Editor’s Note: In this second of a two-part series on difficult learning situations, John Langlois, MD, and Sarah Thach, MPH, of the Mountain Area Health Education Center (MAHEC) Division of Family Medicine in Asheville, NC, provide us with information and tips on managing difficult learning situations. The content of the column is based on materials developed as a part of the Preceptor Development Program (PDP), a comprehensive program of preceptor development materials supported by a Health Resources and Services Administration Family Medicine Training Grant (1D15PE50119-01). Detailed information on this project can be obtained from the PDP Web site at www.mtn.ncahec.org/pdp.

I welcome your comments about this feature, which is also published on the STFM Web site at www.stfm.org. I also encourage all predoctoral directors to make copies of this feature and distribute it to their preceptors (with the appropriate Family Medicine citation). Send your submissions to Paul Paulman, MD, University of Nebraska Medical Center, Department of Family Medicine, 983075 Nebraska Medical Center, Omaha, NE 68198-3075. 402-559-6818. Fax: 402-559-6501. E-mail: ppaulman@unmc.edu. Submissions should be no longer than 3–4 double-spaced pages. References can be used but are not required. Count each table or figure as one page of text.

Medical Students and Health Care Financing Administration Documentation Guidelines

Kathryn G. Chappelle, MA; Shawn H. Blanchard, MD; Miguel F. Ramirez-Williams, MN, RN, FNP; Scott A. Fields, MD

(Fam Med 2000;32(8):459-61.)

Teaching Medical Students in Compliance With HCFA Documentation Guidelines
Over the past decade, community physicians have come to play an increasingly essential role in medical student education. Since the advent of nationwide curriculum reform in the late 1980s, more and more medical schools are placing students with preceptors in outpatient settings as early as their first term of medical school. Working with a preceptor enables medical students to 1) integrate knowledge learned in the classroom with real-life applications, 2) keep sight of the ultimate goal of practicing medicine without getting lost in the minutiae of study and test taking, 3) begin practicing communication and psychosocial skills with patients, 4) be better prepared to make informed decisions about their choice of specialty, 5) form supportive relationships with community physicians seen as role models and mentors, and 6) become familiar with medical practice operations and structures, such as interdisciplinary care, coordination of care and referrals, and managed care influences.

The increasing need to train primary care physicians and the need for expanded ambulatory experiences makes it obvious that community preceptors, particularly family physicians, who offer students a broad exposure to patient care, make a vital contribution to the training of future physicians.

It is ironic that at the same time that community physicians are becoming indispensable to medical education, they are faced with increasing pressures in their practices that may threaten their willingness to teach. Time constraints, prescription formularies, referral processes, multiple expectations of third-party payers, increasing reliance on computer technology, and managed care guidelines are just a few of the challenges faced by physicians today as intrinsic elements of patient care. Time is at a premium. It may take extra time to work with a medical student in your office, although a 1996 study noted that there was no loss in practice productivity due to the teaching of medical students.1

A Common Teaching Method May Put Physicians at Risk for HCFA Violations
A common teaching method used by clinical preceptors has been to have students write or dictate notes to be included in patient charts. This practice gives students the opportunity to learn how to properly record patient information while offsetting the time that preceptors spend teaching with a reduction in the time they spend on paperwork.

Student notes are usually more than thorough, making it unnecessary for teaching physicians to do more than to make a few additions or corrections, then “sign off” on what students have written. Some physicians included a formal statement that they had performed significant portions of the exam or that they agreed with the accuracy of the student note, but in the past, no purpose would have been served by duplicating student efforts.

Documentation of this kind was adequate when the primary purpose of charting was simply to ensure proper medical care for patients. However, relying on medical students to document patient visits may cause physicians serious problems now that medical records are also being used to “prove,” for billing purposes, not only that medical services were provided but that they were provided by the physician. And, while Health Care Financing Administration (HCFA) documentation guidelines may seem to apply only to visits with Medicare patients, this may or may not be the case in the event of a governmental review of practice records. It is possible that other records, particularly those of Medicaid patients in some states, may also be subject to scrutiny. For this reason, and in the interest of consistency, follow the same documentation guidelines for all patients, including those seen with medical students.

Ensure HCFA Compliance While Continuing to Teach Students Documentation Skills
The key issue is to what extent, if any, students may assist physicians with documentation. HCFA maintains that documentation by anyone other than the physician is not sufficient evidence that the physician actually provided the services for which a patient was billed. Therefore, physicians must personally document all key aspects of each patient visit as specified by HCFA guidelines, regardless of whether a medical student has already recorded that same information. According to 1998 instructions circulated by the Association of American Medical Colleges (AAMC), HCFA guidelines do allow medical students to document certain limited portions of a patient visit, but following these guidelines is more complex than warranted for the benefits involved. We realize that this may be frustrating news for some community preceptors, but it is still possible to continue working with medical students in your practice without risk of HCFA violation and without a significant amount of extra effort. Our recommendation? The most certain way to avoid confusion and concerns connected to medical student documentation is to simply not include medical student notes or dictations as part of your patient records. While documentation by medical students has traditionally been a source of some assistance to the teaching physician, we recommend in its stead that preceptors expand potential student responsibilities so that they may assist physicians in other areas of clinical practice.

