Lack of Responsibility on Sub-I

[subtle1epiphany]

I am currently on a sub-I rotation and while the first week went well and the senior resident and attending didn't mind that I wrote progress notes in the patient charts, the current senior and attending ripped all my notes out of the charts.
Evidently it's a "medical-legal issue" for me to write anything in any patient's chart. According to the Chief Medical Staff on the floor, I can't write anything or have anything to do with the charts on this floor.
I am allowed to write things down, but I should keep them for my own edification and learning process (whatever that means). Interns can copy their notes from me, but sign them without my name present (i.e. I do their work for them and get no mention). I have no true responsibility or voice in the management of patients, but I'm welcome to ask why we're doing something so that I may learn.
Is this a common situation for a medical student on a sub-I?

I had huge hopes for this rotation. I envisioned having the responsibility and workload of an intern, but fewer patients. That I'd admit patients while on call (with resident oversight), come up with my own assessment and management, order labs and meds (with co-sigs), and generally have some measure of autonomy over my patients.
Instead I've been relegated to a shadowing role where I see the patients but it's a formality or just to help the interns. I can "suggest" portions of the management plan, but it really isn't the same.

Is this me wanting more than I should be expecting? Am I out of line?

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[surprisedgirl]

i definitely dont think you're out of line.....im a third year student who does everything you just described.....i'll admit i do more than my fellow med students, but my residents encourage it and appreciate it.....i know at our school sub i's are counted as actual interns, they just can't sign off on orders and whatnot.....im sorry you're having such a crappy experience

 

[Winged Scapula]

A medical record is a legal document. However, there are no federal or state rules about who can write in a patient's chart. For Christ's sake, they allow nursing students to write notes, Dieticians, PTs, etc. IMHO, you current team is afraid you might write something which will be used against them in a court of law.

It does happen that staff think the medical student's note is sort of the last word. We used to have a horrible time with Utilization Review reading the charts and seeing the MS-3 write, "plan discharge in am" and then they would want to know why we didn't discharge the patient. Would also have nurses say they read in MS-3/4's note about x, y and z and wanted to know what we were doing about it. Most of the time x, y and z was totally wrong. So it was always my practice to tell students to not write anything definitive in the plan about discharge and to read the notes and make corrections, addendums.

Unless your hospital has some policy about med students not writing in the chart, I think your current team is wrong.

 

[Ypo.]

Hey S1E-same thing goes on here at my site. The only thing we can write is ROS and social history during most of our rotations. A few family practice doctors have let me do all of the charting provided they cosign.

However, a subinternship should be letting you take on more responsibility than that! Maybe it has to do with the fact that you are still a third year?

Anyways, I feel your pain. Personally I think that this kind of policy has the unfortunate effect of tying our hands and making us feel irrelevant to the patient's care, with the effect of steering us away from taking more responsibility for the patients. And I agree with Kim that it is totally stupid that a nurse's assistant can chart but heavens forbid if they let a medical student take any responsibility.

I repeat once again that medical school has been like high school all over again.

 

[haveaniceday]

hmmm, that sounds very frustrating. I have had all the responsibilities that you desire as an MS3 at both private hospitals and the VA (way more at the VA).

It sounds like your situation is team and probably hospital dependent. One thing I've found is the more effort I put in and when I really take full responsibility for the patient, the team will reciprocate when they realize I am interested and competent. The medical-legal issues are hard to overcome, but once the interns/residents realize that your notes are basically the same thing they would write, they will often just sign it as their own and place in the chart (use the same pen for note and sig). Sure, you don't get the "recognition," but the people who matter will know that your notes are good enough.

 

[MSHell]

Sounds incredibly ****ty. Would they even notice if you weren't there? If they're not letting you do anything, why bother?!

 

[akpete]

Why are you doing a sub-I as a 3rd year? I didn't know you could do that. At least at my school you can't. Is that different elsewhere?



But, yeah, that sucks. I do way more than that on my M3 clerkships.

