Friday, August 17, 2012

What do interns do when they're on call?

You may be surprised and dismayed when you find out.

A study in the Journal of General Internal Medicine from a VA hospital affiliated with the University of Wisconsin reveals some startling facts.

During a 14-hour call period of 3 pm to 5 am, medical interns spent 40% of their time on computer work and 30% on “non-patient communication,” such as clinical conversations with team members, other physicians and nurses among other things. Direct patient care accounted for a whopping 12% of their time.

What about teaching and learning? Would you believe 2% of the time?

The study was conducted using observers trained in time-motion research. They followed the 25 interns who volunteered for the project, but did not interact with them or influence them in any way. The study was likely much more accurate than most previous research on this topic, which was based on self-reported surveys of house staff.

Other interesting tidbits from the paper were that the on-call intern cross-covered an average of 27 patients per night, which seems like a lot to me. The amount of time spent on “sign out” or “hand offs” was not stated. They averaged 4 admissions per night. Only 93 minutes [11% of the total time on call] were devoted to “downtime,” that is sleeping, eating and recreational computer time.

So it looks like internal medicine interns at the VA in Wisconsin do a lot of “scut work” and don’t have much time for learning or sleeping. With only 4 admissions per night, you would think there might be more opportunity for sleep, but since this was internal medicine, each admission probably took two hours.

The interns in the study worked every fourth night. Ironically, in the good old days when we worked every second or third night, we cross-covered far fewer patients because there were more of us on call each night. Therefore, we got more sleep and were less tired the next day.

When one looks at the small amount of time allotted to patient care and teaching and learning, one is not shocked that many graduates of residency these days are not confident about starting independent practice.

I suspect the results would be similar if surgical residents were observed.

What do you think about this?

A version of this appeared on Sermo yesterday and most agreed that interns are not being properly trained.


Unknown said...

I wonder how this compares with similar time frame when on a day shift? Surely 30% of time in clinical conversations can be seen as (potential) learning time? If we subscribe to a social view of learning, dialogue with colleagues helps construct our understandings of our work, patient care and our own professional identity? Really interesting study - thank you for inviting comment. Clare

Anonymous said...

When everyone was inhouse the residents during their downtime or on a slow night would band together to read and review cases for educational purposes. There was no 'home' distraction. Now with the 80 hr work week, you get to go home but you can't follow patients throughout their hospitalization since the care is handed off half the day, plus residents have a lot of 'home' issues to deal with. It's a trade off to have a more scheduled down time and home life VS more hospital time. However, I think residency programs have to become more effective in teaching residents. We can no longer afford to hope that residents can get all their knowledge from clinical experience and the trickle down teaching from senior residents. Fact is, they don't spend as much time together as before. At the risk of coddling residents we need to have a more regimented way of teaching. Their lack of confidence is as much a reflection of the teacher as it is of the student.

Josh said...

I suspect your would have very similar findings in a study done on surgery residents (having been one very recently). Even though residency ostensibly has an educational purpose, I feel that education is probably not done all that well out there. Add to that the fact that medical students are less well educated and prepared than in the past, as well as the increasing complexity of modern medicine, and it's no wonder people are so lacking in confidence at the end of it all and are eager to seek narrow specialist practices, when what healthcare is in dire need of is more 'generalists' (PCPs, IM, Gen Surg, etc.).

Anonymous said...

I have to disagree with anonymous--I think this study demonstrates exactly why we should have work hour restrictions and physician extenders on service. How educational are the things you do at night or "after hours" (particularly as a surgical resident)? Staying up all night figuring out how the hell to get someone to a SNF or working on a rehab dispo on a weekend is simply not a good use of a resident's time, but more and more I observe residents tasked with things like this, and these things are taking away educational time. Similarly, after a long day in the OR, rounds, and educational conferences, how educational can dispo planning, SNF placement, and so forth be? For all the efficiency of surgery residents, this type of scut is a glaring inefficiency. What, really, is wrong with either having the night float people help with this, or having a PA/NP to help take care of this floor work while you're in the OR?

Send the residents home. Let them read, and let them rest. How prepared can a resident really be for the next day's cases when they get home at 9 PM, return at 5AM and pass out in their desk chair reading for their next day's case? How can this be quality reading? Furthermore, how does one have time to read on every clinical question they encountered that day?

And as an FYI, I am a resident in a surgical subspecialty, and I see residents in my program staying far later than they need to dealing with crap like this. And I've seen it in other programs as well. The work rules are never met (I've never seen a surgery program truly compliant). It's ridiculous, almost to the point where you feel like you're an office clerk as opposed to a physician. What's wrong with giving us a little help with ancillary staff, hours restrictions and so forth? I'm not advocating for the 40-hour work week or some such garbage, but we need to streamline things for resident physicians to maximize education. Like someone above posted, medical students enter residency much less prepared than previously, and it seems to me that the operative experience isn't what it once was in surgery programs. We need to overhaul things and challenge residents mentally as opposed to physically.

I understand a lot of attendings don't like this idea because they were abused and taken advantage of during their residencies...but why would you want to unnecessarily put others through that? We can always find a better way to do something, and I don't think what we are doing now is working.

Skeptical Scalpel said...

