Several years ago, a collaboration between various medical societies and the Centers for Medicare and Medicaid (CMS) resulted in a game changer in our outpatient world. Suddenly, students were permitted to help document patient encounters. There have been a lot of positive outcomes because of this change, and students now feel better equipped to write office notes. But there have been some negative consequences as well.
Sometimes, there is inordinate attention placed upon note writing to the detriment of the learning experience. What happens is that students start a rotation and are anxious about note-writing. I find it helpful to tell new students that I want to start their rotations by making sure they can obtain a thorough history and carry out an accurate physical exam as well as present in a clear and succinct manner. These sorts of assessments can take several hours or even days to carry out, and I don’t ask the students to begin note-writing until I am certain that they can accomplish these important tasks.
When students do begin note writing, I try to set realistic expectations and ask them to only work on one or two notes per half-day session. This allows them some time to adjust to this new activity and it gives me time to provide feedback on their note-writing efforts. I try to make sure that we carve out time at the end of sessions to talk about our patient assessments so that the students know what ought to be included in the notes.
It’s important to read the student notes carefully. That might sound trite, but it can be easy to gloss over the written notes and not pay much attention. But on occasion, even my very top students sometimes write down things that are erroneous. Also, I try to record some comments as an addendum to the end of all student notes, so that readers are aware that I have carefully reviewed what was written down.
I experiment with different ways that I provide feedback about student notes. In the beginning, I ask them to complete their first notes before seeing other patients, and I review those notes with them in real-time. Later, I review the notes at the end of the sessions, and I ask students to come early to some subsequent sessions so that we have time to review their notes in more detail.
I have found that working with students and note writing has forced me to be more flexible. I usually like to get all my notes done before I go home, or while eating lunch, and with students, that just is not happening most of the time. So, I often tell myself to “take a chill pill” and not fret too much if I must wait a little while for all notes to be completed.
The skill set of note writing is hugely valuable to students, and I think specific, granular feedback about their efforts is critically important to their professional development and maturation. But please remember that note writing is not the main reason that students come work in our offices. They are not scribes. At most, they should help compose 2-4 notes per half day session. If they are forced to work on more than that number, they are unable to learn about all the other important aspects of clinical medicine that we are trying to share with them.