American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

Diminishing Patient Face Time in Residencies and Patient-Centered Care

doctor shaking hands with female patient

One of the more important recommendations coming from the Institute of Medicine’s seminal report on medical errors was the pressing need to implement patient-centered medical care. Although emphatically endorsed and highly influential, adoption of its 6 dimensions in “real life” has been slow, uncommon, and imperfect in most settings studied.

Considering how residents spend their time in training, the absence of patient centeredness in our health systems is not surprising. Time-motion studies have emerged as a promising tool in the analysis of how the hours of a resident’s workday are actually divided.1 Other methods seem more prone to bias. Our literature review revealed 3 such time-motion studies that characterized ≥72 hours of total recorded time among residents. All studies were conducted in academic medical centers in the United States or Canada after the Accreditation Council for Graduate Medical Education published new regulations limiting residents’ working hours to 80 per week (2003) and ≤16 continuous working hours (2011). Block et al2 found that internal medicine residents spent 12% of their time in direct patient care versus 40% of their time using the computer and 15% on educational activities. Fletcher et al3 studied first-year residents rotating on the general medicine ward who were on call, yielding remarkably similar results: 12% of the time was spent on direct patient care and 40% on computer work, whereas education was limited to just 2% of on-call time. Mamykina et al4 recently examined residents’ “typical work day” schedules and found that interacting with patients constituted 9% of the work day (67.8 minutes) compared with 51% spent on computer work and 11% on rounds. Because “rounds” nowadays are frequently conducted at the conference table and not at the patient’s bedside, residents’ time spent in direct patient interaction amounted to a mere 7.7 ± 5.8 minutes per patient2 or slightly more.3 Learning activities also are meager: In one study, just 5.8 minutes per 12-hour shift were devoted to looking up information.4

These data are appalling, especially when contrasted with the classic, often quoted, and widely lauded teachings of Sir William Osler, Francis Peabody, and psychiatrist George Engel. All stressed “hands-on” patient contact, patient-centeredness, and incorporation of each patient’s psychosocial factors as essential in health care delivery.

These precious few minutes that residents spend with patients can never suffice to fulfill even part of the obligatory Institute of Medicine domains, such as understanding the patient’s preferences and concerns, meeting informational needs and promoting health literacy, and providing emotional support.5 None of these domains should be regarded as limited to ambulatory care. Hospitalized patients’ needs are comparable, and the increasing age, prevalent multiple chronic conditions, and growing complexity of admitted patients make the brief time devoted to face-to-face patient care even more poignant. The meager time spent by residents with patients also is at odds with patients’ wishes, even their ethical rights, and counter to the aim of improving the patient’s “experience of care.”5
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-Ami Schattner, MD, Steven R. Simon, MD, MPH

This article originally appeared in the April 2017 issue of The American Journal of Medicine.

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