Another challenge for resident physicians: more “pajama time”

Brendan Murphy , Senior News Writer

With increased use, resident physicians become more efficient working on electronic documentation. Increased proficiency with the EHR, however, does not correlate with residents spending less time on electronic documentation outside of their prescribed work hours, according to a yearlong examination of data.

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“We know this after-hours work is really conducive to burnout,” said A. Jay Holmgren, PhD, lead author of the study, published in Applied Clinical Informatics. This so-called pajama time is “the worst part of the experience of having to go home and document after a long shift in the hospital.”

For the study, researchers examined 12 months of data from 622 residents working in ambulatory care settings at the University of Alabama at Birmingham Health System in 2017 and 2018. Residents studied spanned the spectrum of experience.

The data indicated that residents spend about 45 minutes per patient working in the EHR. That time was mostly spread across a handful of tasks on the platform. Documentation was the biggest share of resident time in the EHR (20.2 minutes), followed by chart review (13.8 minutes) and entering orders (6.5 minutes).

Mohammad Ibrahim, DO, a second-year family medicine resident at Trinity Health Michigan, found that he became more efficient as the way he interacted with the EHR, which changed over the course of his residency training.

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"You definitely learn more about the EHR as you progress through residency, but most of my efficiency progress was actually obtained in the first few months of residency by creating macro keys and dot phrases for any commonly used items," said Dr. Ibrahim, an AMA member.

Past studies have found that attending physicians spend less time in the EHR per patient than do residents. The new study sheds light on another difference between attendings and residents: when they do their EHR work.

“Attending physicians look much more normal in that their usage is concentrated from 8 a.m.–6 p.m., and you might see a slight spike in the evening when they finish up documentation or reply to messages,” said Holmgren, an assistant professor in the department of medicine at the University of California, San Francisco, School of Medicine and the Center for Clinical Informatics and Improvement Research. “Whereas residents, not unexpectedly, have a lot more time spent right before the clinic day starts and right after it ends.

“Part of this is the natural process of developing skills,” Holmgren said. “Maybe you spend more time pre-charting. But there’s also an aspect where these residents clearly feel they have more work to do that they weren’t able to get done.”

The whys behind the fact that work in the EHR extends beyond the typical workday for residents are multifaceted. Certainly, as Holmgren pointed out, familiarity with the platform comes with experience. Furthermore, organizational and workforce constraints can lead to increased patient load and more work in the EHR.  

Dr. Ibrahim said that he is generally able to complete his EHR responsibilities during his prescribed work hours, but he may be one of the fortunate few.

“I do not spend too much time outside of my shifts in the EHR unless I'm following up on things for my own knowledge,” he said. “I do know that many of my colleagues are spending a lot of time on the EHR outside of their shifts on documentation."

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Dr. Ibrahim noted that he tends to “prioritize completing EHR responsibilities during my shift which makes the shift a lot more emotionally draining. It's a tradeoff." He also highlighted that even with a more concerted effort to work on EHR tasks, completing all of that work within a shift is often not possible for his colleagues.

Adjusting the EHR workload is best addressed at the organizational level, Holmgren said.

“It's hard once physicians develop these work habits, to break them. If there’s a place organizations can intervene and think about how to prioritize what is done in the EHR and how to do physician scheduling, residency is a good place to start.”

Learn more about EHR management with the AMA STEPS Forward® Taming the EHR Playbook, and explore strategies for eliminating pajama time with the AMA STEPS Forward® podcast episode Reducing pajama time and work outside of work (WOW).