Medical Student Notes - A Defense

3-11-14 - 'We can say that Muad'Dib learned rapidly because his first training was in how to learn. And the first lesson of all was the basic trust that he could learn.' - Dune

Medical Student Notes - A Defense

'Alright, head out after you finish your notes'
- A ritual blessing and curse from senior residents since time immemorial 

Medical students do not like writing notes. Medical students (not surprisingly) also have a lot of opinions about writing notes. I disagree. I believe that writing notes can be instructive and helpful, provided that it is done mindfully and with purpose. I'll address this using three common complaints of the practice.

'I'll have to write so many as an intern, why should I have to now?'

In recent years, there has been a new found emphasis on not only understanding the pathology, diagnosis, and treatment of diseases, but of the care of the patient as an individual. This came from a recognition that after training, many physicians had poor interpersonal skills leading to decreased patient compliance and satisfaction. As a result, medical schools adjusted their curricula to include professionalism, diversity, and empathy training. The idea was to practice these important skill while in training, so they became second nature and embedded in the day to day practice of our physicians.

I think note writing is in a similar position. As interns and residents, our documentation is part of a patient's medical record, which can function as a legal document. Therefore, accurate, professional documentation is of paramount importance. Combine this with most interns following 10-15 patients on general medicine services with relatively high turnover, and it can become a set up for errors, inaccurate documentation, and copy-pasting. 

Writing notes regularly and with a focus on accuracy and efficiency as a medical student can help alleviate this problem. Similar to the focus on professionalism and empathy, making note writing and documentation a habit can only serve us in the long term. From a more practical view, the attendings and seniors you work with as an intern will recognize this as a sign of independence and reliability, and may trust you with more advanced work.

tl;dr: We're going to be writing notes for the rest of our professional lives, so practice and get feedback as a medical student when you have time and the notes don't matter to patient care.

'It has no educational value!'

One of 2nd year professors in our 'Clinical Assessment and Problem Solving' course told us something that has stuck with me since, and I try to keep it in mind. She told us to take every experience we have in medical school as a learning opportunity. This attitude is so powerful, and I wish I took it to heart everyday. 

Note writing is like this. From the outside, it can seem repetitive and essentially busy work. However, if we go into it with the intention to learn something, it can become a powerful tool to learn with. 

HPI: The HPI allows you take all the information gleaned from the interview trim it into a narrative. This helps in practicing creating a narrative that communicates key information in an easy to understand manner. As you improve in this, your ability to communicate verbally will improve as well as you realize what information is pertinent and what isn't. 

Assessment: The assessment section allows you to clearly organize and prioritize problems as well as create differential diagnoses. Even if you know a patient has a given diagnosis, writing out a short differential with a little reasoning will help you keep the differentials fresh and aware of what to look for if the diagnosis is not so clear cut. Prioritizing is also key, as it helps to triage patients and which problems a patient has to keep the closest eye on.

Plan: Much of being an intern is being able to manage most problems in a standardized manner. As students, you generally do not put in orders. Note writing is the only place we get to have practice formulating formal plans of care, and really taking our knowledge and applying it to the care of a real patient. In addition, it gives you a chance to take standardized orders, such as post-MI pharmacologic interventions (aspirin, beta blocker, statin, etc) and learn the reasoning for each of these. It gives you a chance to ask yourself, 'why are we starting X drug?' and to research it.

Progress Notes: More than H&Ps, inpatient progress notes seem like busy work. For many services, after a patient is stabilized, it is a waiting game until a drug level is achieved, or a lab value normalizes, then the patient can be discharged. Not much changes with the assessment or plan. Despite this, progress notes provide an opportunity to reassess the patient's condition, and most importantly, learn and document how a patient should respond to appropriate medical care.

tl;dr: Notes are an opportunity to delve into patient care as well as organize data and create learning opportunities. 

'No one will read it anyways!'

This is the weakest argument. Medical training is designed to transition you from a student to an independent practitioner. The attitude that you need to be constantly supervised is therefore counterproductive. In the end, you're only responsible to yourself and your patients. Beyond just learning the best, most efficient way to write notes, I firmly believe the practice of forcing yourself to keep up with your notes will encourage you to become more independent.

We need to change our attitude from doing things to impress our supervisors to doing them to ensure we become competent, caring, efficient physicians. There won't always be supervisors to impress, but the patients will always be there.