- Email: [email protected]
Diminishing Patient Face Time in Residencies and Patient-Centered Care
Accepted Manuscript Diminishing Patient Face Time in Residencies and Patient-Centered Care Ami Schattner, MD, Steven R. Simon, MD MPH PII:
S0002-9343(16)31032-4
DOI:
10.1016/j.amjmed.2016.09.025
Reference:
AJM 13742
To appear in:
The American Journal of Medicine
Received Date: 18 September 2016 Accepted Date: 19 September 2016
Please cite this article as: Schattner A, Simon SR, Diminishing Patient Face Time in Residencies and Patient-Centered Care, The American Journal of Medicine (2016), doi: 10.1016/j.amjmed.2016.09.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Diminishing Patient Face Time in Residencies and
RI PT
Patient-Centered Care Ami Schattner, MD and Steven R. Simon, MD MPH
Word count: 1270
M AN U
Article type: Commentary
SC
The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel and the Geriatrics and Extended Care Service, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, Massachusetts, USA
Conflict of interest: None identified
Correspondence:
TE D
Funding: Not applicable
EP
Ami Schattner, MD
AC C
Professor of Medicine Hebrew University and Hadassah Medical School Jerusalem, Israel Phone 972 8 939 0330 Fax
972 9 8609201
e-mail
[email protected]
ACCEPTED MANUSCRIPT 2
One of the more important recommendations coming from the Institute of Medicine's (IOM) seminal report on medical errors was
RI PT
the pressing need to implement patient-centered medical care .
Although emphatically endorsed and highly influential, adoption of its
SC
six dimensions in "real life" has been slow, uncommon and imperfect in
M AN U
most settings studied .
Considering how residents spend their time in training, the absence of patient-centeredness in our health systems can hardly be
TE D
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
EP
(1). Other methods seem more prone to bias. Our literature review
AC C
revealed 3 such time-motion studies that characterized at ≥72 hours of total recorded time among residents. All were conducted in academic medical centers in the US or Canada after the ACGME published new regulations limiting residents’ working hours to 80 per week (2003) and ≤16 continuous working hours (2011). Block et al. found
ACCEPTED MANUSCRIPT 3
that internal medicine residents spent 12% of their time in direct patient care vs. 40% of their time using the computer and 15% on
RI PT
educational activities (2). Fletcher et al. studied first-year residents rotating on the general medicine ward who were on call yielding
SC
remarkably similar results: 12% of the time was spent on direct patient
M AN U
care and 40% on computer work, while education was limited to just 2% of on-call time (3). Recently, Mamykina and colleagues examined residents' "typical work day" schedules and found that interacting with
TE D
patients constituted 9% of the work day (67.8 minutes), compared with 51% spent on computer work and 11% on rounds (4). Since "rounds"
EP
nowadays are frequently conducted at the conference table and not at the patient’s bedside, residents' time spent in direct patient
AC C
interaction amounted to a mere 7.7±5.8 minutes/patient (2) or slightly more (3). Learning activities are also meager: in one study, just 5.8 minutes/12 hrs shift were devoted to looking-up information (4).
ACCEPTED MANUSCRIPT 4
These data are appalling, especially when contrasted with the classical, often-quoted and widely lauded teachings of Sir William
RI PT
Osler, Dr. Francis Peabody and psychiatrist George Engel. All stressed "hands on" patient contact, patient-centeredness and incorporation of
SC
each patient’s psychosocial factors as essential in health care delivery.
M AN U
These precious few minutes that residents spend with patients can never suffice to fulfill even part of the obligatory IOM's domains, such as understanding patient's preferences and concerns; meeting
TE D
informational needs and promoting health literacy; and providing emotional support (5). None of these domains should be regarded as
EP
limited to ambulatory care. Hospitalized patients' needs are
AC C
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 is also at odds with
ACCEPTED MANUSCRIPT 5
patients’ wishes, even their ethical rights, and counter to the aim of
RI PT
improving the patient's "experience of care" (5). Whether the abovementioned studies may be applied more
generally remains an open question. Nevertheless, the consistency of
SC
the findings supports broad validity, and in fact, even less direct
M AN U
interaction with patients may take place in less-academic environments such as community hospitals. Moreover, similar findings were recorded in older studies (6) and could have further deteriorated due to
TE D
increasing reliance on computer for data collection, data entry and communication, as well as decreasing residents' time on the wards
EP
following the current work-hour regulations.
