Intern includes self/patient selfie in H&P physical exam

[Redpancreas]

I don’t know why this is stuck in my head, but interns are starting to do one admit per call shift now. My job is to supervise the H&P/orders process and this person put together a very detailed subjective part with a narrative including the patient’s hobbies, etc. When I went to the patient room, the patient loved that intern and it seems like that intern has gotten that feedback repeatedly which is good. On the other hand, I think some social elements were too detailed/intimate for a note and there were a couple what I feel were semi-important elements of the HPI missing. The bare essentials were there though. The orders were ok but there were some important things to add. They did take me adding things pretty well. I wanted to say something but I don’t want to rain on this person’s parade/humanism because I think that they have a lot of positive energy. I was thinking of doing it for their next H&P assuming the intern maybe jived well with that one patient but the same exact thing happened and the next interview is them taking another selfie with another patient who is smiling broadly with the intern despite being told this admission they had a terminal illness. The H&P still had some details missing.

-thoughts on selfie in the H&P? Is this a thing that some people do?
-how should I frame the feedback without raining on their parade?

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[ChordaEpiphany]

My instinct is that an H&P is no place for a selfie, but it seems more like "annoying quirky" as opposed to "professionally precarious." However, this intern clearly has a way with patients, and maybe mindless professionalism isn't the way forward for medicine. That said, it's worth talking about if only for the intern's own reputation around the hospital, with patients and with colleagues. There's probably a good middle ground where they keep their patient rapport and ditch the selfies in the note. I genuinely can't reason out why taking a selfie with a patient who apparently raves about you needs correction when so many physicians do so much worse. I think you're right that you can't rain on the parade. Broach the subject as one of professional appearances for their own good, which it is.

I also think the real potential pitfall here for you is being overly critical of other pieces of the intern's performance to support your anti-selfie bias. I'm an MD/PhD student, and I've fallen victim to this a few times supervising/mentoring younger graduate students who irk me in some way or just generally give off those "I just finished college" vibes. Suddenly I'm attributing forgetting a control in an experiment to laziness, stupidity, etc... when in another student I might see it as a natural and completely normal learning opportunity. Those are the sorts of feelings you have to recognize and nip in the bud.

 

[operaman]

I think the solution is easy: more admits.

I’m definitely someone who can let the visit expand to the time I have. I do take a lot of pictures of patients though only with Haiku so they go direct into the record. That’s mostly so I can remember them and their families for future visits - I find the visual helps me a lot.

I think increased volume would help curtail the extraneous stuff without crushing their spirit. Ultimately I had to learn that patients want a doctor, not a friend. Being professional and courteous and efficient is more than enough.

 

[HuskyMD Emeritus]

Hobbies, pets and occupation can be an important part of the history because they may be the cause of the patient's illness (e.g., occupational lung disease, hypersensitivity pneumonitis). However, selfies should not be part of the H&P. Remember, the medical record is a legal document, not a place for momentos. Some hospitals have rules regarding taking pictures as it may put the hospital and the doctor in legal and HIPAA violations.

 

[Redpancreas]

Hobbies, pets and occupation can be an important part of the history because they may be the cause of the patient's illness (e.g., occupational lung disease, hypersensitivity pneumonitis). However, selfies should not be part of the H&P. Remember, the medical record is a legal document, not a place for momentos. Some hospitals have rules regarding taking pictures as it may put the hospital and the doctor in legal and HIPAA violations.

Yeah I was wondering as to the legality of it too but so far no one else has said anything. One attending was confused about it but didn’t really seem to care much because the H&P was pretty good (after my edits). Another one thought it was amazing and thought the H&P was so well written (again after my edits).