 

[23 from me]

This is a billing issue.

Medicare will not allow a bill to be submitted for a hospitalized patient with documentation performed by a medical student. A resident can write the same note with an attending tie in note, and a bill can be submitted. The attending must document that he/she was present during critical portions of the evaluation (physical exam, rounds) and that he/she co-formulated the plans of care. The attending note must also reference "the note of Dr. Excellent Resident dated xx/xx/xxxx" in writing. For billing purposes, the attending must re-write an entire med student note (no tie in statement allowed).

If this is not done, the hospital can not submit a bill on behalf of the attending. If a bill is submitted without the above, it represents Medicare fraud. In the early to mid 90's, a number of academic medical centers had multimillion dollar settlements with Medicare for violations of Medicare documentation rules. Academic medical centers instituted billing training courses for attendings where these rules are spelled out.

Surgeons bill for procedures, so I expect that a sub-I would be allowed to write notes on an inpatient surgical service without billing problems. The VA and other federal systems do not bill so medical student documentation is likewise not a problem.

 

[funkless]

To the OP: That's ridiculous. If I were in your shoes, I'd be bitching like hell to my academic affairs and student council.

You're paying big bucks to learn to practice medicine, and without autonomy and genuine input, you don't learn squat.

Hearing about situations like these make me appreciate my school so much...

 

[MacGyver]

Billing issues require only that the attending have a note thats separate from the med student. It does NOT mean that med students cant leave notes on charts.

Attendings and hospitals hiding behind this "billing" crap are liars.

 

[funkless]

Billing issues require only that the attending have a note thats separate from the med student. It does NOT mean that med students cant leave notes on charts.

Attendings and hospitals hiding behind this "billing" crap are liars.

Exactly. While there are countless nit-picky requirements for reimbursement, none of them involve keeping student notes off the record.

Plus, any resident foolish enough to document a physical exam performed by a medical student (without verifying the findings firsthand) deserves what they get.

 

[subtle1epiphany]

Wow, okay, I'll be the first to admit and emphasize that I know nothing about billing or malpractice and legal issues. I get easily confused about these matters, and it's a good idea that I didn't decide to go to law school. I am just trying to get a perspective on the situation and I greatly greatly appreciate the support, the advice, and the comments!

Just to clarify, I'm a third-year and the rotation is technically listed as a sub-I. I didn't know that it was one when I signed up, just that it was an in-patient service, which I hadn't been on and was desperately trying to get access to so that I could learn and do my sub-Is in my fourth-year. The wires must have gotten crossed and I was enrolled in a sub-I, which my med ed coordinator assured me was okay. It turned out that things were really confusing and I may have been scheduled for an out-patient clinic, or something, I never completely investigated it (although I will be doing so) because the attending I began with assured me they had worked it out and I was in the right place. The trouble above began with a new attending (the service switches attendings each week).

My plan - speak with medical education about my concerns and also voice my concerns to my college, hopefully the wires will be uncrossed and no harm will come of it. I'm thinking that I'll be fine, but this being a "sub-I" is highly unlikely. That's okay, I'm still an MS3, but I was so psyched to get the responsibility and patient management (with oversight) that the events really really frustrated and disappointed me.
That's not to say I'll be giving up, but that I understand that I'm a👎 MS3 and what goes with that.

Thanks again to you all and any other advice is most welcome!

 

[Terpskins99]

I am currently on a sub-I rotation and while the first week went well and the senior resident and attending didn't mind that I wrote progress notes in the patient charts, the current senior and attending ripped all my notes out of the charts.
Evidently it's a "medical-legal issue" for me to write anything in any patient's chart. According to the Chief Medical Staff on the floor, I can't write anything or have anything to do with the charts on this floor.
I am allowed to write things down, but I should keep them for my own edification and learning process (whatever that means). Interns can copy their notes from me, but sign them without my name present (i.e. I do their work for them and get no mention). I have no true responsibility or voice in the management of patients, but I'm welcome to ask why we're doing something so that I may learn.

