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Residents have a lot to deal with.

Traditional residency work hours are being questioned.

Unions are forming.

And most recently, NEJM released a podcast titled “Tough Love” that spoke against wellness days and has received considerable blowback - seemingly increasing the divide between educators and trainees.

Notes are the last thing they should have to worry about.

But notes are a problem.

And this problem is not setting residents up for success after graduation.

They face four unique challenges:

1. Unclear expectations

2. Perfectionism

3. Lack of efficiency skills

4. Lack of formal education (by an expert who understands their future productivity pressures while also understanding professional & hospital billing) and therefore copy bad habits from everyone else.

Problem #1: Unclear expectations

“Can you review my note?”

It’s a common question by medical students and residents. But what are they really wanting reviewed? And what is the reviewer reviewing for?

I bet neither knows.

The default expectation? Notes should be a perfect surrogate of their clinical reasoning with every single differential and consideration written out. That expectation is exacerbated by problems #2 and #3.

Problem #2: Perfectionism

Is perfectionism a trait that helps people get into med school? Or is it one that’s created through schooling and training? Maybe a bit of both.

Regardless, it’s one many of us struggle with.

Unfortunately, it can become a toxic trait that can not only lead to anxiety, but for these purposes also an extreme amount of time spent on the “visual” aspects of our medical training.

Will their upper level or attending see them much at the bedside? Probably not.
Can their upper level or attending easily access their note and pass judgement on them? Absolutely. Therefore, that’s where they spend their time - and make it perfect. (<10% of time with patients & >50% with the computer)

Which leads to problem #3.

Problem #3: Lack of efficiency

In residency, efficiency is seen as a dirty word - one the business world of productivity is concerned with.

But efficiency is not a dirty word. There’s a difference between rushing something and decreasing its quality versus removing wasted time (and wasted wordiness) to improve quality. That is efficiency and one we should embrace. The lack of embracing efficiency sets residents up for failure post-graduation.

Problem #4: Lack of formal training

Most whom I talk to say they received either zero formal training or received brief intermittent talks by various professors. Those talks are almost always based around billing guidelines (but notes are much more than billing). Finally, academic attendings who have spent their entire careers in academics may not fully understand the productivity and efficiency pressures their trainees will face (pressures that are growing each year in conjunction with increasingly complex patients).

(Shout out to those academic attendings who subscribe to my newsletter and have given me feedback on how my emails help them teach their residents.)

Therefore, residents copy what everyone else is doing - templated physical exams, auto populated junk, A&P’s loaded with non-prioritized problem lists, copy/paste errors, and difficult-to-find plans in a wall of text.

All not good stuff.

Not good stuff that will only be exacerbated by productivity pressures of the real world.

This lack of formal training is a huge oversight as, after direct patient care and medical knowledge, notes are the biggest factor that will either positively or negatively impact their time, legal risk, patient outcomes, and often their income.

Some say, “Not everything needs to be spoon fed,” and they can learn documentation and billing on the job.

Sure. That’s largely been the default.

And it’s gotten us into the mess we’re in.

There are too many nuances to leave this up to individuals training themselves. Our current documentation practices are leading to burnout, wasted time, and medical errors.

How to combat these challenges?

#1. Set clear expectations

• Academic attendings: do you have a strong expectation for notes? If you expect their notes to detail their clinical reasoning, then make that clear. If not, then make that clear so the student can use their notes as they see fit.

• Also, ask the student. Some may prefer their notes to be used to assess their clinical reasoning because they do their best thinking when writing notes (and performance anxiety during rounds is a real thing). If they prefer that their clinical knowledge and reasoning be assessed in other ways, then allow them that freedom in their notes.

#2. Once expectations are set, assess notes by asking the following questions.

• How long did it take to write?

• Does it include copy / paste errors?

  • Have terms like yesterday, today, and tomorrow been copy forwarded?

  • Are POD#’s accurate?

  • Are medication and lab changes accurate and consistent? (Example: is eliquis stated as being held in one part of the note but continued in another?)

• Is the plan (or recommendations) easy to find?

• Does it include non-standard acronyms that those outside of their specialty can understand? (I’m looking at you ortho and optho.)

• Does it include phrases copy forwarded from previous days? If so, why? Some are helpful to avoid the invisible error of omission. Many are superfluous.

• Have full reports been copy/pasted into the A&P? Or have they extracted only the pertinent parts?

• Are labs and radiology reports auto-populated? If so, why? Some students include these for the sake of having that information available for presentations/rounds which I understand (but they should drop that practice after residency).

• Is the physical exam accurate? Did it use a pre-filled or one-click template? Did they do all of the things claimed were performed?

This is not another checklist for trainees to perfect or be anxious about. It’s a checklist to help them be more efficient by SIMPLIFYING their notes by removing copy/forward errors and unnecessary duplication (aka note bloat aka over documentation). This ultimately helps them think and stay organized, prevent medical errors, and write readable notes.

#3. Prioritize progress over perfection.

• If they’ve made some mistakes, let them know it’s okay. You did not expect perfection. Clearly state you will perform another review later and you hope to see some improvement. Practice makes progress, not perfection.

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

When you’re ready, there are two ways I can help you:

Check out The Resident Guide to Clinical Documentation. The course that helps you:

• Cut note-writing time by >50%

• Prevent medical errors and lawsuits by using notes to stay organized

• Have the confidence to write shorter yet more effective notes.

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