Sometimes when I’m the first one to a patient and I’ve caught the rn in the midst of a dressing change, I take a picture of a wounds and put them in epic on admission or dc summaries with the patient’s permission on Haiku/Epic. It minimizes the number of dress changes so the medical student, residents, consultants, and attending visits don’t all have to include taking down the wound. That said, I just find the selfies half bizarre and half endearing. This resident is a prelim going into a psychiatry so it’s not like I’m trying to crush their sole and tell them next year they’re going to have to admit 10 while helping interns with cross coverage/their 1 admit which is what I’m doing.

 

[TelemarketingEnigma]

Your interns are just starting to do one admission per shift??? We were expected to do multiple from day 1…

If the selfie is going anywhere other than the medical record it may violate hospital policies (patient privacy/consent, social media, etc). If it’s just going in the medical record, probably not breaking rules but it is very weird

Also psych requires a prelim year? I didn’t think they did

 

[Osteosaur]

One per shift??? What else do they do? My night is like 50% admits and getting collateral history on AMS. Or it feels like it.

Two issues:

1) most HIPPA trainings (more likely hospital policy so they can pretend you never worked there if you suck) forbid taking your picture with patients. Across 2 hospitals they say not to do this.

2) it's weird. I'd be really uncomfortable and question my care if I or a family member had some zoomer taking a selfie with BNP of a billion.

3) most importantly for the intern... no one has time for this. A selfie and history including hobbies?

I think you should add another admit and tell him while you admire his attention to detail it's just not going to be efficient. I might personally be someone who responds more to getting yelled at than praise but if I suck I want to know it. You'd be doing him a service to get him taking those admits faster.

 

[cj_cregg]

So, I do occasionally put things like hobbies, pets, family members, job/work history, etc. in my social history....but I'm a family doctor and do this exclusively for my primary care panel and nursing home patients, not when I'm admitting people to the hospital unless it's relevant to what's going on during the admission. The selfie thing is a little weird. I definitely will put in pics of wounds, rashes, etc. as you said above but it has never even crossed my mind to take a selfie with a patient at all let alone put it in the medical record.

If I were giving the feedback, I'd probably say something like: "I LOVE that you are connecting well with your patients - they clearly enjoy having you take care of them and have given me a lot of positive feedback about you. [insert some specific kind feedback you got here]. I do want to talk with you about tightening up your H&Ps a bit to save you time, especially when you start taking on more admits and patients as the year progresses, and also to save time for other members of the care team who are looking through your H&P for specific relevant information.

We really need to think about the reason the H&P exists and who the audience is - it's to communicate with the whole care team about why the patient is being admitted, the relevant pieces of their history, and what the plan of care is, and it also serves as a legal document when needed. We often get lots of information from the patient when we're taking the H&P, and part of our job as the physician is to pare that information down to what's most relevant and what's important to actually go into the note. I notice that you often include a lot of extraneous details in your note. [here, maybe pull up some of their prior H&Ps and point out specific things you would not have included].

I also see that you're sometimes including a selfie with the patient. As you transition into the physician role, I'd encourage you to think carefully about the headspace that patients are in when they're getting admitted to the hospital - for some people, this might be the worst day of their life. They're almost certainly feeling poorly, probably not looking what they'd think to be their best, and might have gotten bad news about a new diagnosis. Probably not a time many people would want a picture taken of them, and because of the power differential between physicians and patients, some patients might not feel comfortable saying no when you ask. [if relevant: I also worry about the possibility of you running afoul of HIPAA or a hospital policy with taking photos of patient's faces on your personal phone]."

Then circle back to some positive feedback on things they're doing well with their H&Ps and admissions.

 

[ACSurgeon]

Since when so brand new interns show up and start new trends? And senior residents and attendings are being careful not to hurt their feelings?

Med school teaches a standard H&P. A selfie isn’t part of that.

And lol at the poster above who said “anti-selfie” as if there’s two groups in medicine, one pro and one against putting selfies in the chart.

The world is becoming a very interesting place

 

[Oso]

Very weird and cringe inducing.

