At teaching hospitals, senior physicians don’t just treat patients—they’re also expected to supervise and mentor junior doctors, called “residents,” as part of their core job duties.
So how do these responsibilities affect senior doctors’ workload? Does the added supervisory duty subtract from time with patients?
Or, conversely, do their patient obligations subtract from time spent teaching residents? “There’s always been quite a debate about, are residents being exploited, or are they really learning?” says Jan Van Mieghem, the Harold L. Stuart Professor of Managerial Economics at Kellogg.
In a new study, Van Mieghem, along with Kellogg PhD student Yue Yin and several coauthors, analyzed how senior doctors spend their time at a teaching hospital versus a nonteaching hospital. Over four months, Yin followed emergency room doctors for hundreds of hours as they cared for patients at two different institutions.
The team found that senior, or “attending,” physicians spent just as much time in patients’ rooms in the teaching and nonteaching 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 that they likely offloaded to residents.
But that did not mean residents were being exploited. The study also found that attending doctors in the teaching hospital spent about nine minutes per hour—a substantial portion of their days—on supervision, suggesting that residents are not merely used as inexpensive labor, but indeed receive ample opportunities to learn valuable skills.
While the researchers didn’t directly measure quality of care, the study suggests that at least patient time with an attending physician isn’t compromised. At teaching hospitals, patients “will still get what they can get in nonteaching hospitals,” Yin says. “There’s no significant decrease in direct patient care.”
Tracking ER Doctors
Residents are junior doctors who have graduated from medical school, but their training is not considered complete until they finish their residency.
But it wasn’t necessarily clear what senior doctors get out of supervising residents. Attending physicians are typically not paid more for working in a teaching hospital, yet they often feel more tired after a day of supervision, the researchers had learned in converations with doctors. “So if I’m the attending, and I work with residents, how much time do I put into teaching residents, and what do I as the attending get out of that?” Van Mieghem wondered.
He and Yin hypothesized that residents might “compensate” supervising physicians by taking labor—especially uninteresting grunt work—off of their plates.
“If I’m the attending, and I work with residents, how much time do I put into teaching residents, and what do I as the attending get out of that?”
— Jan Van Mieghem
In addition, the researchers wanted to know whether senior doctors in teaching hospitals were actually spending much time supervising residents, as previous research had found a clear relationship between the value of a residency program and how much time attendings spend teaching.
So Van Mieghem and Yin collaborated with Itai Gurvich at Cornell University, as well as emergency medicine physician Ernest Wang at NorthShore University HealthSystem in Illinois, and several other local doctors, to systematically collect data from a teaching ER and a nonteaching ER in the Chicago area.
At first, the researchers thought that they could track doctors’ activities using wearable sensors. But hospital staff members worried that the devices would interfere with medical equipment.
Which is why they decided to follow doctors the old-fashioned way.
“I’m a believer in really going into the field and getting the data to do true empirical work,” says Van Mieghem. “I think that’s how science should work, right? There is a theory, and then we should try to refute the theory based on real data.”
For six months in 2017, Yin shadowed 25 senior ER physicians, each of whom split their time between the teaching and nonteaching ERs. During each four-hour session, she noted the doctor’s actions on an iPad app. Yin did not enter patients’ rooms for privacy reasons, but she counted the time the physician spent in those rooms as direct patient care, since the physician was likely examining, treating, or talking to patients. She also recorded resident supervision and indirect-care tasks performed outside patients’ rooms, such as writing notes, ordering tests, and communicating with other doctors and nurses.
Yin watched physicians treat cases ranging from stroke to opioid addiction. “I have seen everything,” she says.
Do Doctors Spend Less Time with Patients When Residents Are Present?
In all, the researchers monitored 400 hours of physician work time, recording more than 35,000 tasks. They found that senior doctors, whether they were in the teaching or nonteaching ERs, spent about one-third of their time in patients’ rooms, roughly in line with what the researchers expected based on conversations with physicians.
One possible reason patient interaction didn’t decrease in the teaching hospital is that patients often consider only the attending physicians to be “real” doctors and want to spend significant time with them.
However, the indirect-patient-care numbers—hours spent doing tasks like calling other providers and entering information into electronic medical records—looked very different between the two ERs. Senior doctors 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 suggested that when residents were around, they were likely performing 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 at the teaching hospital, presumably 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 nonteaching hospital.
Further data also revealed that having residents around changed the way doctors allocate their attention.
“Most of us prefer to be able to have an uninterrupted block of time so that we can really go deep and focus on a task,” says Van Mieghem. Yet in the hectic ER environment, doctors typically have to shift their attention rapidly among different things, focusing on each for only a short amount of time.
When residents were present, however, the researchers found that “the attending could actually carve out longer, more contiguous blocks of time,” says Van Mieghem. The average duration of a senior doctor’s interaction with a patient, for instance, was 15 percent longer in the teaching hospital than the nonteaching hospital.
The team didn’t measure quality of care or health outcomes, so they can’t say for sure whether patients at the teaching hospital were treated as well as those at the nonteaching hospital. But the two ERs appeared to perform similarly on some productivity metrics. For instance, each doctor discharged about seven patients per four-hour observation period at both hospitals. The fraction of patients who left without being seen by a doctor (a proxy for how long they had to wait) was also similar, around 1 percent.
The researchers also asked patients how satisfied they were with their experiences, and the results tentatively indicated that patients in 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 instance, in academia, where professors are expected to both teach and supervise PhD students.
Yin and Van Mieghem note a few important caveats in the ER study. Importantly, they examined only two ERs, and the circumstances at other hospitals could be very different. (For example, some ERs are staffed entirely by residents.)
In addition, Yin observed the attending physicians only during their shifts, so the researchers don’t know if they put in extra work catching up on writing notes or other tasks after hours. And the residents at the two hospitals she visited were usually third- or fourth-year residents, who likely required much less of the senior physicians’ time than first-year residents would.
It would be ideal if future research could capture data from more hospitals with residents of varying experience levels, Yin says. Monitoring quality of care metrics such as readmission rates also would be illuminating.
Nonetheless, the present research helps answer a critical question about the costs and benefits of supervision, which could be useful to patients, physicians, and hospital administrators. “Our study gives a clear portrait of how doctors spend their time,” she says.
Roberta Kwok is a freelance science writer based near Seattle, Washington.
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 Versus a Community Emergency Department.” AEM Education and Training. doi:10.1002/aet2.10334.
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