Time-motion studies of internal medicine residents’ duty hours: a systematic review and meta-analysis

Figures & data

Table 1 Search terms used for the electronic bibliographic database queries

“time and motion studies”

(time adj2 motion).tw.

(real time adj3 observation$).tw.

Workload

duty hour$.tw.

Work Schedule Tolerance

“Personnel Staffing and Scheduling”

Workflow/or work flow.tw. or workflow.tw.

(work hour$ or workhour$).tw.

workload.tw.

work load.tw.

education, medical, graduate/or “internship and residency”

exp Physicians

physician$.tw.

Medical Staff, Hospital

(intern?1 or residen$).tw.

(surgeon$ or an?esthesiologist$ or cardiologist$ or respirologist$ or

p?ediatrician$ or obstetrician$ or dermatologist$ or endocrinologist$ or

gastroenterologist$ or geriatrician$ or gerontologist$ or hematologist$

or nephrologist$ or neurologist$ or oncologist$ or orthop?edist$ or

psychiatrist$ or rheumatologist$ or radiologist$).tw.

limit to english language

remove duplicates

Figure 1 The data collection flow diagram.

Table 2 Published time-motion studies on/or including internal medicine residents

Authors (year)	Study size (residents observed)	Total recorded time (hours)	Number of hospitals involved
Block et al (2013)^Citation8	29	873	2
Fletcher (2013)^Citation10	25	357.5	1
Gabow et al (2006)^Citation9	2	48	1
Accreditation Council for Graduate Medical Education 2003 regulations
Parenti and Lurie (1993)^Citation11	35	N/A	1
Knickman et al (1992)^Citation13	8	223.1	2
Leslie et al (1990)^Citation14	12	472	1
Lurie et al (1989)^Citation12	35	N/A	3
Gillanders and Heiman (1971)^Citation15	5	351.9	3

Note: Observation hours reported (average) =387.6.

Abbreviation: N/A, not available.

Table 3 Characteristics of the included studies

Authors	Location	Day or on-call	Special features	Methodology
Block et al^Citation8	Maryland, USA	Both	Categorized tasks as direct patient care, indirect patient care, education, and miscellaneous activities. Found that the greatest percentage of time (12.3%) was spent in direct patient care and the least percentage of time (9.3%) was spent on miscellaneous activities	Recorded over two academic health centers. Data recorded using an iPod Touch application. Included only PGY-1 residents
Fletcher^Citation10	Milwaukee, USA	On-call	Categorized tasks as clinical computer work, non-patient communication, direct patient care, downtime, transit, and teaching/learning. Greatest percentage of time (40.0%) was spent doing clinical computer work, and the least percentage of time (2.0%) was spent in teaching/learning activities	Recorded over a single academic health center. Data collected using a laptop computer program
Gabow et al^Citation9	Colorado, USA	Both	Study included residents of internal medicine, pediatrics, obs–gyn, and general surgery. Tasks were not categorized	Times recorded on data entry sheets, not explicitly described. Only 24 hours of observations. Included both PGY-1 and PGY-2 residents
Parenti and Lurie^Citation11	Minnesota, USA	Both	Categorized tasks as procedures, patient evaluation, basics, communication, and miscellaneous. Greatest percentage of time (38.5%) was spent in communication, and the least percentage of time (3.0%) was spent performing procedures	Recorded over a single academic health center. Wrist watch used to keep track of time. Time rounded to the nearest minute. Potential for time bias for tasks <60 seconds. Included PGY-1, PGY-2, and PGY-3 residents
Knickman et al^Citation13	New York, USA	Both	Categorized tasks as education, information gathering, personal, testing, consulting, documenting, in transit, procedures, interaction with patients, and administration. The greatest percentage of time (20.7%) was spent in education, and the least percentage of time (1.8%) was spent in administrative tasks	Recorded over two academic health centers. Method of collection not explicitly described
Leslie et al^Citation14	Edinburgh, Scotland	Both	Categorized tasks as patient oriented duties, clinical investigations, communication, giving treatment, traveling time, and time spent not working. Found that the greatest percentage of time (50%–71.5%) was spent doing tasks considered to be patient-oriented duties	Recorded over a single academic health center. Methods of data collection not explicitly described
Lurie et al^Citation12	Minnesota, USA	On-call	Categorized tasks as procedures, patient evaluation, communication, basic (personal), and miscellaneous. Found that the greatest percentage of time (58.1%) was spent performing “basic” or personal tasks and the least percentage of time (5.25%) was spent doing procedures	Recorded over three academic health centers. Wrist watch used to keep track of time. Time rounded to the nearest minute. Potential for time bias for tasks <60 seconds
Gillanders and Heiman^Citation15	California, USA	Both	Categorized tasks as individual interaction, nonverbal communication, procedures, laboratory work, interpersonal communication, special education, and ancillary activities. Found that the greatest percentage of time (20.0%) was spent in nonverbal communication activities such as charting, while the lowest percentage of time (10.0%) was spent performing procedures	Recorded over two academic health centers. Wrist watch used to keep track of time. Time rounded to the nearest minute. Potential for time bias for tasks <60 seconds. Included only PGY-1 residents

