In 800 BCE, the Greek physician Zenobius wrote, “Despite my best efforts to document, I find myself plagued by the inaccuracies and omissions in the patient’s medical record.”
Ok, there is no Zenobius, but I can imagine that doctors in the ancient world did not have to worry about writing and printing notes, filling out release of medical information forms, making sure telemetry strips are printed out and in the patient’s chart, and writing discharge summaries at home on their off day (their ONLY day off per week).
Fast forward to today: we’re not detoxifying people of their miasmas anymore, but as a medicine intern, I feel like I’m spending a lot more time typing at a computer than seeing and examining my patients. In fact, I might go further and say I feel like one of the monkeys in that old saying, but instead of writing Shakespeare, I’m writing a crappy progress note.
My experience is evidence-based. A 2011 study in the Journal of Graduate Medical Education found that on average, residents spent 43% of their time in the workroom writing notes, and 25% of their time doing paperwork. Only 19% of the time were they discussing plans with their residents or attendings. Most alarmingly, the residents only spent 15 minutes per patient on direct patient care.
This study from 2012 backs up the earlier findings. Residents spent 35% of their working day documenting in progress notes, and half their day in total on the computer. Another study, which looked at the kinds of activities in clinical care that were deemed most educationally valuable and cross-referenced that with the activities that interns did, concluded that:
Housestaff spend the greatest part of their day in indirect patient care, despite the fact that these activities receive the lowest ratings for educational value and lower ratings for patient care value than direct patient care.
These findings have not escaped public notice. As Pauline Chen writes in this New York Times article, the amount of time spent on the computer takes away from the time that patients have with their resident physicians. That does not escape unnoticed, I’m sure.
There are changes afoot, though. More and more emergency departments, and some primary care practices, are hiring medical scribes to do documentation, which leaves doctors and nurses more time to do clinical work and spend time with patients. UCLA recently ran a small experiment with “physician partners” who did paperwork and minor tasks for physicians, which resulted in nearly 40 minutes of work saved per 4-hour session, with no paperwork left to take home. 79% of patients thought that the physician partners made the visit smoother.
Paperwork is the bane of the intern work day, but there are alternatives. And we have to remind ourselves that it is not the end-all, be-all of what it means to be a doctor. It can only suck out our souls if we let it. So as Kisha Davis, a family practitioner, writes, maybe this is the right attitude to have:
I will soon forget the paperwork, but I won’t soon forget talking with my patient as we learn her cancer may have returned, or congratulating my patient who lost 20 pounds and dropped his cholesterol by 50 points, or helping a couple start the process of adoption after a long battle with infertility.