in the workplace has been controversial since 2003, when the Council for Accreditation of Higher Medical Education (ACGME) began to limit residents' hours of work. Residents' work hours were limited to 30 hours and work weeks to 80 hours. Residents had to have at least one day off every seven days and the frequency of night calls was limited. Since the introduction of these limits, the ACGME has granted exemptions to certain programs that allow longer work periods while maintaining the 80-hour work week ceiling, the maximum number of night calls and mandatory days off.
iCOMPARE is a cluster-based randomized trial that compares flexible residential programs with normal-day residency programs for patient care, residency training, and well-being. The study was conducted in 63 residency programs across the country, from July 2015 to June 2016.
Results previously reported by iCOMPARE suggested that several measures of patient safety, including patient death, did not differ for programs with standard working hours versus those with flexible work hours. The results also suggested similar effects on residents' well-being, including chronic sleep loss and excessive sleepiness.
Other results from iCOMPARE suggested that there was no significant difference in the time spent on patient care for flexible-hour programs compared to standard-hour programs, although that residents of standard time programs report greater satisfaction with training and work-life balance.
Questions remain about the effects of reduced hours on the quality of physician training, especially for interns who work the most hours in hospital and whose learning curves are the most steep.
To provide some answers, the researchers undertook a sub-study of iCOMPARE's larger trial. The smallest study included three flexible-hour internal medicine residency and three standard-hour resident residency programs at university medical centers (66.7%) and community hospitals (33.3%).
Researchers used temporal movement techniques to track 80 trainees throughout the day and observe how they spent their time. The analysis covered 194 teams, or 2173 hours. The median shift duration was 10.5 hours. The study took place over a period of 2.5 months in the spring of 2016 and included morning, afternoon, evening and night shifts.
For each 24-hour period, interns spent an average of 15.9 hours (66% every 24 hours) on indirect care provided to patients. Much of this time – 10.3 hours, or 43% of each 24-hour period – was spent on the use of electronic medical records and documents.
Over a 24-hour period, interns spent only 3.0 hours (13% of their time) on direct patient care and only 1.8 hours (7% of their time) spent on education.
The proportion of time spent on these tasks was similar throughout the day, as trainees work in the morning, afternoon, evening or night.
In addition, trainees often engaged in multiple tasks, combining indirect patient care and direct patient care. For each 24-hour period, trainees combined 23% of all direct patient care and 28% of all educational activities with indirect patient care.
Spending as much time doing multiple tasks at a time can reflect the need to accumulate more and more work in less time. The study can not determine whether spending time in multitasking and less with patients is good or bad. The results could provide an important baseline of current resident experience. Training programs could use these results to implement changes that improve education and reduce trainee burnout, according to the authors.
The findings raise questions about whether these changes merely reflect a shift in medicine towards increased reliance on teamwork and computer technology or whether they reflect a deterioration in the quality of life. humanism in medicine, according to Christopher Moriates, MD, and F. Parker Hudson, MD, MPH, both of the Dell Medical School at the University of Texas at Austin, who were asked to write a comment on the study.
"Whether this modern snapshot of the daily life of the interns is a call to reinvest in the humanistic aspects of medical training or simply become a marker of an inexorable evolution of what it means to be a doctor, belongs to all of us and ultimately reveal what that we really appreciate, "they wrote.
Since the study included only six internal medicine training programs, the majority of which were affiliated with universities, the results may not be generalized to other environments. In addition, the "education" category may have been too narrow to capture educational opportunities throughout the day, for example during rounds.
The study was funded by the National Institute of Heart, Lung and Blood and ACGME. One or more authors have benefited from grants, personal fees and / or participation in a reading committee from one of the following organizations: the National Institutes of Health, the National Institute of heart, lung and blood and ACGME. Co-author David A. Asch, MD, MBA, partially owns VAL Health. Hudson completed his medical and residency studies at the University of Pennsylvania, where the iCOMPARE study was coordinated. He has no connection to the study and is no longer at the University of Pennsylvania for more than 5 years.
JAMA Intern Med. Posted online 15 April 2019. Full text, commentary
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