AC C
Thus, with dangerously diminishing patient contact and increasing dependence on laboratory and imaging data printouts, the practice of Medicine is jeopardized and so are our patients, their rights, safety and health outcomes which correlate with a patient-centered approach (7). Do our patients really want to be treated by board-certified
ACCEPTED MANUSCRIPT 6
hospitalists and primary care physicians whose total supervised patient exposure was so sparse? Would we let a commercial pilot take
RI PT
responsibility of an aircraft after an hour per day of actual flying experience?
SC
“Hands on” patient care is not the sole inadequacy. The high road
M AN U
to improved health outcomes requires physician–patient relationship and bonding, patient satisfaction, trust, and patient activation and engagement by the physician (7). Certainly, the delivery of health care
TE D
needs to be scientifically correct; however, the training of physicians must nurture Curiosity about the patient (8), getting the patient’s
EP
“story” (9), understanding prevalent and influential “non-medical”
AC C
factors (emotional, contextual) and the patient’s preferences, as well as providing information, health literacy and sincere empathy (10). These essential components of professional care can never be accomplished with only a few minutes allotted for the face-to-face engagement with patients in between looking-up patient data, order
ACCEPTED MANUSCRIPT 7
entry and documentation via the computer. The flimsy resident-patient contact creates an impossible time constraint and its quality is often
to worried family members (2, 7).
RI PT
further degraded by multitasking (4) and the fleeting attention given
SC
The short time spent with patients has adverse effects on
M AN U
residents too. In contrast with human interaction which fulfils the foundational desire of physicians to care and to heal, interacting primarily with a computer does not offer much gratification;
TE D
frustration mounts and work-life satisfaction deteriorates. Together with the prevalent multitasking and the paucity of time devoted to
EP
stimulating new-learning experience, they contribute to the very high
AC C
and unchanging prevalence of burnout, fatigue and depression among residents (75%, 59% and 20%, respectively) (11, 12), which appear to develop much earlier in physicians’ careers than before . Physicians’ well-being is threatened and repercussions include not only residents’
ACCEPTED MANUSCRIPT 8
poor quality of life but also increased errors and lower quality of care
RI PT
(12). Assuring more time with the patients and improving the depth and quality of the physician–patient interaction are essential to the training
SC
of our physicians. Addressing these gaps in training is particularly
M AN U
urgent, because habits and attitudes acquired during residency will form the basis of future practice style. A recent time-motion study in ambulatory practice exposed that EHR and desk work consume nearly
TE D
double the time of direct patient care (13).
A national leadership move is urgently needed to return residents
EP
to the bedside and resuscitate the patient-centered and physician-
AC C
enriching clinical encounter. Improved resident wellness may be an important by-product (8). We suggest a three-pronged approach based on Education, Mindfulness and Evaluation. First, residents may need to be better educated on the primacy of the personal clinical encounter with their patient and the myriad benefits of a comprehensive,
ACCEPTED MANUSCRIPT 9
patient-centered approach that cannot be gleaned from any computer screen (8). Arguably, residents in medicine, pediatrics and family
RI PT
practice should accumulate and document a minimum quota of new
patient admissions to qualify for board certification, just as surgeons
SC
must perform and document a minimum number of independent
M AN U
operations. Second, in the spirit of Mindfulness (14), as part of the traditional admission process, residents should be encouraged to meditate, identify and record a unique personal aspect they noticed in
TE D
their patient, adding a brief comment on their reaction and feelings and the implications for the future care of the patient. Attending
EP
physicians should prompt residents to discuss this personal feature, gleaned from a careful history and examination, on rounds. Finally, to
AC C
reiterate the integral importance of person-person interaction during the encounter, patients should be routinely asked to evaluate their experience and satisfaction, with emphasis on residents' sensitivity, attention, grasp of the patient's concerns and empathy. This feedback will be independently gathered and provided to residency program
ACCEPTED MANUSCRIPT 10
directors, who can use it in formative evaluation. Such an approach may be an easily implemented and cost-effective way to reiterate the
RI PT
unique and central role of the patient's point of view and of direct high-quality patient-centered care in the training of our future
AC C
EP
TE D
M AN U
SC
generation of physicians.
