All in a day’s work: an observational study to quantify how and with whom doctors on hospital wards spend their time

An average hospital doctor’s working day is one long series of heroic events — saving lives of grateful patients — intermingled with meaningful interchanges with colleagues and occasionally interrupted by infuriating exchanges with an administrator who never has patients’ interests at heart. Well, that’s how it is depicted in popular television shows. In reality, as all doctors know, an average working day is far removed from such portrayals.

Research into hospital doctors’ work has largely focused on the hours they work,1-3 rather than on what they do. A review of MEDLINE revealed few quantitative data describing how hospital doctors actually spend their time. Few hospitals know, for example, how much time their doctors spend in critical areas, such as direct patient care, versus searching for missing records.

Obtaining baseline data about current patterns of work is important for assessing the effects of interventions designed to improve care delivery models. A good example is the increased investment in and implementation of computerised clinical information systems, which are expected to improve the safety and efficiency of health care delivery.4 While such systems are promoted as reducing administrative tasks of clinicians,5 concerns have been raised that many tasks, such as ordering medication and tests, may take longer with new systems than paper-based systems.6,7 Further, introducing new systems may change communication patterns, with doctors spending more time alone,7 and less time in face-to-face communication with nurses.8,9 Without data reflecting current task time distributions, the accuracy of such claims cannot be tested, nor can we measure the extent to which any time costs are offset by safety gains.10

We conducted a time and motion study to quantify how much time doctors on wards spend in various activities, and with whom, and what information tools they use. In addition, we quantified the number of interruptions to work and the extent of multitasking.

We observed the five registrars for a total of 43.5 hours, the seven residents for 60.25 hours, and the five interns for 47.25 hours. During 151 hours of observation, 6243 tasks were recorded. Individual task times ranged from one second (eg, signing a form) to 90.6 minutes (eg, attending a meeting), with a median of 38 seconds. Twenty per cent of doctors’ time was spent multitasking.

For all groups, professional communication consumed the greatest proportion of time (Box 3). Registrars spent proportionally more time in professional communication, and in supervision and education than either residents or interns (χ2 = 145.5; P < 0.001). On average, interns spent less time in direct care and considerably more time completing documentation and in general administrative tasks (χ2 = 599.7; P < 0.001). The proportion of observed time interns spent documenting (22%) was almost double that engaged in direct care.

Hospital doctors spent two-thirds of their time on three broad categories of tasks: professional communication, social activities and indirect care. The work of interns differed significantly from that of residents and registrars and was characterised by considerably more time spent in documentation and administrative activities, and less on direct care. This is consistent with reports of interns’ dissatisfaction with the high level of indirect care and administrative tasks they are required to undertake.12,13

Over half of these doctors’ work was carried out in the presence of another doctor and about a quarter was undertaken alone. On average, doctors spent more time with patients than they did with nurses or any other non-medical health professional. The rate of interruptions to these ward doctors (2.9 per hour) was less than half of the reported rates for doctors in emergency departments (6 to 15 per hour).14-18

We observed doctors only in the wards during weekdays from 08:30 until 19:00, so results may not be generalisable to weekends, evenings or early morning shifts. Direct, close observation lends itself to the Hawthorne effect, whereby participants improve their performance while being observed. In this study, the effect might be expected for time spent in social activities. Yet social activities were observed to take more time than most of the other types of task. We did not have the power to examine differences between wards, but have previously found few differences between nurses’ patterns of work across wards, despite beliefs that these existed before measurement.10

The study represents one of the few, and largest, time and motion studies of hospital doctors identified, and as such, provides a useful baseline for future studies. Our results support previous survey data of junior doctors’ experiences,1,12 and debunk commonly held perceptions about the time consumed by specific tasks. For example, doctors had asked us to measure the time spent searching for x-rays and records, because these tasks occupied “all of our time”. Yet they consumed less than 1% of their time. The greater weight given to these tasks in discussions clearly reflects the frustration these tasks generate. We have reported a similar situation among nurses, who complained of time wasted following up illegible medication orders, yet when this was measured, we found nurses spent, on average, less than 2 minutes per shift on this task.19

This study provides a basis for comparing changes in doctors’ patterns of time distribution after the introduction of interventions such as computerised electronic medical record systems. Further, the results raise questions such as: Should junior clinicians spend more time in direct care? How much time, on average, should doctors spend on specific categories of work? Would more time in some tasks produce better patient outcomes?

1 Work measurement tool

Personal digital assistant used to collect data, showing main work tasks, and people and information tools involved in tasks.