 

[ortnakas]

There is a way for you to compliment your intern’s humanism and communication skills while also telling them they need to be more efficient and that selfies aren’t okay. Figure out how to do that.

Even if your interns inexplicably only do one admit now… soon enough they’ll do five and next year they’ll do ten. They need to figure out how to make a connection without spending hours on their life story.

 

[Osteosaur]

My instinct is that an H&P is no place for a selfie, but it seems more like "annoying quirky" as opposed to "professionally precarious." However, this intern clearly has a way with patients, and maybe mindless professionalism isn't the way forward for medicine. That said, it's worth talking about if only for the intern's own reputation around the hospital, with patients and with colleagues. There's probably a good middle ground where they keep their patient rapport and ditch the selfies in the note. I genuinely can't reason out why taking a selfie with a patient who apparently raves about you needs correction when so many physicians do so much worse. I think you're right that you can't rain on the parade. Broach the subject as one of professional appearances for their own good, which it is.

I also think the real potential pitfall here for you is being overly critical of other pieces of the intern's performance to support your anti-selfie bias. I'm an MD/PhD student, and I've fallen victim to this a few times supervising/mentoring younger graduate students who irk me in some way or just generally give off those "I just finished college" vibes. Suddenly I'm attributing forgetting a control in an experiment to laziness, stupidity, etc... when in another student I might see it as a natural and completely normal learning opportunity. Those are the sorts of feelings you have to recognize and nip in the bud.

Have you not done your rotations yet? And unless I am reading the OPs post wrong this is a doctor with a medical degree we are discussing. Not a Sub-I or even a medical student.

A selfie with a patient is not part of an h&p. It's also potentially a HIPPA violation. I have never once seen this in any doctor's note.

It is professionally precarious both as a HIPPA violation, and because as an intern we need to be learning efficiency. The more time you spend discussing patient A's boggle championship the less time you can focus on patient B's CHF or triaging nursing texts, rapids, etc. For an inpatient admit on a call shift you need to always be thinking "why is this person here? when can they go home?"

 

[anesussy]

Have you not done your rotations yet? And unless I am reading the OPs post wrong this is a doctor with a medical degree we are discussing. Not a Sub-I or even a medical student.

A selfie with a patient is not part of an h&p. It's also potentially a HIPPA violation. I have never once seen this in any doctor's note.

It is professionally precarious both as a HIPPA violation, and because as an intern we need to be learning efficiency. The more time you spend discussing patient A's boggle championship the less time you can focus on patient B's CHF or triaging nursing texts, rapids, etc. For an inpatient admit on a call shift you need to always be thinking "why is this person here? when can they go home?"

First of all, it's HIPAA. Secondly, please explain to me why you think this is a HIPAA violation?

 

[ortnakas]

First of all, it's HIPAA. Secondly, please explain to me why you think this is a HIPAA violation?

Explain how the patient’s likeness on a personal phone isn’t one?

 

[CoolBreezes]

Explain how the patient’s likeness on a personal phone isn’t one?

Did OP state that the selfie was taken with a personal phone and not a practice camera?

 

[VA Hopeful Dr]

Explain how the patient’s likeness on a personal phone isn’t one?

It depends. If its just on a personal phone that goes the icloud of google photos, probably is.

If its the function on Epic where you can use your phone in the epic app to put pictures into the chart, it isn't.

 

[ortnakas]

It depends. If its just on a personal phone that goes the icloud of google photos, probably is.

If its the function on Epic where you can use your phone in the epic app to put pictures into the chart, it isn't.

Fair point.

Selfie on personal phone = HIPAA violation.
Selfie in patient’s EMR = awkward and weird (and edit to add: almost definitely against hospital regulations) but not illegal

 

[VA Hopeful Dr]

Fair point.

Selfie on personal phone = HIPAA violation.
Selfie in patient’s EMR = awkward and weird but not illegal

Yep. And I would absolutely tell the intern to stop in the 2nd scenario FWIW.

