A Day in the Life of an Internal Medicine Resident - A Time Study: What Is Changed from First to Third Year?

BACKGROUND: In the past decade, internal medicine residencies have undergone major changes in competency-based assessments, work-hour restrictions and the implementation of the electronic medical record. The aim of this study is to compare a typical day of a first year post-graduate (PGY1) to that of a third year post-graduate (PGY3) internal medicine resident and examine if the differences in their days demonstrate the American Board of Internal Medicine's (ABIM) desired progression towards competency-based milestones and unsupervised practice. METHODS: We conducted an observational time study documenting 14,103 minutes, 9 major categories, and 17 subcategories while shadowing 10 internal medicine PGY1s and 10 PGY3s during inpatient, non-call days. The following day, house staff completed surveys of their perceived time allocation of the previous 24 hours. RESULTS: PGY1s spent an average of 12.5 hours managing an average of 6 patients. Thirty-eight percent of their time was spent on the computer, 21% discussing patients and 18% directly with patients. PGY3s, overseeing an average of 12 patients, worked 1.5 hours less per day (p<0.001), had 1.5 hours less computer time (p=0.001), 24 minutes less direct patient contact (p=0.045), and 36 minutes more patient care discussions (p=0.011). CONCLUSION: The difference between PGY1s' and PGY3s' daily time allocations is minimal. Whereas a PGY3 spends 1.5 hours less than a PGY1 on writing computer notes and discharges, they also work 1.5 hours less per day. The additional 36 minutes of patient care discussions was the only significant time quantity difference that would be considered a higher level of practice for the PGY3 compared to the PGY1. With residents now caring for fewer patients, there has been a marked increase in computer time per patient for both PGY1s and PGY3s.

Prevalence, Timing, Causes, and Outcomes of Hyponatremia in Hospitalized Orthopaedic Surgery Patients.

BACKGROUND: Hyponatremia is common among orthopaedic patients and is associated with adverse clinical outcomes. We examined the prevalence, timing, causes, and outcomes of hyponatremia in adult hospitalized orthopaedic surgery patients. METHODS: We evaluated the medical records of 1067 consecutive orthopaedic surgery patients admitted to a tertiary academic institution. The medical records were reviewed to investigate hyponatremia (serum sodium <135 mEq/L) that (1) had been present on hospital admission or (2) had developed postoperatively. The primary outcomes were the prevalence and timing of, and risk factors for, presentation with or development of hyponatremia. Secondary outcomes were hospital length of stay, total hospital cost, and discharge disposition. Multivariable logistic regression models were used to assess the variables associated with hyponatremia and the effects of hyponatremia on clinical outcomes. RESULTS: Of the 1067 patients, seventy-one (7%) had preoperative hyponatremia and 319 (30%) developed hyponatremia postoperatively. Of the latter, 298 (93%) developed hyponatremia within forty-eight hours postoperatively. Compared with patients with normonatremia, those who presented with hyponatremia, on the average, were older (67.2 versus 60.5 years, p < 0.001), had longer hospital stays (4.6 versus 3.3 days, p < 0.001), incurred higher hospital costs ($19,200 versus $17,000, p = 0.006), and were more likely to be discharged to an extended-care facility (odds ratio [OR] = 2.87, p < 0.001). Developing hyponatremia postoperatively resulted, on average, in a longer hospital stay (3.7 versus 3.3 days, p = 0.002) and greater hospital cost ($18,800 versus $17,000, p < 0.001). Age (OR = 1.13 per decade, p = 0.012), spine surgery (OR = 2.76 versus knee, p < 0.001), hip surgery (OR = 1.76 versus knee, p < 0.001), and the amount of lactated Ringer solution used (OR = 1.16, p = 0.002) increased the risk of developing hyponatremia. CONCLUSIONS: Hyponatremia in orthopaedic patients is associated with longer, costlier hospitalizations. The factors that significantly increased the risk of developing postoperative hyponatremia were an older age, spine fusion, hip arthroplasty, and the amount of lactated Ringer solution used.