Residency Programs Encourage Young Physicians to Spend Less Time with Patients

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TIME-thumbEfficiency is a major focus in the modern healthcare setting, as is technical prowess, but is this at the expense of the patients? wonders Pauline W. Chen, M.D., in a New York Times article.

Chen relates how a doctor-in-training recently told her, “My generation is different from yours. …We can’t have the same relationships with patients as you did. We just don’t have the time.”

He related how he had been caught sneaking back into the hospital during his residency to check on a patient and say hello. Because he had already signed out, this would have taken him over his 80-hour work limit and threatened the accreditation of his residency program.

She writes this isn’t an isolated experience, according to a recent study that found “doctors-in-training are spending less time with patients than ever before.”

Although the roots of this matter extend back many years, it was in 2003, Chen recalls, that the Accreditation Council for Graduate Medical Education, “under increasing pressure from politicians, unions, and sleep experts…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.”

Although these measures were intended as improvements to a ragged system, they’ve produced “a perfect storm of unintended consequences.” Johns Hopkins University and University of Maryland researchers have found the average intern was “devoting about eight minutes each day to each patient, only about 12 percent of their time.”

What is causing this? All of those “constraints” that were enacted to protect the intern or improve the healthcare system: duty-hour limits and electronic medical record-keeping. Chen reports, “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.”

The emphasis is now on efficiency.

“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.”

Naturally, the immediate impact is felt in patient satisfaction scores and other outcomes, but what are the long-term consequences and repercussions?

“A young doctor’s experiences during training strongly influence how he or she treats patients once in practice,” Chen explains. “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.”

“Medicine is such an experiential learning experience,” Dr. Kathlyn E. Fletcher, associate professor of medicine at the Clement J. Zablocki Veterans Administration Medical Center and at the Medical College of Wisconsin in Milwaukee, observed. “It’s really astonishing that so little time is spent at the patient’s bedside…There is just no substitute for time in doctor-patient relationships. Efficiency is important, but it isn’t the end of the story.”

As healthcare executives who are concerned about the quality of your organization’s patient care, present and future, what is your perspective on this article? Have you noticed this trend of spending less time with patients among your medical residents or new physician hires?

-by Pete Fernbaugh

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