{"id":972,"date":"2013-09-16T16:32:26","date_gmt":"2013-09-16T20:32:26","guid":{"rendered":"http:\/\/blogstemp2.wpengine.com\/?p=972"},"modified":"2015-06-04T14:24:43","modified_gmt":"2015-06-04T18:24:43","slug":"medical-interns-not-at-the-bedside","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2013\/09\/medical-interns-not-at-the-bedside\/","title":{"rendered":"Medical Interns &#8211; Not at the Bedside, but Not to Be Blamed"},"content":{"rendered":"<div style=\"width: 250px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" class=\" \" alt=\"\" src=\"http:\/\/blogs.nejm.org\/general-medicine\/wp-content\/uploads\/sites\/4\/2013\/09\/sh_26862580_doctor-laptop_CS_1.jpg\" width=\"240\" height=\"194\" \/><p class=\"wp-caption-text\">If only all interns looked so happy on the job&#8230;<\/p><\/div>\n<p>This past week in <em>NEJM Journal Watch General Medicine<\/em>, <a href=\"http:\/\/www.jwatch.org\/na32008\">Abigail Zuger reviewed an article <\/a>from the <a href=\"http:\/\/dx.doi.org\/10.1007\/s11606-013-2376-6\"><em>Journal of General Internal Medicine <\/em>by Lauren Block et al. <\/a>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 <strong>interns<\/strong> on inpatient rotations<strong> spend only 12% of their time in direct patient care<\/strong> and spend only 8 minutes daily\u00a0with each patient on their inpatient services. Dr. Zuger notes this \u201cdistressing paucity\u201d of direct patient care should cause leaders in graduate medical training to effect change in interns\u2019 daily routines.<\/p>\n<p>To those of us in training or just out of training, the reasons for less direct patient care are myriad and obvious:<\/p>\n<ul>\n<li>A <strong>focus on multidisciplinary care<\/strong> and ever-increasing specialization results in each medical patient having a dozen or more physicians, consultants, nurses, pharmacists, case\u00a0managers, 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 \u201cquick questions\u201d \u2014 which are never quick and rarely are questions.<\/li>\n<li><strong>Patient acuity<\/strong> in academic centers also continues to rise. Patients on medical wards often are\u00a0admitted 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.<\/li>\n<li>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 <strong>shifts in payment<\/strong> affect a house officer? The intern has to spend all the more time ensuring\u00a0safe and timely discharges. Tasks like medication reconciliations and communicating with outpatient providers suck up even more of the intern\u2019s day at the expense of face time with the patient.<\/li>\n<li>Finally, <strong>documentation<\/strong> 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.<\/li>\n<\/ul>\n<p>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, &#8220;Does the percentage of\u00a0interns\u2019 time spent in direct patient care matter?&#8221;<\/p>\n<p>An smaller percentage of interns\u2019 time spent directly interfacing with patients may not mean that patients get worse care. We don\u2019t have any direct data that the distressing paucity of direct patient care is resulting in poor outcomes. Moreover, the very \u201cnon-patient\u201d tasks outlined above are entirely necessary in today\u2019s 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\u2019s bedside.<\/p>\n<p>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\u00a0thorough histories and physicals. But if we don\u2019t encumber the interns with all of this work, who will do it?<\/p>\n","protected":false},"excerpt":{"rendered":"<p>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 [&hellip;]<\/p>\n","protected":false},"author":25,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[27,29,31,37],"class_list":["post-972","post","type-post","status-publish","format-standard","hentry","category-about-residency","tag-healthy-choices","tag-internal-medicine","tag-patient-care","tag-resident-experience"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v17.1.2 (Yoast SEO v20.8) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Medical Interns - Not at the Bedside, but Not to Be Blamed - Insights on Residency Training<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2013\/09\/medical-interns-not-at-the-bedside\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Medical Interns - Not at the Bedside, but Not to Be Blamed\" \/>\n<meta property=\"og:description\" content=\"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. 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