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Dejà vu day

October 2010

When I came across the recent articles in the Journal of Hospital Medicine about time-motion studies looking at how a typical day went by at the North Western Memorial Hospital, I had a distinct sensation of dÃjà vu! It sure did sound like my full shift at work, at least when I was a day-time hospitalist. I’ve been working as a nocturnist for one year now. And ues, I now have extra large pupils (to help me see me better in low-light conditions) and I tend to sleep upside down during the day. From what my day-time friends assure me, the pattern of how the day goes has not changed.

We recently discussed the “Where did the day go?–A time motion study of hospitalists.” It sure was an interesting study done by hospitalists at Northwestern Memorial Hospital in Chicago. The only other time motion study looking at hospitalist workflow was done at this same institution in 2006. Also in the same issue was a systematic review of time-motion studies pertaining to physicians in the hospital.

When we discussed these articles at our hospital medicine journal club, we unanimously thought that the study findings reflected a typical day at our institution. The study states that the biggest chunk of the day (34.1%) goes toward using the EMR. The next major portion was swallowed by communication: 25.9%. Direct patient care accounted for 17.4% of the day. The authors also revealed how time was used in the both the EMR category–documenting, chart review, placing orders–and in communications, with how much time was spent communicating with other physicians, nurses, patients’ families, primary care providers, and other hospital support staff.

The study validates to some extent the role of the hospitalist as the coordinator in chief for hospitalized patients. One interesting tidbit was that, on average, 16% of the day was spent multitasking, typically using the EMR and being on the phone. Here our perceptions differed from the findings: We all felt that we multitask more than 16% of the day.

I often feel that one of the prerequisites for being a hospitalist is the ability to multitask. This is not to say that multitasking is a desirable attribute or quality. Our group felt that although this study was well done and reflected how our own days are consumed, we’re looking forward to the next set of studies, which should look at how interruptions shape our decision-making ability. I am sure there is correlation between interruptions and errors or, more commonly, near misses.

This study brings another reality to the fore: that medicine is increasingly drifting away from an individual practice model to a more team driven one structured by standardized care protocols and guidelines, where metrics are “king.” As such, we will see more studies and analytical tools that have shaped the efficiencies of the assembly line being applied to the patient care line.

We also all agreed that the study is a good starting point to look at ways to improve efficiency. Clearly, we spend two-thirds of our time on indirect patient care. One could argue–especially non-clinicians and administrators– that perhaps this isn’t the best way to spend physician time in terms of value. That especially true when hospitalists salaries are subsidized up to $100k a year per hospitalist.

The time spent communicating is inordinately large, even when compared to ED physicians who typically spend only half that amount of time (13%) communicating with other docs. Interestingly, the JHM study found that only about 5% of our time communicating was spent in discussions with family members.

This study does highlight the question of how much of the time spent during the day is “billable” time in terms of patient care, as defined by the CMS. Billable time is a slippery slope as hospitalist benefits are not only related to direct patient care but also to intangibles such as shorter patient stay, increased ability of PCPs to see patients in their offices and increased procedure time for specialists, etc.

In terms of improving efficiency and reducing costs, how might this study shape care organization in the future? Will it mean that someone somewhere will design a more clever EMR-user interface, allowing for faster documentation and review?

Will it mean more use of nurse practitioners and physician assistants, especially if studies prove that they are as effective in care coordination as MDs/DOs? That could well be the case, given the fact that, as hospitalists, we tend to do less and less of the “real” or traditional doctor stuff, such as laying our hands on patients to examine them or doing procedures.

Or will the study lead to redefining what the “real doctor stuff” really is? Perhaps in today’s world, this IS the real doctor stuff. Perhaps we should be training future hospital medicine physicians differently, teaching them to type faster and offering many more courses on communication and on how to enhance multitasking capabilities and supervise teams of care support staff. That’s in addition to traditional medical education, but obviously relying less on trying to figure out whether the murmur is pan-systolic with widened S2 split just by auscultation.

What do you think?