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Saturday, July 31, 2010

Duty hours and what constitutes work

We are moving to dedicated use of an EeMR and electronic notes in a busy outpatient clinic setting. The pace is quick and the patients are very complicated, often on a host of immunosuppressive medications. The workflow is  still very awkward which results in us taking notes in the room and then later completing the actual note. In fact, the ratio of "work" done during the face to face encounter vs. after the patient has departed is one or greater. Appropriate management generally includes subsequent reading, synthesis of all data obtained during the actual visit as well as subsequently, discussion and reflection, and ongoing tweaking of the management plan. The question is, is that activity which happens after the patient leaves and perhaps even at home or somewhere off site actual work which counts toward duty hours?

The ACGME defines duty hours as:
All clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. 
There is a stark contradiction in this definition since it states in the first statement that duty hours are "All" clinical and academic activities related to the program while in the last statement it says it does not include reading and preparation time spent away from the site. This statement is based upon an archaic concept of what constitutes actual work and where it can and should be done. In the present world, "work" may not  necessarily linked to a specific place.

Let me throw out a hypothetical scenario. I have a patient who developed an unusual immunological reaction to an device that was implanted. As part of the resident's role in the care for this patient they took on the responsibility of researching the possible offending substances, contacting the manufacturer's representatives regarding the actual makeup of this and related devices, and the possible approaches to sort out the problem, all directed at solving this patient's problem. This actually takes many hours and of all the activities which will in fact provide value to the patient, these activities are most essential.

They do not appear to qualify as work that applies to duty hours. They involve much reading and preparation and do not happen on site. There are no CPT codes which apply. The patient is not physically present although there might be communications via phone or email. There is no financial value to the health care system in doing these activities despite any value they provide to the patient. There are no additional RVUs which would be credited to that particular physician.  By all objective measures of value, this does not appear to be work in virtually anyone's book.

This is crazy. Not that I want to make duty hour tracking any more difficult but I believe this (and other similar scenarios) underscore a fundamental problem with how we view work and value within the health care system. This is a throwback to the pre-market based systems of work and value which were held hundreds to thousands of years ago. These philosophical systems basically viewed that any activity which did not involve physical labor or producing something tangible did not constitute work. There was great distrust of merchants who were perceived as providing no value since they functioned as middle men, facilitating the distribution of things that other men made. There was little concept of creating value through cognitive work as opposed to producing tangible items or doing physical labor.

In the world at large we have moved beyond this narrow minded concept of work and value, that is except for medicine. We are stuck with the idea that worthwhile work is somehow confined to discrete and definable packets of physical activity. It permeates how we think about what constitutes work by trainees. It thoroughly has corrupted all metrics of physician productivity. RVU's are linked to discrete encounters and fail to account for value created cognitive work outside of specific face to face encounters.

While at first blush it might appear to be a trivial point to focus upon. However, this conceptual problem has resulted in real world consequences where what is valued financially in the work of health care is not necessarily what benefits patients. It results in a huge hole in the valuation of a particular set of activities which appear to be essential for the functioning of an integrated health care industry. What we need are the middle men of medicine, those who may not actually do things directly to patients but provide value by coordinating the activities of others. Just because Aristotle did not see the value of such activities it does not seem we should continue holding these views.  The legacy of this misunderstanding goes back centuries and is still accepted without much thought as to its origins.

1 comment:

  1. This is absolutely true, and I agree that it is very unfortunate. When I was a first year resident, I had several patients on whose behalf I spent a considerable amount of time advocating even while I was not on hospital premises. This included speaking with local charities about funding the patients’ palliative therapy, speaking with the patients’ extended family by phone (who could not come to the hospital during regular daytime hours), and in one instance even speaking at length with a local lawyer about the fine points of the definition of ‘emergency’ treatment. When I found myself spending many hours on one particular patient, I asked my chief resident whether I should be including this time when reporting my duty hours. He told me that off the top of his head he thinks it would be obvious that I should. However, he ‘double-checked’ with the program director, who replied (after quoting the official definition of work hours) that this time should definitely not be counted.
    I was very disappointed to learn that all the time I spent writing “H&P’s” and progress notes (often having to include irrelevant information so that a sufficient number of ‘items’ was covered in order to satisfy the billing office) counted as work. The actual activity of working to help patients didn’t ‘count.’