SAN DIEGO – Surgical residents spend a large part of every working day in front of a computer screen, with first-year residents saying they spend an average of more than 13 hours a day on electronic medical records (EMRs).
“Residents are spending a lot of time sitting at a computer, and residents seem to be in agreement that this is time they could potentially be spending learning how to operate and care for patients, which is one of the fundamental purposes of residency training,” study lead author Edward S. Shipper III, MD, a PGY-3 general surgery resident at UT Health-San Antonio, said in an interview after he presented the study findings at the annual clinical congress of the American College of Surgeons.
Research into the EMR burden on residents is sparse. In 2015, researchers at the Medical College of Wisconsin, University of Wisconsin–Madison, and Northwestern University launched a study that they described as the first to examine changes in EMR use over time during surgical residency. The analysis of videos of patient-resident interactions in the exam room found that senior family medicine residents used EMRs more than junior residents (Fam Med. 2015;47:722-26). The current study of surgical residents, however, showed the reverse: Senior residents used EMRs less than juniors.
Dr. Shipper and his colleagues analyzed survey results from 229 U.S. surgical residents who were reached via the Resident and Associate Society of the American College of Surgeons.
Of the 169 who reported demographic data, nearly half were women and 84.6% were training in general surgery, with the rest in subspecialties. The wide majority were in academic or academic-affiliated programs. Residents reported using EMRs exclusively for most clinical tasks, such as medication orders (90.8%), discharge summary (73.5%), and consultation requests (61.7%).
Only about half of those surveyed reported using EMRs exclusively for operative notes (which were often dictated) and signout/handoffs.
In terms of EMR workload per day, PGY-1 residents (n = 23) reported spending an average of 13.6 hours on the records. The average amount of time spent on EMRs per day fell to 10.8 hours for PGY-2 residents (n = 40) and dwindled to 4.6 among PGY-5 residents (n = 20). The researchers reported that the difference in daily EMR time between senior and junior residents is statistically significant.
“Whether or not you believe the specific numbers quoted by the residents, I think the message most people can agree upon is that residents are spending a lot of time during residency sitting in front of a computer,” Dr. Shipper said. “A parallel trend with the rise of the EMR is the rise of increased standards for, and tracking of, documentation requirements by the government and by insurance companies.”
Why are senior surgical residents spending less time on EMRs? “More senior residents generally have the primary responsibility of operating on the patients, and being in the operating room all day means less time spent in front of a computer,” he said.
Of the 63 open-ended responses about the use of EMRs in surgical education, 49% were negative and the rest were evenly divided between natural and positive. One resident described the records as essential to patient care because of their efficiency, while another said, “In this age of duty-hour limits, I spend most of my day in front of a computer interacting with the EHR. This significantly detracts from my educational experience.”
Dr. Shipper said that the study raises questions about how EMRs are affecting how surgical residents learn their craft. But Oren Sagher, MD, professor of neurosurgery at the University of Michigan, Ann Arbor, who has questioned the effect of EMRs on medical education (PLoS Med. 2009;6:e1000069), isn’t impressed by the new research.
Dr. Sagher said an interview. “It’s well established that medical documentation usually falls mainly to the junior residents in surgery program. That was also true prior to EMRs. I would agree that EMRs do tend to take up more time than traditional paper charts did, but this finding is not earth shattering.”
The limit on duty hours would presumably push the burden of EMRs from residents to others, such as physician extenders, but it’s interesting that residents still report using EMRs for the bulk of their days, he added.
In the big picture, Dr. Sagher said, “EMRs are not optimized for the delivery of care. They appear to be mostly driven by billing concerns and safety optimization. Consequently, the people forced to use these systems are not very happy. I think this contributes to physician disenfranchisement and burnout.”