I'm still a 3rd year, and I'm expected to write in every chart of every patient I see. (Co-signed, of course, by the a resident/attending.) I've never tried to write on the physician order's sheet though.

It has to just be with your hospital (my guess is they had a legal dispute involving a student's note in the past).

I'd just make the most of your situation. Smile, work hard, show interest. 👍

 

[beasleys]

You know what you should do is to write your note under someone else's note so that it can not be ripped out, ha ha. Even if you have to extend your note to the next page just write continued. Then you can write whatever you want I think!

 

[Miami_med]

Um...

I write notes on ALL of my patients on ALL of my rotations, and I would probably be failed if I didn't. These notes are usually cosigned by my intern or resident if they are up to par. If not, they do a correctional addendum and then sign. I do this as a regular MS-3.

 

[Hallm_7]

You should definitely be writing notes. In fact, that's the absolute minimum you should be doing. I'm currently on a peds inpatient rotation and we're expected to write notes on 2-3 patients per day as well as do H&Ps (which is later dictated by the intern) for admissions. My senior also likes me to write inpatient orders, admission orders, discharge orders, and discharge summaries which can later be co-signed by her.

It's not against the law or medicare rules to write in the chart, but your attending may be worried about being sued if something in the medical student note ends up being true and missed by the attending. Med students often think of "zebras" since we're coming out of 2nd year and finished studying for Step I (as a side note I've learned that if you want to know about pathophysiology or pharmacology the 3rd year med student is often the most knowledgeable member of the team), and since we think zebras we often put that in our assessment/plan. Of course it almost never turns out to be that zebra, and it would be considered bad medicine to pursue them early in the hospitalization. However, if the zebra ends up being true and the diagnosis is missed, then lawyers could have a lot of fun saying, "Hey! The med student even picked up on this, why did the attending physician miss it?"

I think that's a poor excuse, however, for not letting students write notes. If the attending didn't want that extra responsibility and liability then they shouldn't have gone into academic medicine. I bet if you were to ask your attending how much responsibility he/she had as a student they would admit they played a role much closer to the role your intern plays than the role you currently play.

This is all part of a larger problem in healthcare (just add it to the list of things) when you let a single large payer (Medicare and the Federal Government) and lawyers (essentially the entire US Congress and all the scum trial lawyers looking to make a buck) run healthcare. In my opinion, we've come to rely on residencies programs to teach medicine, and as a result we're graduating too many MDs who can't proplerly manage patients.

 

[Anka]

As a subI I wrote note on all patients, which had to be addended by my resident (with a certain number of comments for each section for billing purposes) and then the resident addendum was tied in to the attending note for billing purposes. I wrote all orders, which were cosigned by a resident. The plan of care was usually mine, except where what I was doing was really off base (in particular, there were cases where the attending would say "Well, I usually prefer Drug X in this situation, but Drug Y [my suggestion] sounds pretty reasonable so go ahead and try it" or "Well, here's how I usually do it... if you don't feel strongly about it, why don't we do it my way this time so you learn another way of doing it, and then next time we'll do it your way so I can learn how you do it.") I was listed as the primary contact for RNs and consults, but would quickly bump up any time the pt looked unstable. The thing that made me feel most like a doctor on my rotation, though, was that I was the person talking to patients about their prognoses, code status, etc. The attending would then rediscuss that stuff with the patient later (and we'd always talk before and debrief after I had those kind of discussions). Overall, it was a very busy but very rewarding experience.

But, everyone has had the experience you describe to one degree or another -- where you feel very marginalized. Some of the worst feelings you have on clinical rotations are 2/2 that sort of thing. Just try to learn as much as you can, keep trying to get your head in the huddle, and eventually one of two things will happen (1) your rotation will be over and you'll go onto something new and hopefully better; or (2) you'll gain their trust and be able to do more. I'd avoid going to any council or making a formal complaint. At the end of the day, it's hard to argue that you have a right to anything other than them reading over your notes which you did for your own edification. That's the downside of the whole "Medical students are primarily here for their own edification" arguement (as opposed to the older idea of the "academic contract", where the idea is I help my seniors with their work, and they teach me).