 

[TelemarketingEnigma]

Wait to clarify: this is like a posed selfie featuring both intern and patient, yes?

Not a selfie in the sense of what my boomer parents think is a selfie (aka any photo of a person) right?

There are uses for patient photos (ie, to show dysmorphic features for a genetics consult) but it’s still sounding weird either way, just way more weird if it’s the first one

 

[mrbreakfast]

I am similarly confused, but it sounds like you are describing the intern posing with the patient for a picture, then uploading that picture (which includes the intern) into the patient's chart.

Whatever hospital you work at has a long photography/multimedia policy (it's 20 pages long at mine) which painstakingly details every possible circumstance where photos and recordings can and cannot be done. Doing what it sounds like you're describing is almost certainly in violation of that policy. For example, this intern is:

-Taking the picture with their own camera/phone (violation)
-Uploading information to the chart that has no value to the patient's care
-Uploading a picture for "identification" that ostensibly shows two people (and while it might be obvious which one is the patient, that may not be so obvious from a legal perspective)

They might be able to do all of the above with consent from the patient, of which they have no documented evidence. All it takes is for someone a week later to see this, ask them "hey, did you know Dr. X was going to take a picture of himself/herself with you and put it in the chart?" and all that patient has to say is "what? I don't really remember that."

-how should I frame the feedback without raining on their parade?

Tell them they could be fired for doing this. It's that simple. Also, who cares about raining on their parade? Part of being an upper level is telling intern they're being idiots. It's your job.

Your post seems to imply this intern did a mediocre job on a single admission; while I agree with the other posters that it's inconceivable that an intern is expected to cap at just one admission by August, they will regardless be eventually expected to do more than that, and you can help them to build good habits now. If they are writing a note that is really pleasant to read but is missing vital information that might compromise a patient's care, that needs to be straightened out, and you can do so without hurting their feelings.

 

[patriot6]

wtf

 

[VenusinFurs]

wtf

You and me both brother

Look, op, we’d all love to have a drum circle in the ED and sing kumbaya with our patients but you have to draw the line somewhere, and at the risk of sounding like an old man yelling at clouds here, you all are being way too soft on these interns and I am very scared for the future if they are just starting to do one admission after being in residency for 7 weeks, and that apparently some of them haven’t learned what an h and p is for. You crush that kid’s soul, do it now, for their own good.

 

[daddydoctor]

This new doctor will learn soon enough that outshining your senior residents and attendings is one of the most damaging things that can be done as an intern. Work as a team and leave your ego at home.

 

[mistafab]

Bruh... 1 H&P per shift? what the hell kind of place are you working at?

 

[Med Ed]

-how should I frame the feedback without raining on their parade?

You imagine a loved one gets ill, goes to the hospital, and has this person as their doctor. Then you imagine that this person is still a clown because no one ever had genuine expectations of them in training. Then you realize that if this person sucks as a doctor, you're partly responsible for it.

If this intern is so fragile, such that some direct feedback on a H&P will permanently scar them, then they shouldn't be in the profession.

 

[Neopolymath]

It's honestly almost as weird that these peeps are doing 1 admission a night. Are you joking?

 

[operaman]

It's honestly almost as weird that these peeps are doing 1 admission a night. Are you joking?

Yeah I’m thinking back to July of intern year doing an admission every hour or so while also cross covering a huge list. There was definitely no time for selfies! Or eating. Or sleeping. Or peeing. Man I’m really glad that’s over!

 

[Redpancreas]

I think it depends on the context. There’s a progression and by senior years the same residents are admitting 10 and cross covering 80 so it’s a progression and everyone starts differently. The amount of H&Ps depends on the field at hand too. Surgical subspecialty H&Ps/admissions are different than general medicine ones.

