Wednesday, April 24, 2013

Johns Hopkins: Thanks to EHRs, time with patients seems “squeezed out” of medical training, investigator says

Question:  Who would have thought it?  That there is yet another potentially deadly unintended consequence of bad health IT and health IT hyper-enthusiasm?

Suggested answer:  anyone who truly understands the issues at the intersection of medicine, information science, information technology, and Social Informatics - which probably excludes 95% of the health IT "experts", pundits and opportunists.

Which only goes to show how dense such people can be - as the medical trainees of today will be treating them, their families, and their children in the future:

Johns Hopkins Medicine
Release Date: 04/23/2013

Medical interns spend just 12 percent of their time examining and talking with patients, and more than 40 percent of their time behind a computer, according to a new Johns Hopkins study that closely followed first-year residents at Baltimore’s two large academic medical centers. Indeed, the study found, interns spent nearly as much time walking (7 percent) as they did caring for patients at the bedside.

I can honestly say much if not most of my time in training, several decades ago, was spent at the bedside.

Compared with similar time-tracking studies done before 2003, when hospitals were first required to limit the number of consecutive working hours for trainees, the researchers found that interns since then spend significantly less time in direct contact with patients. Changes to the 2003 rules limited interns to no more than 30 consecutive hours on duty, and further restrictions in 2011 allow them to work only 16 hours in a row.

“One of the most important learning opportunities in residency is direct interaction with patients,” says Lauren Block, M.D., M.P.H., a clinical fellow in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine and leader of the study published online in the Journal of General Internal Medicine. “Spending an average of eight minutes a day with each patient just doesn’t seem like enough time to me.”

An understatement, as most critical information comes from the H&P and ongoing patient interaction - not from cybernetics.  Further, that's probably all the time a butcher spends processing a slab of meat...

“Most of us went into medicine because we love spending time with the patients. Our systems have squeezed this out of medical training,” says Leonard Feldman, M.D., the study’s senior author and a hospitalist at The Johns Hopkins Hospital (JHH).

For the study, trained observers followed 29 internal medicine interns — doctors in their first year out of medical school — at JHH and the University of Maryland Medical Center for three weeks during January 2012, for a total of 873 hours. The observers used an iPod Touch app to mark down what the interns were doing at every minute of their shifts. If they were multi-tasking, the observers were told to count the activity most closely related to direct patient care.

The researchers found that interns spent 12 percent of their time talking with and examining patients; 64 percent on indirect patient care, such as placing orders, researching patient history and filling out electronic paperwork; 15 percent on educational activities, such as medical rounds; and 9 percent on miscellaneous activities. 

Researching the history is made more complex by today's low-usability EHR systems, so much so that I personally know of cases (through my legal work) where trainees and even attendings did not know the patient's history.  In the past, this would have been considered a severe medical faux pas.

The researchers acknowledge that it’s unclear what proportion of time spent at the bedside is ideal, or whether the interns they studied in the first year of a three-year internal medicine training program make up the time lost with patients later in residency. But 12 percent, Feldman says, “seems shockingly low at face value. Interns spend almost four more times as long reviewing charts than directly engaging patients.”

Not to be critical of the Hopkins piece, it is excellent - but academics often use disclaimers and softeners in their conclusions as a custom and tradition.  At a blog I can be more direct:  12% is shockingly low.  No "seems" is actually necessary.

Feldman says questions raised by his study aren’t just about whether the patients are getting enough time with their doctors, but whether the time spent with patients is enough to give interns the experience they need to practice excellent medicine. 

Personally, I would really be nervous under the care of graduates who'd only spent a tenth of their clinical hours actually seeing, speaking to and examining patients, and a majority of their time frittering around with computers.

With fewer hours spent in the hospital, protocols need to be put in place to ensure that vital parts of training aren’t lost, the researchers say.

“As residency changes, we need to find ways to preserve the patient-doctor relationship,” Block says. “Getting to know patients better can improve diagnoses and care and reduce medical errors.” 

As opposed to getting to know the (needlessly complex and confusing) EHR better, which adds little.

The researchers say better electronic medical records may help reduce time spent combing through patient histories on the computer.

After several decades of the health IT industry being in business,  it's sad that an organization of the (deserved) stature of Johns Hopkins has to provide remedial education 101 to that industry in 2013.

Perhaps that's the most important finding of all in this study.

There's some wisdom in this comic strip.  Click to enlarge.

-- SS


Steve Lucas said...

A few years ago I was startled as a doctor when upon entering the room and without looking up pronounced me very ill. Funny, since I felt fine when I entered the office. Challenged, he beat a pen on a clip board and proceeded to inform me everything he needed to know was in the chart and seeing patients only slowed his process down. Things went downhill from there and we parted on poor terms.

Recently I have noticed when talking with doctors how they all are extraordinary and can see 30 or even 40 plus very ill patients a day due to their honed medical ability and above average intellect. (Drug reps tell them all the time how smart they are in prescribing their product.) This training, I feel, supports this concept and with lowered reimbursement feeds a system that allows for over medicating and testing, a problem often sighted in our search for medical cost reduction.

So now we train our doctors to rely on the paperwork, or computer screens, to give background information that leads to testing and medications that may or may not be appropriate. Additionally we promote the establishment of an even bigger divide between patient and doctor.

The result then becomes a patient is no more than a widget and any doctor will do because they can all read the chart.

Sad, since there is so much more to the patient.

Steve Lucas

medicine for real said...

Amen brother. I hadn't seen the Johns hopkins data but i can believe it.

Cynthia said...

That comic strip is catchy! Totally made sense, I also believe that the industry needs remedy but it would be better to have further improvement as far as health and technology is concerned.

Unknown said...

It can kill! see at
Computerized hospitals: not all that glitters is gold American Journal of Medicine 2010 ;123:e15;

InformaticsMD said...

Challenged, he beat a pen on a clip board and proceeded to inform me everything he needed to know was in the chart and seeing patients only slowed his process down. Things went downhill from there and we parted on poor terms.

"Everything he needed to know was in the chart and seeing patients only slowed his process down?"

Sounds like you made a very wise choice dumping this physician.

-- SS

Anonymous said...

Confirmation of the devolution of medical care.