Tuesday, April 27, 2010

Doctors Patients Paperwork

I just learned something a bit disconcerting. The New York Times (a good source of medical information - I often see a report here before it gets to my medical sites) reported on a study published in the Annals of Internal Medicine journal looking at work hours for residents (trainees) in internal medicine. What they found was that residents spend more hours on documentation and clerical work than they do on seeing patients.

This study was done by survey and represents self reports which can sometimes be unreliable. As part of the 2006 US Internal Medicine In-Training Examination the residents completed a survey. 16,402 residents and 235 post doctoral fellows completed the survey. 67.9% reported spending in excess of 4 to 6 hours per day on documentation. The majority of residents also reported that program directors do not give any feedback on all this documentation.

What is causing this? More studies will need to be done but there are probably several reasons. One reason is that resident work hours are capped. Residents are not permitted to work more than 80 hours per week or more than 30 hours at a time. This is very different from when I was in training when there was no cap at all. Overall the cap is a good thing as it has been demonstrated to reduce medical errors due to drowsiness and fatigue. But it also means that all the clinical and administrative work must be done in a limited amount of time. Another probable reason is the changing role of the medical record. The main purpose of the medical record in the past was to have a document that would allow communication between providers. But that has changed. The medical record now is used to document activity for billing purposes. Also documentation has been markedly increased to reduce medical malpractice liability. Under the current malpractice system if it is not documented it didn't happen. Therefore all the information discussed with the patient needs to be included in the record to show if needed that it did occur. The lack of tort reform is a big problem that wasn't addressed at all in the new health reform law. The electronic medical record is another likely factor. While electronic medical records increase overall efficiency and help reduce medical errors they do take more physician time interacting with the computer system. Dictated notes are much faster. There are probably some other reasons that are involved as well.

So, regardless of the reasons it seems that doctors in training are spending much less time with patients that they used to. This is not a good thing. It may become worse as the Institute of Medicine has recommended a decrease to 16 hours per shift or a five hour "mandated" nap. If this occurs (and it may need to to reduce medical errors due to fatigue (I don't really know) then with decreased patient contact training programs should be extended in length to allow residents enough face to face time with patients to learn what they need to learn to be competent.

Thought for the day

I must continue to be grateful for small things.

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