Documenting or operating: where is time spent in general surgery residency?
Open accessAbstract
Objective The utilization of electronic health records (EHR) has become essential in the daily activities of physicians for documentation and as an information source. However, the amount of time spent by residents utilizing the EHR has not been thoroughly evaluated, particularly within surgical specialties. This study aims to analyze EHR usage by general surgery residents and to assess the association between this use and case volume at a single academic institution.Design For general surgery residents in clinical years (CY) 1-5, de-identified login and logout time data between September 2016 and June 2017 were retrospectively extracted from the Epic EHR (Verona, WI). A binary time series was created for each resident to indicate and track over time whether he or she was utilizing the EHR system. Comparisons between categorical variables were performed with Fisher's exact test. Continuous variables were compared using Wilcoxon rank sum test. Longitudinal linear mixed-effects models were used to assess the EHR usage among the surgery residents. The association between EHR time and the number of operative cases logged was evaluated with Pearson's correlation coefficient.Setting This study was performed by the Department of Surgery in conjunction with the Office of Graduate Medical Education at Duke University Health System.Participants All active general surgery residents during the 2016-2017 academic year.Results Thirty-six general surgery residents (28 males, 8 females) spent a median of 2.4 hours per day and 23.7 hours per week using the EHR. CY2 had the highest median usage per week (28.9 hours), while CY3 had the lowest (16.7 hours) but no significant difference based on EHR usage was found among the analyzed CYs (p = 0.164). Residents spent significantly more time logged into the EHR during the week compared to weekends and during the day compared to nights (all p < 0.001). For the residency program as a whole, a median of 151.5 total work hours per day was dedicated to documentation. On average, interns on dedicated night rotations spent 7% of their login time outside regularly scheduled duty hours while interns on dedicated day rotations spent 27%. There was no overall correlation between monthly case logs and EHR usage (r = 0.06, p = 0.30); however, CY2 had a significant negative correlation (r = -0.2, p = 0.038).Conclusions In the era of a maximum 80-hour work week, general surgery residents spend a substantial portion, at least 30%, of their time utilizing the EHR. One third of EHR usage by interns occurred outside the scheduled 12-hour shift, demonstrating the difficulties of completing paperwork as part of the scheduled work day. Additionally, the lack of correlation to case logs is likely due to an underestimation of the documentation burden associated with operating, which includes preparatory effort and operative notes. Ultimately, these quantitative EHR usage results will be correlated to burnout prior to implementing programs to improve efficiency and decrease the burden of charting.
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Cox et al proposed the "amount of EHR usage taking place after scheduled duty hours" specifically for surgical residents.
“For example, Cox et al proposed the “amount of EHR usage taking place after scheduled duty hours” specifically for surgical residents.13”
From Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review (2021) · cites this paper as [13]
Of the 35 included studies, only 1 study intended to develop a measure of burden (EHR usage outside shift).
“Of the 35 studies included, only 1 study intended to develop a measure of burden (ie, EHR usage outside shift),13 while 2 studies individually employed TM studies to empirically validate proposed measures of workflow and the use of EHR usage log data in characterizing workload.27,70”
From Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review (2021) · cites this paper as [13]
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Lo, B., Sequeira, L., Strudwick, G., Jankowicz, D., Almilaji, K., Karunaithas, A., Hang, D., & Tajirian, T. (2022) · Applied Clinical Informatics · doi:10.1055/s-0042-1756424 · Cited by 1 · see citing works
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Culture of Safety and Era of Better Practices
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Multitasking or distracted? Surgery resident engagement with the EHR during protected education time
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Moral Distress in Resident Physicians: A Scoping Review
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- Authors
- Cox, M. L., Farjat, A. E., Risoli, T., Peskoe, S., Goldstein, B. A., Turner, D. A., & Migaly, J.
- Affiliations
- Duke University (US)
- Duke University Health System (US)
- Corresponding author
- Cox, Morgan L.
- Venue
- Journal of Surgical Education
- Publisher
- Elsevier BV
- Published
- 2018-11
- Volume
- 75
- Issue
- 6
- Pages
- e97-e106
- ISSN
- 1878-7452 (ISSN-L)
- 1931-7204
- PMC
- PMC10765321
- OpenAlex
- W2902726648
- Cited by
- 68
- References
- 27
- Citations by year
- 2026: 7 · 2025: 6 · 2024: 9 · 2023: 8 · 2022: 12 · 2021: 13 · 2020: 9 · 2019: 4
- FWCI
- 8.20
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of surgical education (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (T32HL069749)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Keywords
- electronic health records, general surgery residents, clinical documentation, operative case volume, resident work hours, graduate medical education, Epic EHR, documentation burden
- MeSH terms
- Documentation, Internship and Residency, Personnel Staffing and Scheduling, Retrospective Studies, General Surgery, Surgical Procedures, Operative, Time Factors, Electronic Health Records
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