Abbreviation: PGY, postgrad year.

Table 4 Total number of hours each study recorded per category

Authors	Hours of education	Hours of communication	Hours of transit	Hours of patient care	Hours of personal/other
Block et al^Citation8	128.5	203.9	51.5	431.5	81.2
Fletcher^Citation10	7.2	107.3	17.9	185.9	38.8
Gabow et al^Citation9	8.6	6.5	1.7	13.1	10.3
Parenti and Lurie^Citation11	N/A	6.9	N/A	20.5	14.3
Knickman et al^Citation13	46.3	30.7	18.4	99.0	28.5
Lurie et al^Citation12	N/A	12.3	3.6	34.4	35.3
Gillanders and Heiman^Citation15	51.3	83.7	N/A	153.8	7.8

Note: Study by Leslie et al¹⁴ was removed from subanalysis as ACGME work hour restrictions do not apply in Scotland.

Abbreviation: N/A, not available.

Table 5 Percentage of time each study recorded per category

Authors	Education	Communication	Transit	Patient care	Personal/other
Block et al^Citation8	14.7	23.4	5.9	43.0	9.3
Fletcher^Citation10	2.0	30.0	5.0	52.0	10.9
Gabow et al^Citation9	18.0	13.5	4.0	27.3	21.1
Parenti and Lurie^Citation11	N/A	14.3	N/A	42.8	29.7
Knickman et al^Citation13	20.7	13.8	8.3	44.4	13.2
Lurie et al^Citation12	N/A	14.0	4.1	39.1	40.8
Gillanders and Heiman^Citation15	14.6	23.8	N/A	43.7	2.2
Average	13.8	18.1	6.6	41.8	19.7

Note: Study by Leslie et al¹⁴ was removed from subanalysis as ACGME work hour restrictions do not apply in Scotland.

Abbreviation: N/A, not available.

BlockLHabichtRWuAWIn the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?J Gen Intern Med201328449523319412

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FletcherKEThe composition of intern work while on callJ Gen Intern Med201328449523319412

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GabowPAKarkhanisAKnightADixonPEisertSAlbertRKObservations of residents’ work activities for 24 consecutive hours: implications for workflow redesignAcad Med200681876677516868436

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ParentiCLurieNAre things different in the light of day? A time study of internal medicine house staff daysAm J Med19939466546588506894

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KnickmanJRLipkinMJrFinklerSAThompsonWGKielJThe potential for using non-physicians to compensate for the reduced availability of residentsAcad Med19926774294381616554

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LesliePJWilliamsJAMcKennaCSmithGHeadingRCHours, volume, and type of work of preregistration house officersBMJ19903006731103810412344513

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LurieNRankBParentiCWoolleyTSnokeWHow do house officers spend their nights? A time study of internal medicine house staff on callN Engl J Med198932025167316772725617

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GillandersWHeimanMTime study comparisons of 3 intern programsJ Med Educ19714621421495540257

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