Thanks for all the above comments. I agree that the figures would be similar for surgery residents except you might be able to classify OR time as teaching. I agree that surgical education needs a complete overhaul. I have blogged about this before. It's hard to effect change. The people running surgical education are not in touch with reality.

Anonymous said...

Interesting post. I'm a PGY-2 in a surgical subspecialty right now. I did my intern year within my institution's general surgery program as the first intern class working under the 16-hour shift limit. During my time at our largest trauma center, the intern call (which was weekends only since there was a nightfloat Mon - Thurs) consisted of fielding all the floor calls from nearly every surgical patient in the hospital (probably around 100) plus responding to all the traumas. There was also an in-house midlevel resident that took all the consults and an in-house chief that operated/oversaw everything else. The result of a system like that is excessive coverage during regular business hours and dangerously scant coverage over night and on weekends. Basically all the surgery services pack it up at 5 pm Mon - Fri and either a three-man night float team overs Sunday - Thurday night or a three-man call team covers Saturday and Sunday. Weekend calls were 24 hours except for the interns, who either did a "day call" or "night call" since we couldn't go over 16 hours.

Your beeper would go off literally every 5 minutes. The night nurses, I think, also got used to just calling in request after request to the inexperienced intern since he/she doesn't know much about the patient or that some of the calls would be considered downright inappropriate by someone more senior.

It also encourages a little sloppiness on the part of the day teams--especially when you get the calls about the post op day 0 patient that just got to the floor that doesn't have pain meds or a diet or whatever. If the person that actually wrote the orders got paged about it instead of the night person that starts covering after 5 pm--it would cause the daytime person to be more careful next time and leave the night person with less junk to clean up.

I know a lot of the old-timers may have been "on call" for 36 hours at a time, but I think more of those hours may have actually been genuine "call"--i.e. you get some down time until someone calls you to do something. When you're cross-covering every team in the hospital without much signout, you don't sleep at all, ever. A lot of times you have to go see the patients, dig through the chart, or work things up that you would otherwise be able to just handle quickly over the phone if it was on one of the patients you were following during the day. It really shouldn't have been called "on call" since that implies you're kind of waiting around to do something--it was just nonstop work.

The system may make you a little better at thinking quickly on the fly with little information (like an ER doc) but it doesn't do very much for you in terms of learning from continuity of care. It's also probably not that great for the patient.

Skeptical Scalpel said...

Thanks for the detailed comments. You reinforce my feeling that cross-coverage on the scale you participated in can be hazardous to your health and the patients' too.

I agree that sloppiness by the day people would disappear if they handled their own follow-up calls for omitted meds and the like.

Maybe the spirit of teamwork was better in my day. I would have been embarrassed to have left any work for my colleagues. Of course, we could stay a little past the witching hour back then too.

Anonymous said...

When I was an intern, I remember spending an inordinate amount of time "looking for the chart". . .nurses station? nope? another doctor have it? nope? social worker? nope? Is it in the med room? nope...oh there it is: quality assurance! HMO/Nurse reviewer! HOURS wasted on this crap.

Skeptical Scalpel said...

I remember looking for charts too. Now I spend time looking for a vacant computer and not always finding one.

Anonymous said...

What is this "looking for a vacant computer"? I'm entering this on nexus7 tablet, it will do everything you need and even fit in your lab coat pocket! And if you record charts online you will never have to hunt for them, always have the latest and be able to access from everywhere!

Take the extra 30 minutes you save to hug a child or your significant other!

Skeptical Scalpel said...

Thanks for commenting. It is great that your system supports such features. Unfortunately, most EMRs do not. What system is your hospital using?

Anonymous said...

I also was first intern class working under the 16-hour shift limit in level I trauma center, the intern was night float Sunday-Thursday for one month and during the NF friday-saturday another surgical intern comes and cross covers while original NF intern was off. We also covered all the floor calls from every surgical patient in the hospital and also responded to all the traumas. There was also an in-house PGY-2 or PGY-3 resident that took all the consults, but as an intern you had to go see consult write it up or do H&P and after that call your midlevel resident, midlevel resident comes sees the patient,talks to attending,writes some orders,gives you the plan. After that you suppose to dictate a consult. Many times it was 12-13 consults overnight who you as an intern suppose to see (it was interns job see c/s write them up and dictate). Also, when you respond to floor calls even if its something like give PRN extra dose of Zofran to chronically nauseated cancer patient you suppose to come examine the patient and write a note, there were many calls like that overnight. Needless to say that you have to go through all chart and know everything about the patient before calling w questions or asking for advice or just simply update your midlevel resident. And if trauma alert/code comes all other stuff gets delayed...Interns were told ask for help if u get slammed, but many times intern was called weak and inefficient if he/she asked for help of middle level resident. Its all than went up the ladder to attendings who really did not work w you personally but based their opinion from opinion of junior or senior level residents and you could see in your evaluation things that never happen...There was an in-house chief that operated, but to ask him/her for help was sign of weakness. Well...Skeptical Scalpel, I agree with you maybe the spirit of teamwork was better in your days. Now as a resident there is no way I will make my intern to see 12 consults by himself/herself and if I have time I go on the floors and see whats needed...good 75% of my work as an intern was paperwork....

Skeptical Scalpel said...

Anonymous, thanks for the comments. It looks like you were pretty busy. With 75% of of your time spent on paperwork, I wonder when you learned anything. The system you work in is broken. Good luck.

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