Spoke to the intern in question, they were quite receptive. They basically said they recognized there was a lot of time so they just felt that their time was best spent focusing on the “humanistic” aspects of the patient. I let them know that would be cool if the medical side of their H&P was comprehensive but it wasn’t and it needs improvement and I advised them to place an artificial time limit of an hr for the complete H&P process for the sake of good training despite there being way more time. I left the selfie part alone because I thought it was weird but said they may wanna double check the media policies for the hospital.

 

[TelemarketingEnigma]

I think it depends on the context. There’s a progression and by senior years the same residents are admitting 10 and cross covering 80 so it’s a progression and everyone starts differently. The amount of H&Ps depends on the field at hand too. Surgical subspecialty H&Ps/admissions are different than general medicine ones.

Spoke to the intern in question, they were quite receptive. They basically said they recognized there was a lot of time so they just felt that their time was best spent focusing on the “humanistic” aspects of the patient. I let them know that would be cool if the medical side of their H&P was comprehensive but it wasn’t and it needs improvement and I advised them to place an artificial time limit of an hr for the complete H&P process for the sake of good training despite there being way more time. I left the selfie part alone because I thought it was weird but said they may wanna double check the media policies for the hospital.

Your hospital must run very differently than mine. While the seniors are responsible for supervising all the admissions, the work is done by the interns. I have friends in lots of specialties and I think all of them this far into intern year are capable of doing multiple admissions in a shift

Did you suggest a 1 hour cap for just the interview or the whole process (interview, orders, staffing, notes)? Because one hour is WAY too long for just the interview but more reasonable for the latter

If they keep up with the selfies you really need to address that directly

 

[Redpancreas]

Your hospital must run very differently than mine. While the seniors are responsible for supervising all the admissions, the work is done by the interns. I have friends in lots of specialties and I think all of them this far into intern year are capable of doing multiple admissions in a shift

Did you suggest a 1 hour cap for just the interview or the whole process (interview, orders, staffing, notes)? Because one hour is WAY too long for just the interview but more reasonable for the latter

If they keep up with the selfies you really need to address that directly

Program, not the “hospital”. I encouraged 1 hr for the whole process because that’s the ideal. Every resident progresses differently with most ending up at the same level by the end and each program is different so I don’t think it’s worth questioning/judging the apparent ease but do agree this time-excess breeds this sort of weirdness. I also have multiple friends in multiple specialties. Some haven’t even been on a primary service yet and are on electives. We go gradually from 1 to 2 and progress to 3 per shift (drip, no admitting days so this is every day) with year 2s dedicated admitting doing 10 admissions during the day and night shifts, supervising the additional intern admits.

Regarding the selfies, I did bring it up to the attending on the admitting service because I don’t know the exact policy and he said he’d address it. I’m not supervising him and the attending’s going to be supervising.

Anyways, I think this thread has run it’s course. Overall I think his rapport with patients was admirable and think there’s something great he’ll do in psychiatry.

 

[username456789]

What in the actual f*ck.

None of this is remotely normal.

One admission per shift? Selfies? Senior residents/attending tiptoeing around the poor intern’s feelings?

I honestly recognize none of this. This is insanity.

 

[Med Ed]

What in the actual f*ck.

None of this is remotely normal.

One admission per shift? Selfies? Senior residents/attending tiptoeing around the poor intern’s feelings?

I honestly recognize none of this. This is insanity.

Welcome to GME in 2022.

 

[username456789]

Welcome to GME in 2022.

Absolutely horrifying.

 

[Mad Jack]

There is no reason for a physician to be pictured in a patient's note. This is, quite frankly, narcissistic and weird.

 

[username456789]

There is no reason for a physician to be pictured in a patient's note. This is, quite frankly, narcissistic and weird.

Which is, frankly, an adequate summation of twenty-somethings.

Oldmanyellsatcloud.jpg

 

[aldol16]

That seems like something the intern should not be doing. But then again, I hated when attendings or senior residents would nit pick on my notes. So my answer is selfie - not okay; minor details in notes - let it go. (Surgical resident)