When I was in medical school, and even throughout my residency program, medical records were totally on paper. Patient charts lived in three-ring binders that whirled about on large carousels in the nursing station. Some of those charts were literally overflowing with sheets of paper and sticky notes. Order sets were all on paper. Physician and nursing notes were hand written. About the only section of the chart that was actually printed on a machine came from the lab. That’s what we had in those days. That is how I was trained, and somehow it all worked. I ordered tests, wrote up histories and physicals, and scribbled progress notes with my terrible hand writing for each of my patients during daily rounds. As a physician in training my orders and notes had to be co-signed by my instructors or the patient’s attending physician, but everything I did and everything I wrote became part of the “official” patient record.
So imagine my horror when I read the other day an excellent article, Are med schools failing future docs?, written by Mike Miliard in Healthcare IT News. According to the article, just 64 percent of med schools currently allow physicians in training to use electronic medical records. And of those that do, only two-thirds are allowing students to actually write notes in the electronic record. While that statistic is based on a two year old study from the Alliance for Clinical Education, I still find it alarming.
Today’s medical students and residents are digital natives. Few aspects of their lives can be conducted without a smartphone or tablet within reach. Yet, we are teaching them to become physicians using paper and pen! How can that be? I guess I’m not totally surprised. As the article points out, most med school structure and curriculum is based on work originally developed by Abraham Flexner in 1910. It’s a model that medical schools have been following ever since.
I don’t spend much time in medical schools now. The last time I visited my own school was probably 5 years ago. At the time, I remember thinking that things hadn’t changed all that much since I was in training. Yes, I saw computers being used in the lecture halls and some students were carrying around laptops, but I suspect it was business as usual in many of the community clinics and hospitals where the students were doing their clinical rotations.
My point isn’t to throw stones at medical education. I understand why, especially in the academic environment, that change is often ploddingly slow. Mr. Miliard’s article does report on some of the remedies being applied by the AMA and other organizations to fix medical education, and address the gaps in the use of IT. But I have to wonder if we are preparing new doctors for the realities of the world in which they will soon be practicing? Are we taking people who are perhaps the most computer literate among us, and forcing them to use tools that are no longer relevant in either education or medicine?
Read Mr. Miliard’s article and weep. Imagine how frustrating it must be for today’s clinicians in training to be told more or less, “You can look at the computer but don’t touch it.” Maybe we’re afraid this new generation of docs and nurses might actually be able to teach us something, instead of the other way around. Medical education is due for a shake-up. Turning out clones of “clinicians of yesteryear” simply must come to an end. Otherwise I fear only the uninspired will seek out careers in medicine. I mean, come on….. even the doctors and nurses on television’s Grey’s Anatomy are using Surface tablets these days.
Bill Crounse, MD Senior Director, Worldwide Health Microsoft
There are a lot of changes in medicine and medical education. Unfortunately, medical educators and academic clinicians have little control over most of them and medical students have even less. Many "rules" have good intentions but the unintended consequences are widespread and often outweigh advantages.
Students aren't allowed to use computers in clinical settings for a few key reasons:
1. Graduate and undergraduate medical education regulations have made it harder for students and residents to act independently in clinical settings. Notes and orders in the computer are the tip of the iceberg.
2. Physician billing changes require attending physicians to do more of the documentation. Reviewing, commenting and co-signing a med student note does not suffice for billing or CMS/Joint commission requirements for a daily hospital note. If a student writes a note, the resident or attending still has to write a separate note AND review the student note carefully if it's in the chart.
3. When several notes in the chart describe the same events, subtle differences in wording can become a medicolegal nightmare. Student notes may include incorrect conclusions and need careful review. In the olden days, a student could write multiple drafts on paper and put the final note in the chart. Now, if the student writes a note in the computer and signs it for attending review, the errors are locked into the system. Commenting/editing by an attending is VERY cumbersome due to horrible functionality of EHR systems. This increases risk to patients (when bad info creeps into the record) and increases perceived medicolegal risk for attendings.
There are other impediments to student use of clinical computing but if these were fixed, academic faculty would be delighted for students to move into the electronic era.