ACCEPTED MANUSCRIPT 11
1. Leafloor CW, Lochnan HA, Code C, et al. Time-motion studies of internal medicine residents' duty hours: a systematic review and meta-analysis. Adv Med Edu Practice 2015; 6:621-9.
RI PT
2. Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med 2013; 28:1042-7.
SC
3. Fletcher KE, Visotcky AM, Slagle JM, et al. The composition of intern work while on call. J Gen Intern Med 2012; 27:1432-7.
M AN U
4. Mamykina L, Vawdrey DK, Hripcsack G. How do residents spend their shift time? A time and motion study with a particular focus on the use of computers. Acad Med 2016; 91:827-32. 5. Berwick DM. What 'patient-centered' should mean: confessions of an extremist. Health Aff (Millwood) 2009; 28:w555-65.
TE D
6. Parenti C, Lurie N. Are things different in the light of day? A time study of internal medicine house staff days. Am J Med 1993; 94:654-8. 7. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood) 2013; 32:207-14.
EP
8. Schattner A. Curiosity. Are you curious enough to read on? J R Soc Med 2015; 108:160-4.
AC C
9. Sharon R. At the membranes of care: Stories in narrative medicine. Acad Med 2012; 87:342-7. 10. Lown BA, Rosen J, Martila J. An agenda for improving compassionate care: a survey shows about half of patients say such care is missing. Health Aff (Millwood) 2011; 30:1772-8. 11. Ripp JA, Bellini L, Fallar R, et al. The impact of duty hour restrictions on job burnout in internal medicine residents: a three-institution comparison study. Acad Med 2015; 90:454-9.
ACCEPTED MANUSCRIPT 12
12. Fahrenkopf AM, Sectish T, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ 2008; 336:48891.
RI PT
13. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016; Sep 6. doi: 10.7326/M16-0961.
AC C
EP
TE D
M AN U
SC
14. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009; 302:1284-93.
S0002-9343(16)31032-4
DOI:
10.1016/j.amjmed.2016.09.025
Reference:
AJM 13742
To appear in:
The American Journal of Medicine
Received Date: 18 September 2016 Accepted Date: 19 September 2016
Please cite this article as: Schattner A, Simon SR, Diminishing Patient Face Time in Residencies and Patient-Centered Care, The American Journal of Medicine (2016), doi: 10.1016/j.amjmed.2016.09.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Diminishing Patient Face Time in Residencies and
RI PT
Patient-Centered Care Ami Schattner, MD and Steven R. Simon, MD MPH
Word count: 1270
M AN U
Article type: Commentary
SC
The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel and the Geriatrics and Extended Care Service, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, Massachusetts, USA
Conflict of interest: None identified
Correspondence:
TE D
Funding: Not applicable
EP
Ami Schattner, MD
AC C
Professor of Medicine Hebrew University and Hadassah Medical School Jerusalem, Israel Phone 972 8 939 0330 Fax
972 9 8609201
[email protected]
ACCEPTED MANUSCRIPT 2
One of the more important recommendations coming from the Institute of Medicine's (IOM) seminal report on medical errors was
RI PT
the pressing need to implement patient-centered medical care .
Although emphatically endorsed and highly influential, adoption of its
SC
six dimensions in "real life" has been slow, uncommon and imperfect in
M AN U
most settings studied .
