In teaching hospitals, senior doctors don’t just treat patients – they are also expected to supervise and mentor junior doctors, called ‘residents’, as part of their core job duties.
So how do these responsibilities affect the workload of senior doctors? Does the additional supervisory duty take away from time with patients?
Or, conversely, do their patient responsibilities take away from the time they spend teaching residents? “There’s always been a big debate about whether residents are being exploited or are they really learning?” says Jan Van Mieghemthe Harold L. Stuart Professor of Managerial Economics at Kellogg.
In a new study, Van Mieghem, along with Dr. Kellogg Yue Yin and several co-authors, analyzed how senior physicians spend their time in a teaching hospital versus a non-teaching hospital. Over four months, Yin watched emergency physicians for hundreds of hours as they cared for patients at two different institutions.
The team found that senior doctors, or “watchers,” spent an equal amount of time in patient rooms in teaching and non-teaching emergency rooms (ERs). However, senior physicians in the teaching ER spent less time on indirect care tasks, such as calling other providers or ordering tests—work they likely offloaded to residents.
But this did not mean that the residents were being exploited. The study also found that attending physicians at the teaching hospital spent about nine minutes an hour—a significant portion of their days—on supervision, suggesting that residents are not just being used as cheap labor, but actually have ample opportunities to learn valuable skills. .
Although the researchers did not directly measure quality of care, the study suggests that at least a patient’s time with an attending physician is not compromised. At teaching hospitals, patients “will still get what they can get at non-teaching hospitals,” Yin says. “There is no significant reduction in direct patient care.”
Monitoring of ER physicians
Residents are junior doctors who have graduated from medical school, but their training is not considered complete until they complete their residency.
But it wasn’t necessarily clear what senior doctors were getting out of supervising residents. Attending physicians typically aren’t paid more for working at a teaching hospital, yet they often feel more tired after a day of supervision, researchers had learned in conversations with physicians. “So if I’m the attending and I’m working with residents, how much time do I spend teaching the residents and what do I get out of it as an attending?” Van Mieghem wondered.
He and Yin hypothesized that residents could “compensate” the supervising physicians by taking work—especially uninteresting grunt work—off their plates.
“If I’m an attending working with residents, how much time do I spend teaching residents and what do I get out of it as an attending?”
— Jan Van Mieghem
In addition, the researchers wanted to know whether senior physicians in teaching hospitals actually spent a lot of time supervising residents, as previous research had found a clear relationship between the value of a residency program and the time participants spend teaching.
So Van Mieghem and Yin teamed up Itai Gurvich at Cornell University, as well as an emergency physician Ernest Wang at NorthShore University HealthSystem in Illinois, and several other local physicians, to systematically collect data from a teaching ER and a nonteaching ER in the Chicago area.
At first, researchers thought they could track doctors’ activities using wearable sensors. But hospital staff members were concerned the devices would interfere with medical equipment.
So they decided to follow the doctors the old-fashioned way.
“I believe in actually going into the field and getting the data to do real empirical work,” Van Mieghem says. “I think that’s how science should work, right? There’s a theory, and then we have to try to disprove the theory with real data.”
For six months in 2017, Yin shadowed 25 senior ER physicians, each splitting their time between teaching and non-teaching ERs. During each four-hour session, she noted the doctor’s actions on an iPad app. Yin did not enter the patients’ rooms for privacy reasons, but counted the time the doctor spent in those rooms as direct patient care, since the doctor was likely examining, treating, or talking with patients. She also recorded supervisory and indirect care tasks performed outside of patient rooms, such as writing notes, ordering tests, and communicating with other doctors and nurses.
Yin watched doctors treat cases ranging from stroke to opioid addiction. “I’ve seen everything,” he says.
Do physicians spend less time with patients when residents are present?
In total, the researchers monitored 400 hours of physician work time, recording more than 35,000 tasks. They found that senior doctors, whether they were in teaching or not, spent about a third of their time in patients’ rooms, roughly in line with what the researchers expected based on conversations with doctors.
One possible reason that patient interaction did not decrease in the teaching hospital is that patients often view only attending physicians as “real” physicians and want to spend significant time with them.
However, indirect patient care numbers — hours spent doing tasks such as calling other providers and entering information into electronic medical records — looked very different between the two ERs. Senior physicians spent 42 percent of their time on these activities while working in the teaching ER, but 54 percent of their time on them in the nonteaching ER. This suggests that when residents were around, they likely performed these indirect care tasks, Yin says.
But the researchers also found that senior doctors spent a full 14 percent of their time interacting with residents when they were at the teaching hospital, apparently imparting valuable knowledge and skills.
The average duration of a senior doctor’s interaction with a patient was 15 percent longer in the teaching hospital than the non-teaching hospital.
Further data also revealed that having residents around changed the way doctors allocated their attention.
“Most of us prefer to have an uninterrupted period of time so we can really dig in and focus on a task,” says Van Mieghem. However, in the hectic ER environment, doctors usually have to shift their attention quickly between different things, focusing on each for only a short time.
When residents were present, however, the researchers found that “bystanders could actually carve out longer, more contiguous chunks of time,” Van Mieghem says. The average length of a senior doctor’s interaction with a patient, for example, was 15 percent longer at the teaching hospital than the non-teaching hospital.
The team didn’t measure quality of care or health outcomes, so it can’t say for sure whether patients at the teaching hospital were treated as well as those at the non-teaching hospital. But the two ERs appeared to perform similarly on some productivity metrics. For example, each physician discharged approximately seven patients per four-hour observation period at both hospitals. The percentage of patients who left without being seen by a doctor (a proxy for how long they had to wait) was also similar, about 1 percent.
The researchers also asked patients how satisfied they were with their experiences, and the results tentatively showed that patients at both ERs had similar levels of satisfaction.
The costs and benefits of supervising medical residents
Van Mieghem suggests that future research could test whether similar results hold in other contexts “where there is a close apprenticeship relationship between supervisor and apprentice”—for example, in academia, where professors are expected to teach and supervise doctoral students .
Yin and Van Mieghem note some important caveats in the ER study. Importantly, they only looked at two ERs, and conditions in other hospitals could be very different.
In addition, Yin observed the attending physicians only during their shifts, so the researchers don’t know if they did extra work to write notes or other tasks after hours. And the residents at the two hospitals he visited were usually third or fourth years, who probably needed much less time from senior doctors than first years.
It would be ideal if future research could capture data from more hospitals with residents of different experience levels, Yin says. Monitoring quality of care, such as readmission rates, would also be enlightening.
Nevertheless, the present research helps answer a critical question about the costs and benefits of surveillance that could be useful to patients, physicians, and hospital administrators. “The study gives us a clear portrait of how doctors spend their time,” he says.
About the Author
Roberta Kwok is a freelance science writer based near Seattle, Washington.
About the Research
Wang, Ernest E., Yue Yin, Itai Gurvich, Morris S. Kharasch, Clifford Rice, Jared Novack, Christine Babcock, James Ahn, Steven H. Bowman, and Jan A. Van Mieghem. 2019. “Resident Supervision and Patient Care: A Comparative Time-Study in a Community-Academic Department versus a Community-Based Emergency Department.” AEM Education and Training. doi:10.1002/aet2.10334.