Analyzing the Time and Value of Housestaff Inpatient Work

Authors

  • Timothy R. Dresselhaus MD, MPH,

    1. Medical Service, San Diego Veterans Administration Medical Center, and the Department of Medicine, University of California, San Diego,
    2. Veterans Administration Center for the Study of Provider Behavior, San Diego, Calif.,
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  • Jeff Luck PhD, MBA,

    1. Veterans Administration Center for the Study of Provider Behavior, San Diego, Calif.,
    2. Health Sciences Program, RAND, Los Angeles, Calif.
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  • Brian C. Wright,

    1. Medical Service, San Diego Veterans Administration Medical Center, and the Department of Medicine, University of California, San Diego,
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  • Roger G. Spragg MD,

    1. Medical Service, San Diego Veterans Administration Medical Center, and the Department of Medicine, University of California, San Diego,
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  • Martin L. Lee PhD,

    1. Veterans Administration Center for the Study of Provider Behavior, San Diego, Calif.,
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  • Samuel A. Bozzette MD, PhD

    1. Medical Service, San Diego Veterans Administration Medical Center, and the Department of Medicine, University of California, San Diego,
    2. Veterans Administration Center for the Study of Provider Behavior, San Diego, Calif.,
    3. Health Sciences Program, RAND, Los Angeles, Calif.
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Dr. Dresselhaus: VAMC-SD, Mail Code 111, La Jolla Village Dr., San Diego, CA 92161.

Abstract

OBJECTIVE:

To determine time allocation and the perceived value to education and patient care of the weekday activities of internal medicine housestaff on inpatient rotations and to compare the work activities of interns and residents.

DESIGN:

An observational study. We classified activities along five dimensions (association, location, activity, time, and value), developed a computer-assisted self-interview survey, and demonstrated its face and content validity, internal consistency, and interrater reliability. Subjects were assigned survey computers for 5 consecutive weekdays over a 24-week period, into which they entered data when prompted several times a day.

SETTING:

The medical service of a university-affiliated Veterans Administration Medical Center.

PARTICIPANTS:

Sixty housestaff (36 interns, 24 residents) rotating on the inpatient wards.

MEASUREMENTS AND MAIN RESULTS:

We analyzed activities according to content (direct patient care, indirect patient care, education), association, and location. Likert-scale ratings of perceived value to education and patient care were also obtained. Housestaff provided complete responses to 3,812 (95%) of 3,992 prompts by a median of 11 seconds; 93% of responses were logically consistent across the measured dimensions. Housestaff spent more time in indirect patient care (56%) than in direct patient care (14%) or educational activities (45%). Formal educational activities had the highest educational value (66 on 0–100 scale), and direct care had the highest value to patient care (81). Over 30% of time was spent in administrative activities, which had low educational value (40). Compared with residents, interns allocated significantly less time to educational activities (38% vs 57%) and more time to lower-value activities such as documentation (19% vs 12%).

CONCLUSIONS: Improved data collection methods demonstrate that housestaff in our program, particularly interns, spend much of their workday in activities that are low in educational and patient care value. Selective elimination or delegation of such activities would preserve higher-value experiences during reductions in overall inpatient training time. Planners can use automated random sampling to guide the rational redesign of housestaff work.

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