In “The Hostile Hospital,” from the Lemony Snicket “Series of Unfortunate Events” books, the three young orphans at the center of the story visit the fictitious Heimlich Hospital, where Babs, the head of human resources, asks them if they know what the most important work done in a hospital is.
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“Healing sick people?” one of the children asks innocently.
“You’re wrong,” Babs growls, silencing the children. “The most important thing we do at the hospital,” she continues without flinching, “is paperwork.”
It’s a satirical stab that comes uncomfortably close to the truth.
Paperwork, or documentation, takes up as much as a third of a physician’s workday; and for many practicing doctors, these administrative tasks have become increasingly intolerable, a source of deteriorating professional morale. Having become physicians in order to work with patients, doctors instead find themselves facing piles of charts and encounter and billing forms, as well as the innumerable bureaucratic permutations of dozens of health insurance companies.
But despite the paperwork burden, there are few studies on the amount of time current doctors devote to charting, ordering, filling out forms and dictating. That is, except among one subset of doctors — doctors-in-training, or residents.
According to a study published earlier this year, residents now spend up to twice as much time on documentation as their counterparts did two decades earlier. Analyzing the results of a national survey of over 15,000 trainees in internal medicine, researchers at the Mayo Clinic in Rochester, Minn., found that a majority of residents reported spending as many as six hours a day documenting, while only a small fraction of residents spent as much time with patients.
In other words, young people who are learning to doctor spend as much time writing, typing or dictating about their patients as they do seeing them.
“Residents are learning a lot of their medicine from the computer,” said Dr. Amy S. Oxentenko, lead author of the study and an assistant professor of medicine at the Mayo Clinic. “That does nothing to foster the relationship with the patient.”
But the increase in paperwork has not only been absolute; it has also been relative. For residents, the sheer volume of administrative tasks they must complete is compounded by the fact that their work hours have decreased while documentation requirements have remained unchanged. “You can only fit so many activities into a day,” Dr. Oxentenko said.
Even though fatigue-related errors might be decreasing as a result of duty hours reform, new types of errors are now on the rise. Residents must make clinical decisions with less time to investigate the complexities of a patient’s symptoms and relatively little information culled from a one-on-one interview. “If you are spending so much time entering a note just because you have to enter a note,” Dr. Oxentenko said, “that’s less time to review that patient’s history, drug interactions, contraindications and the best test to order for that particular patient.”
While the introduction of electronic medical records has increased overall efficiency by allowing access to all of a patient’s previous documents, they have also spawned a whole host of electronic ways of bypassing actual patient contact when doctors are pressed for time. Residents may rely on notes written by other doctors instead of talking to the patients themselves. These other notes may have also been pieced together from previous notes rather than from actual interactions with the patient. As a list, a paragraph or whole sections get pasted into progressively more documents, important information, like a reaction to a certain treatment, can be lost in the transfer. Clinicians who rely mostly on computer notes for their information are at risk of inadvertently choosing the wrong therapeutic course of action for a patient.
A doctor’s note turns into a cut-and-paste collage instead of an accurate and personalized narrative of illness; and documentation becomes an electronic and potentially dangerous version of the game “Telephone.”
In the years ahead, achieving some kind of balance between documentation and patient interaction for physicians-in-training will be an ongoing challenge for doctors and medical educators. But the fundamental question driving these changes will be even more difficult to answer. Doctors and, even more significantly, patients must ask themselves what is the most important thing that young doctors must do with their limited hours of training.