• Isaac H Goldstein, Michelle R Hribar, Sarah Read-Brown, and Michael F Chiang.
• Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland.
• JAMA Ophthalmol. 2018 Jan 1; 136 (1): 20-26.

ImportancePhysicians face pressure to improve clinical efficiency, particularly with electronic health record (EHR) adoption and gradual shifts toward value-based reimbursement models. These pressures are especially pronounced in academic medical centers, where delivery of care must be balanced with medical education. However, the association of the presence of trainees with clinical efficiency in outpatient ophthalmology clinics is not known.ObjectiveTo quantify the association of the presence of trainees (residents and fellows) and efficiency in an outpatient ophthalmology clinic.Design, Setting, And ParticipantsThis single-center cohort study was conducted from January 1 through December 31, 2014, at an academic department of ophthalmology. Participants included 49 448 patient appointments with 33 attending physicians and 40 trainees.ExposuresPresence vs absence of trainees in an appointment or clinic session, as determined by review of the EHR audit log.Main Outcomes And MeasuresPatient appointment time, as determined by time stamps in the EHR clinical data warehouse. Linear mixed models were developed to analyze variability among clinicians and patients.ResultsAmong the 33 study physicians (13 women [39%] and 20 men [61%]; median age, 44 years [interquartile range, 39-53 years]), appointments with trainees were significantly longer than appointments in clinic sessions without trainees (mean [SD], 105.0 [55.7] vs 80.3 [45.4] minutes; P < .001). The presence of a trainee in a clinic session was associated with longer mean appointment time, even in appointments for which the trainee was not present (mean [SD], 87.2 [49.2] vs 80.3 [45.4] minutes; P < .001). Among 33 study physicians, 3 (9%) had shorter mean appointment times when a trainee was present, 1 (3%) had no change, and 29 (88%) had longer mean appointment times when a trainee was present. Linear mixed models showed the presence of a resident was associated with a lengthening of appointment time of 17.0 minutes (95% CI, 15.6-18.5 minutes; P < .001), and the presence of a fellow was associated with a lengthening of appointment time of 13.5 minutes (95% CI, 12.3-14.8 minutes; P < .001).Conclusions And RelevancePresence of trainees was associated with longer appointment times, even for patients not seen by a trainee. Although numerous limitations to this study design might affect the interpretation of the findings, these results highlight a potential challenge of maintaining clinical efficiency in academic medical centers and raise questions about physician reimbursement models.

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