Considering how residents spend their time in training, the absence of patient-centeredness in our health systems can hardly be
TE D
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
EP
(1). Other methods seem more prone to bias. Our literature review
AC C
revealed 3 such time-motion studies that characterized at ≥72 hours of total recorded time among residents. All were conducted in academic medical centers in the US or Canada after the ACGME published new regulations limiting residents’ working hours to 80 per week (2003) and ≤16 continuous working hours (2011). Block et al. found
ACCEPTED MANUSCRIPT 3
that internal medicine residents spent 12% of their time in direct patient care vs. 40% of their time using the computer and 15% on
RI PT
educational activities (2). Fletcher et al. studied first-year residents rotating on the general medicine ward who were on call yielding
SC
remarkably similar results: 12% of the time was spent on direct patient
M AN U
care and 40% on computer work, while education was limited to just 2% of on-call time (3). Recently, Mamykina and colleagues examined residents' "typical work day" schedules and found that interacting with
TE D
patients constituted 9% of the work day (67.8 minutes), compared with 51% spent on computer work and 11% on rounds (4). Since "rounds"
EP
nowadays are frequently conducted at the conference table and not at the patient’s bedside, residents' time spent in direct patient
AC C
interaction amounted to a mere 7.7±5.8 minutes/patient (2) or slightly more (3). Learning activities are also meager: in one study, just 5.8 minutes/12 hrs shift were devoted to looking-up information (4).
ACCEPTED MANUSCRIPT 4
These data are appalling, especially when contrasted with the classical, often-quoted and widely lauded teachings of Sir William
RI PT
Osler, Dr. Francis Peabody and psychiatrist George Engel. All stressed "hands on" patient contact, patient-centeredness and incorporation of
SC
each patient’s psychosocial factors as essential in health care delivery.
M AN U
These precious few minutes that residents spend with patients can never suffice to fulfill even part of the obligatory IOM's domains, such as understanding patient's preferences and concerns; meeting
TE D
informational needs and promoting health literacy; and providing emotional support (5). None of these domains should be regarded as
EP
limited to ambulatory care. Hospitalized patients' needs are
AC C
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 is also at odds with
ACCEPTED MANUSCRIPT 5
patients’ wishes, even their ethical rights, and counter to the aim of
RI PT
improving the patient's "experience of care" (5). Whether the abovementioned studies may be applied more
generally remains an open question. Nevertheless, the consistency of
SC
the findings supports broad validity, and in fact, even less direct
M AN U
interaction with patients may take place in less-academic environments such as community hospitals. Moreover, similar findings were recorded in older studies (6) and could have further deteriorated due to
TE D
increasing reliance on computer for data collection, data entry and communication, as well as decreasing residents' time on the wards
EP
following the current work-hour regulations.
AC C
Thus, with dangerously diminishing patient contact and increasing dependence on laboratory and imaging data printouts, the practice of Medicine is jeopardized and so are our patients, their rights, safety and health outcomes which correlate with a patient-centered approach (7). Do our patients really want to be treated by board-certified
ACCEPTED MANUSCRIPT 6
hospitalists and primary care physicians whose total supervised patient exposure was so sparse? Would we let a commercial pilot take
RI PT
responsibility of an aircraft after an hour per day of actual flying experience?
SC
“Hands on” patient care is not the sole inadequacy. The high road
M AN U
to improved health outcomes requires physician–patient relationship and bonding, patient satisfaction, trust, and patient activation and engagement by the physician (7). Certainly, the delivery of health care
TE D
needs to be scientifically correct; however, the training of physicians must nurture Curiosity about the patient (8), getting the patient’s
EP
“story” (9), understanding prevalent and influential “non-medical”
AC C
factors (emotional, contextual) and the patient’s preferences, as well as providing information, health literacy and sincere empathy (10). These essential components of professional care can never be accomplished with only a few minutes allotted for the face-to-face engagement with patients in between looking-up patient data, order
ACCEPTED MANUSCRIPT 7
entry and documentation via the computer. The flimsy resident-patient contact creates an impossible time constraint and its quality is often
to worried family members (2, 7).
RI PT
further degraded by multitasking (4) and the fleeting attention given
SC
The short time spent with patients has adverse effects on
M AN U
residents too. In contrast with human interaction which fulfils the foundational desire of physicians to care and to heal, interacting primarily with a computer does not offer much gratification;
TE D
frustration mounts and work-life satisfaction deteriorates. Together with the prevalent multitasking and the paucity of time devoted to
EP
stimulating new-learning experience, they contribute to the very high
AC C
and unchanging prevalence of burnout, fatigue and depression among residents (75%, 59% and 20%, respectively) (11, 12), which appear to develop much earlier in physicians’ careers than before . Physicians’ well-being is threatened and repercussions include not only residents’
ACCEPTED MANUSCRIPT 8
poor quality of life but also increased errors and lower quality of care
RI PT
(12). Assuring more time with the patients and improving the depth and quality of the physician–patient interaction are essential to the training
SC
of our physicians. Addressing these gaps in training is particularly
M AN U
urgent, because habits and attitudes acquired during residency will form the basis of future practice style. A recent time-motion study in ambulatory practice exposed that EHR and desk work consume nearly
TE D
double the time of direct patient care (13).
