Med students left out of note-writing process in clerkships
After the 1910 publishing of The Flexner Report, a survey on the state of U.S. medical education, the training of physicians shifted from apprenticeship toward classroom-based education in academic centers. However, a large portion of the training of future physicians effectively remains an apprenticeship, with third- and fourth-year students learning through hands-on experience while assisting physicians with patient care.
This aspect of our medical education largely consists of “rounding” and of composing notes. The notes, in particular, are an integral part of our education. Writing them allows us to develop skills we’ll need to manage patient care.
Unfortunately, my classmates and I have noticed that some teaching hospitals are restricting us from writing notes.
They do this in order to toe the line on Medicare’s reimbursement rules. Understandably, Medicare must be certain physicians are personally doing the work they are charging for. And of course, patients must receive care at the hands of fully trained, licensed and accredited physicians.
“Nobody at these hospitals is trying to cheat anyone. Our supervising physicians are simply helping us learn.”
But charting is a vital learning tool for medical students. Besides teaching us to document medical records, note-taking helps us demonstrate our problem-solving skills and provides a record of our progress during a clerkship. We must figure out how to protect this crucial piece of our education.
I conducted an informal online survey of 120 of my fellow students and found that most have been restricted from writing notes. Seventy-seven percent of respondents said they have been denied this educational opportunity on at least one clinical rotation, with 22% citing Medicare rules as the reason.
Rules don’t reflect reality
Under Medicare’s rules for billable services, the only acceptable student contributions to patient charts are the review of systems and past medical, social and family histories. Attending or resident physicians must re-document all other student-composed elements of the record, including history of present illness, physical exam, and evaluation and management. It is not enough for a physician to edit and take responsibility for the student’s entry.
While well-intentioned, these guidelines do not ensure complete patient care and billing in the teaching environment. As Robert Gesumaria, OMS IV, told me, Medicare falsely presumes that a note from an attending means the patient’s exam was thorough. “If anything, allowing students to write notes allows physicians more time to give thorough and effective care,” said Gesumaria, who attends the Rowan University School of Osteopathic Medicine in Stratford, N.J.
One way hospitals and physicians can follow Medicare’s rules while maintaining the learning experience is by having the student write a separate note not used for billing purposes. But this approach could be dangerous. “Although student notes should be clearly labeled, that is not a guarantee that a nurse would not read the note and assume it represented the team’s plan,” Matthew Brown, MD, the executive director of medical education for Resurrection Health Center, a teaching hospital in Chicago where I’ve served rotations, wrote in an email.
While barring us from the hands-on experience we need, Medicare’s reimbursement rules simply contradict the reality of what is happening at teaching hospitals.
While on clerkships, my fellow students and I have entered notes electronically while signed in as a resident or attending. Or we have been identified in the record as scribes. Or we have seen a supervising physician take responsibility for our documentation without noting that it originated with a student.
What students need
Many physicians seem to be unaware of the Medicare rules, hospitalist David F. Hitzeman, DO, has said to me. He also acknowledged that “some of the benefits of student training experience are getting affected by Medicare reimbursement rules.” He said that when he was training, students were free to dictate history and physical examinations.
Some in the field, such as Dr. Hitzeman, believe that teaching hospitals are enforcing Medicare’s rule because the agency has been ramping up audits as part of a wider effort to prevent waste and fraud.
Nobody at these hospitals is trying to cheat anyone. Our supervising physicians are simply helping us learn.
The Medicare rules aren’t going to change anytime soon. Within the confines of the system, attending physicians need to be granted more time to re-document student notes and to go over notes with their students.
When students can’t write notes, a clerkship becomes little more than a shadowing experience, my classmate Jessica Chan, OMS IV, told me.
Arta Zowghi, OMS III, said limited ability to write notes in patient charts would severely hamper her medical education. “Having me write the note does not lessen the quality of patient care, and it allows me to learn,” said Zowghi, who attends the Midwestern University/Arizona College of Osteopathic Medicine in Glendale.
“The best educational experiences I’ve had are when the attending basically treats you like an intern, and you are fully involved in writing notes and orders and developing treatment plans,” Gesumaria told me. “If not for these opportunities, we may as well not be on rotations.”
It is imperative that hospitals and physicians reaffirm their dedication to granting students the important educational experience of note writing. If they don’t, future physicians will enter the field in droves without sufficient clinical experience to successfully care for patients.
Timothy Beals, OMS IV, attends the Midwestern University/Chicago College of Osteopathic Medicine in Downers Grove, Ill.