Over the last 5 years, we have spent considerable time directly teaching students and housestaff and have been involved in numerous meetings of academic physicians concerned about the apparent erosion in quantity and quality of medical student and resident teaching at our medical schools and teaching hospitals.1
The causes of this progressive deterioration in what many consider the best medical education system in the world are myriad: Economic challenges forced faculty to spend much of their time doing direct clinical work rather than teaching; program directors have needed to spend more time and effort on regulatory documentation; administrative restrictions have been placed on medical student participation in patient care; duty hour constraints have been placed on resident work schedules, thereby decreasing the amount of time that residents can devote to teaching students as well as each other; and inpatient physicians are given performance metrics that emphasize efficiency of patient flow at the expense of bedside teaching and role modeling. Departments of medicine have evolved into business centers or “product lines” instead of the medical center's academic compass.
Teachers have less time to teach; residents have less time to learn; and medical students are often relegated to the role of voyeurs. And from this environment we hope to find the solution to reverse the trend of dwindling number of students seeking careers as general internists and academicians.
In an attempt to correct the deteriorating educational environment, a number of proposals have been suggested and implemented at institutions around the nation. These include mandatory protected time for instruction inserted into the work week of residents and students; the creation of medical school academies of excellence in education to support concepts of quality teaching and to find ways to protect faculty time for dedicated educational activity; and restrictions on the number of admissions and the total number of inpatients and outpatients that residents manage at any given time combined with shifting some of the inpatient workload to full-time hospitalist internists. Unfortunately, many of these (and other) innovative solutions require additional clinicians and funding.
We would like to suggest a modest proposal that seeks to improve medical student education: permit the return of the meaningful medical student admission note. Two advantages of our suggestion are that it does not require additional financing from already constrained medical school, departmental, and hospital funds, and it is likely to improve the esprit of teaching physicians. This proposal is based on our experience in years past when medical students were used as “front line troops” in the care of inpatients. Medical students were the first members of the health care team sent to evaluate a new admission. Students were allotted a substantial amount of time to take a detailed history from the patient and perform a thorough physical examination (H & P). Thereafter, students prepared the initial history and physical examination form that became part of the permanent record of that patient's chart. The medical student admission H & P was the place where attending physicians, nurses, and residents could go to read all that they needed to know about a particular patient's history. Residents and attending physicians confirmed the key points and then amended the detail and nuance of the history and examination, and appended brief notes to the medical student H & P, summarizing the issues to be dealt with and emphasizing the diagnostic and therapeutic needs of the patient.
The initial note of the medical student (or resident) became a dynamic learning and teaching dictum of patient care, instead of the current practice of inserting multiple, duplicative notes by the attending to justify regulatory and billing requirements. Current electronic records have the ready capacity to track these changes, noting the involvement of the supervising staff.
The student's comprehensive and detailed approach to patient evaluation disappeared when Medicare authorities decided that information collected by medical students, with minor exceptions, was not valid and would not be accepted as a basis for reimbursement.2 The knowledge base used for this decision remains a mystery. The result of this decision, however, was evident immediately. Medical students no longer played a primary role in the care of patients. Instead, they became passive observers in daily patient care activities. At the time of its implementation, we found this decision to be not only harmful to student education but also potentially deleterious to patient care. Current harried resident H & P's are rarely as detailed or as clearly written when compared with the carefully constructed medical student notations of the past. The medical student note was the written introduction to the patient's entry into the hospital, but also was the nexus of the student's clerkship grade and the structural foundation for the notes the student would write in the future as a resident and then as staff. The medical student note truly mattered.
Thus, our modest proposal: Let us ask Centers for Medicare & Medicaid Services (CMS) to rescind the order that prevents medical students from playing a primary role in patient care. Let's return to the system used in the past of expecting the medical student to provide the official and also the most comprehensive and detailed H & P in the admission medical record. Let us pose the challenge to our electronic medical record colleagues to assist in developing templates appropriate for quality patient care, as well as tracking the entries and edits of our trainees' notes in a manner that can be used for effective evaluation and feedback. The structured note should behave as a whiteboard to record clinical information and be a window to our learner's thought processes. These notes, with the annotated edits of senior clinicians, can be the crux of the student's (resident's) inpatient rotation education portfolio.
Residents and attending physicians would still be required to review and amend, as well as write (and sign) short, pithy summaries and plans of action that would be appended to and within the medical student H & P. Daily progress notes also would be written by medical students, again with appropriate supporting commentary from residents and attending physicians.
This modest proposal for once again accepting the trainee's initial note as the primary source document in the chart (once reviewed by the attending staff) does not require any additional funding and will return the medical student squarely to the middle of daily clinical inpatient activity. It also would markedly increase medical student dedication to patient care during inpatient rotations because they would, in essence, be functioning as apprentices to the residents. We predict that a reversal of CMS's earlier decision will assist in fostering professional growth and sense of responsibility in medical students because they will be active participants in patient care decisions and intimately involved in the care of their assigned patients. In addition, a medical student who plays a substantial role in the care of a patient with a serious medical condition is more likely to remember the lessons learned from caring for that patient. We strongly urge CMS/Medicare to return “back to the future” and to rescind their earlier educationally harmful decision that has functionally excluded medical students from routine and meaningful involvement in patient care.
Feel free to post a comment on our blog, http://amjmed.blogspot.com, regarding this editorial or other Journal content.
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