Best,
Anka

 

[t33sg1rl]

Geez, I am required to write daily notes on all patients! It's true that the resident has to cosign them... but the residents still have to write their own notes from scratch, because the student notes don't mean anything. (The student notes are clearly marked as such). I also have to write all my patient's orders (which aren't active until the resident signs them) but I don't put in an order ever without talking to the intern first (99% of the time I'm wrong so it'd be a waste of everyone's time anyway).
We also see patients being admitted and are expected to present a plan (again wrong most of the time, but that's what learning is all about I guess).

 

[Acherona]

Do an internal rotation at mcgill if you want a highly unpleasant experience of being thrown into basically the equivalent of internship having only completed, say, your psychiatry rotation. Nobody covers your patients but you, you are expected to write a daily note, sometimes the attending will read and sign them but not always, you write all the orders (you need to get them cosigned but the residents gave us their code so we wouldn't harrass them all the time). If you forget to order that CBC, nobody is going to cover your ass so be prepared to be bitched at at sign out if somebody notices. You do all the admissions for the night (usually 1-3) and write up the impression/plan. The senior resident scrutinizes it, pimps you, and then writes an addendum saying either she agrees with the I/P, or rewrites most of it in which case you know you f-ed up and will likely be told you suck at a later date. Your admission note is the most important document in the chart which all consult teams etc will read thereafter so make it good. Basically the only differnece between you and the intern is that you have fewer patients (usually around four), but have to write more complete notes, and you get bitched at waaay more because obviously you make more mistakes as you have zero experience. So be thankful people. I'm hoping to have *less* responsibility on my away sub-I.

 

[beasleys]

But usually at places such as that nobody will actually know if you messed up, yes? If a place is so strange as to make the student into the doctor then probably nobody knows what they are doing including the residents, ha ha. Even when they correct you I believe that they often are wrong, correct? So that is what I think.

 

[Acherona]

But usually at places such as that nobody will actually know if you messed up, yes? If a place is so strange as to make the student into the doctor then probably nobody knows what they are doing including the residents, ha ha. Even when they correct you I believe that they often are wrong, correct? So that is what I think.

uhhh no. Are you a pre-med? The attendings and residents are highly competent and have very high standards for everyone. They know exactly what is going on and what should be done and they are watching to see if you know what to do. The senior residents know their **** and will swoop down if the med student is floundering.

 

[beasleys]

If that is so then why do they do it that way? Are they just lazy?

 

[Acherona]

If that is so then why do they do it that way? Are they just lazy?

omg no. the residents have more than enough to keep them busy. this is simply how the system works here the rationale being that it gives students good clinical experience while providing free labor. I would guess that at schools where the intern oversees the med students the interns are the ones that end up with more work and stress.

btw it is of course the patients that suffer in this sort of system, but that's what you get with socialized healthcare. the school doesn't seem to be too concerned about the collateral as litigation is not as much an issue.

 

[beasleys]

But the intern is still graduated from medical school while the students are not. It seems, as you say, unfair to place such a burden on them. But that is my thought only.

 

[hyperbaric]

I'm writing notes on all of my patients on all rotations to date. Although, few sites have required us to put 'scribed for Dr Attending' at the end of the note. The reason given was "for billing purposes".

 

[Richie Truxillo]

Same here. I have written H&Ps and progress notes on all of my rotations (including medicine and surg sub-I's). Of course all notes are countersigned and reviewed by my attendings, however I think it is important that you are allowed to write notes. It hones your history-taking and physical exam skills while forcing you to make decisions and documenting them correctly.

I had no idea that there was a billing issue though. I'll ask my attending tomorrow about it and see that they say. 🙂