Addressing HCFA Documentation Guidelines Through “Value-added” Experiences for Medical Students
Physicians probably run little risk of HCFA violation by including medical student dictations or notes along with their own as long as they are sure to personally document or redocument all key information according to HCFA guidelines. However, it is not cost-effective for practices to have both students and physicians dictating notes on the same patients. Nor do handwritten student notes, which are essentially duplicated by physician notes, provide a significant benefit to patient charts.

Not using student notes in patient charts is an adjustment that need not have a large impact on preceptors’ teaching time or effort. If you are currently working with a medical student, we encourage you to consider alternative ways, such as the 12 suggestions that follow, to make teaching a “value-added” activity in your practice. Students can save time for you and contribute in many ways other than documenting patient visits.

Although some preceptors are hesitant to involve students in projects or tasks that aren’t directly related to seeing patients, students will ultimately benefit from learning about any aspect of clinical practice.

Twelve “Value-added” Suggestions for Working With Medical Students in Your Practice

1. Students can prepare high-quality patient educational materials on issues common to your practice (smoking, nutrition, weight loss, hypertension, etc).

2. Students can research and communicate with community resources for a specific patient’s needs.

3. Students can research and compile lists of community resources for general use in your practice.

4. Students can talk at length with patients you’ve been “meaning to talk to” when you have time. Your patients will benefit from the extra attention while students practice educational and motivational interviewing skills on a variety of health-related topics (smoking, nutrition, weight loss, hypertension, etc).

5. Students (depending on their level of expertise) can accomplish a great deal on their own with patients, if you establish a time-efficient routine that takes advantage of what they have learned before you enter the exam room.

6. Students can take responsibility for gathering all ancillary information for each patient visit (test results, X rays, etc) so everything is at hand when you enter the patient’s room.

7. Students can assist with phone communications with different facets of your health care team, (eg, set-up referrals, access community resources, coordinate physical therapy visits, etc).

8. Students can perform literature searches when you need information on specific patient issues. (Students are becoming more and more astute with MEDLINE and other databases.)

9. Students can perform chart or database reviews if your practice is in need of tracking particular patient information. They might even suggest ways you might better track the data in which you are interested.

10. Students can make follow-up phone calls to patients concerning treatment plans, lab results, etc.

11. Students can conduct phone surveys of patients to address quality assurance issues, such as, “Have all your elderly patients gotten a flu shot?”

12. Students can conduct medication reviews with patients who take several different prescription drugs.

As you can see, there are many ways, other than documenting patient visits, that students can make valuable contributions to your practice. We feel it is important to acknowledge the current pressures and frustration that physicians must cope with daily in their practices. Not only do these problems affect preceptors’ willingness to take on the time-consuming, albeit satisfying, task of working with medical students in their practices, but they may also affect the quality of their teaching when they do work with students. A physician who is frustrated with the perceived restraints and drawbacks of modern medical practice is not able to convey the encouraging attitude toward patient care and community involvement important to students just entering the profession.

For the most part, however, teaching keeps physicians excited about the practice of medicine and less focused on the day-to-day frustrations. While documentation by medical students has traditionally been a source of some assistance to the teaching physician, we recommend instead that preceptors expand potential student responsibilities so they may assist physicians in other areas of clinical practice.

HCFA documentation worries should not keep physicians who are enthusiastic about teaching from continuing to work with students: we cannot allow narrow interpretations of governmental guidelines to erode the educational environment for our learners. We encourage community physicians to work through their local and national organizations toward more favorable interpretations or amendment of these guidelines while continuing to do what they do so well: providing medical students with invaluable clinical experiences.

Acknowledgments: The Health Care Financing Administration is the federal agency that oversees payments for services for patients covered under Medicare. This material for this article is exerpted from material previously published in Family Practice Management. Reprinted with permission from the May 2000 issue of Family Practice Management. Copyright American Academy of Family Physicians. All rights reserved.

Corresponding Author: Address correspondence to Ms Chappelle, Oregon Health Sciences University, Department of Family Medicine, 3181 SW Sam Jackson Road, Portland, OR 97201. 503-494-6948. Fax: 503-494-4496. E-mail: chappell@ohsu.edu.

Reference
1. Vinson DC, Paden C, Devera-Sales A. Impact of medical student teaching on family physicians’ use of time. J Fam Pract 1996;42: 243-9.