A national leadership move is urgently needed to return residents
EP
to the bedside and resuscitate the patient-centered and physician-
AC C
enriching clinical encounter. Improved resident wellness may be an important by-product (8). We suggest a three-pronged approach based on Education, Mindfulness and Evaluation. First, residents may need to be better educated on the primacy of the personal clinical encounter with their patient and the myriad benefits of a comprehensive,
ACCEPTED MANUSCRIPT 9
patient-centered approach that cannot be gleaned from any computer screen (8). Arguably, residents in medicine, pediatrics and family
RI PT
practice should accumulate and document a minimum quota of new
patient admissions to qualify for board certification, just as surgeons
SC
must perform and document a minimum number of independent
M AN U
operations. Second, in the spirit of Mindfulness (14), as part of the traditional admission process, residents should be encouraged to meditate, identify and record a unique personal aspect they noticed in
TE D
their patient, adding a brief comment on their reaction and feelings and the implications for the future care of the patient. Attending
EP
physicians should prompt residents to discuss this personal feature, gleaned from a careful history and examination, on rounds. Finally, to
AC C
reiterate the integral importance of person-person interaction during the encounter, patients should be routinely asked to evaluate their experience and satisfaction, with emphasis on residents' sensitivity, attention, grasp of the patient's concerns and empathy. This feedback will be independently gathered and provided to residency program
ACCEPTED MANUSCRIPT 10
directors, who can use it in formative evaluation. Such an approach may be an easily implemented and cost-effective way to reiterate the
RI PT
unique and central role of the patient's point of view and of direct high-quality patient-centered care in the training of our future
AC C
EP
TE D
M AN U
SC
generation of physicians.
ACCEPTED MANUSCRIPT 11
1. Leafloor CW, Lochnan HA, Code C, et al. Time-motion studies of internal medicine residents' duty hours: a systematic review and meta-analysis. Adv Med Edu Practice 2015; 6:621-9.
RI PT
2. Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med 2013; 28:1042-7.
SC
3. Fletcher KE, Visotcky AM, Slagle JM, et al. The composition of intern work while on call. J Gen Intern Med 2012; 27:1432-7.
M AN U
4. Mamykina L, Vawdrey DK, Hripcsack G. How do residents spend their shift time? A time and motion study with a particular focus on the use of computers. Acad Med 2016; 91:827-32. 5. Berwick DM. What 'patient-centered' should mean: confessions of an extremist. Health Aff (Millwood) 2009; 28:w555-65.
TE D
6. Parenti C, Lurie N. Are things different in the light of day? A time study of internal medicine house staff days. Am J Med 1993; 94:654-8. 7. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood) 2013; 32:207-14.
EP
8. Schattner A. Curiosity. Are you curious enough to read on? J R Soc Med 2015; 108:160-4.
AC C
9. Sharon R. At the membranes of care: Stories in narrative medicine. Acad Med 2012; 87:342-7. 10. Lown BA, Rosen J, Martila J. An agenda for improving compassionate care: a survey shows about half of patients say such care is missing. Health Aff (Millwood) 2011; 30:1772-8. 11. Ripp JA, Bellini L, Fallar R, et al. The impact of duty hour restrictions on job burnout in internal medicine residents: a three-institution comparison study. Acad Med 2015; 90:454-9.
ACCEPTED MANUSCRIPT 12
12. Fahrenkopf AM, Sectish T, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ 2008; 336:48891.
RI PT
13. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016; Sep 6. doi: 10.7326/M16-0961.
AC C
EP
TE D
M AN U
SC
14. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009; 302:1284-93.