A Good Note Is Like a Haiku

It’s generally not a good sign for patients to be disappointed to see me. However, it’s happened more than once, and each time I was proud. Sometimes the patients would call them by name, or sometimes they’d simply ask, “Where’s that learning doctor?” They were looking for my students!

I taught third-year medical students for 3 weekly half-day sessions to satisfy the outpatient portion of their 2-month internal medicine clerkship. In an effort to encourage more graduates to go into my specialty, I was tasked with turning a total day-and-a-half experience of patient care into an inspiration for a lifelong career. A bit of a tall order, but what primary care doc doesn’t love the challenge of squeezing something immensely meaningful into a time slot made for a TV ad? If primary care were an art form, it would be an epic poem composed of self-contained haikus.

Given the typical speed of a busy primary care clinic, the presence of students can threaten to slow things down, but recent updates in medical education and other regulations have begun to soften the blow. I was thrilled last year when the Centers for Medicare & Medicaid Services (CMS) changed its rules for student documentation, allowing attendings to cosign student notes rather than requiring that we redocument their findings. However, a recent commentary in Annals of Internal Medicine (1) was less enthusiastic. Authors were appropriately cautious, warning that students’ education on note-writing would focus too much on billing requirements, this new independence would lead to attendings spending less time with learners, and the responsibility to document would turn meaningful team members into mere “student scribes.”

Their concerns are reasonable but in my opinion are outweighed by benefits. The new regulations make some previously difficult-to-teach primary care skills much more feasible. Yes, note-writing does expose students to billing—which, as much as we hate it, is an important skill for any practice. The fact that these students’ experience of internal medicine is predominantly inpatient means that most of their notes overdocumented my primary care visits. It did take more time for me to give them feedback, but less time than expected editing or supplementing their notes. (As someone who greatly prefers teaching to documenting, this has been a welcome trade.) Most of my pointers focused on identifying relevant data for a primary care visit, honing the haiku: Make every word count. What do we need to know now? What is new or different? What does it mean? And what are you going to do about it?

Admittedly, the burdens of counting numbers of systems reviewed or minutes spent coordinating care to meet evaluation and management (E/M) or Chronic Care Management (CCM) codes in clinic may turn even the most enthusiastic learner (or clinician!) away from primary care. However, CMS has also recently decided they will simplify these processes (2) over the next few years. It is a moving target, but students should at least have access to the bow and arrow so they know how to shoot when the final target is set.

Meanwhile, note-writing allows students to practice time management by giving them a full experience of the tasks at hand and providing a framework for organizing their thoughts. Even the highest-scoring students may struggle with the multitasking and rapid pace required of primary care. Just as much of a haiku’s beauty is in its rule-constrained brevity, the proper implementation of a note’s form can allow data to transform into information.

Lastly, the simple act of putting one’s thoughts into writing raises the level of commitment to those ideas and to that patient. The autonomy and responsibility of note-writing fosters a sense of ownership of care that I think contributes to the number of patients asking after their “learning doctors” at future visits. The student’s thoughts are formalized and validated “on record.”

Each time a patient recalled their time with my students, I felt a spark of Marie Kondo joy. Yes, having students in the clinic can clutter the patient flow. It can make me late for dinner and add some extra work. And yes, the looming threat of billing might detract from some more clinical skills. But when we do finally agree on the best way to pay for outpatient care like mine—and I’m hopeful that we will—we still need primary care docs to perform that care.

So for now, however imperfect, the CMS student documentation regulations make it easier for my students to practice some of the more intangible but gratifying elements of primary care: building relationships, managing time, organizing thoughts, and taking ownership.

It is a calling
To listen and to learn how
To tell a story.

References

1. Cassese T, Sharkey MS, Pincavage AT, et al. Avoiding pitfalls while implementing new guidelines on student documentation.  Ann Intern Med. 2019;170:193-4. [PMID: 30641548] doi:10.7326/M18-1924
2. Internists tell CMS not to proceed with changes to payments for E/M services that undervalue care [news release]. Philadelphia: American College of Physicians. 10 September 2018. Accessed at www.acponline.org/acp-newsroom/internists-tell-cms-not-to-proceed-with-changes-to-payments-for-em-services-that-undervalue-care on 30 May 2019.