Sunday, December 4, 2011

Tabby cat

A friend of mine named Jane works as an attending supervising residents in a clinic. After the residents see the patients with Jane (or whatever attending is supervising), Jane signs off on the resident note and returns the chart to them.

One resident apparently thought that the attendings were not reading their notes. So he devised a note about a patient named Tabby. Tabby was a cat whose chief complaint was a hairball.

One day in clinic, this resident handed his note about Tabby the Cat to Jane, who signed the note. The resident then circulated the fake note to all his resident buddies as proof that he was right.

Of course, the note got back to Jane's supervisor and she got a note in her file.

Honestly, I'm sympathetic to Jane. Sure, she didn't read the resident's note. But who suspects that after the resident presents the patient to you that they're going to write something so entirely different? How many attendings truly read resident notes that carefully?


  1. In my first month of residency I was writing really long, detailed, complicated notes about patients every morning and at some time during the day an attending would come around and sign them. I suspected no one was reading these things because I had no idea how to manage vascular surgery patients, so I was essentially writing "consider D/C" and stuff like that in the "plan" part and no one was correcting me.

    I was rounding with an attending once and he stopped, saw my note, and signed it without reading it. I called him on it, he said "fine, I'll read it," and then proceeded to read it out loud.

    Me: Hurry up, I'm hungry
    Him: I'm not done reading this note yet!
    Me: I get it. Point taken. Let's move on.

    After that I understood why no one was reading these things and subsequently wrote shorter notes, which I'm sure no one was reading either.

  2. Nope, not sympathetic at all. Residents are, in the end, still in training, and the reason their charts need to be checked by an attending is to avoid mistakes that could, you know, harm the patient. Now if Jane didn't notice the note was about Tabby the Cat, how would she notice if the note were actually about John the Patient, but an important finding were omitted or a wrong medication prescribed? She wouldn't. Because she didn't read the note. Because she didn't do her job. Sure, the resident was sneaky. So what? Jane was plain old lazy. And speaking in the long term, the resident may have very well saved her a pile of lawsuits by reminding her that YES, she DOES have to supervise her trainees or else she will have to take responsibility for the mistakes they made and she missed which ended up harming the patient.

  3. As someone who has done a lot of resident/med student supervision, I've come to realize that there is never enough time to review everything that the people under you are doing. (At least not with how the system is currently set up at my institution). If I had to read all 35 patient notes every day while I was ward senior, I would be leaving at 8 PM instead of 7 PM every day and cutting further into my already almost non-existent study time. You have to trust that the people under you are doing a lot of things right, and I choose to focus my time on those things that are most important to patient care (orders, notes on new patients, etc.). It sounds kind of funny for a trainee to write a note about a cat with a hairball to prove a point, but I think it's more an abuse of the trust that supervisors put in their trainees.

  4. Snarky: But wouldn't a medication mistake be caught by looking at the orders rather than an extensive note?

    Jess and Solitary: I'm with you... I think reading these notes is generally a waste of time and that resident betrayed her trust and probably made things harder for everyone. After this happened, Jane said, "From now on, I'm going to make the residents wait for me to read their notes and they're going to hate it."

  5. Fizzy: and an H&P mistake by looking at the note, still. And really... she did not notice the note was about a CAT and her hairball. There is no way in hell I'll EVER believe that Jane reviews orders with due care and diligence, if her note-reading doesn't even include reading the chief complaint.

    And if you think reading the notes is such a waste of time, why don't you go ask your residents how they feel about writing said notes, especially if gets proven to them in such a ridiculous way that they are of no consequence whatsoever.

    Solitary: what about the abuse of the trust trainees put in their supervisors? I'm sorry, but I have this aversion to harming patients. Either I can trust my attending to pay enough attention to the patients and their charts to catch my mistakes by rounds the next day at the latest, or I will nor write a single order without calling the attending first. I seriously doubt it'd be all that time-saving if I decided to do that to protect patients from my junior-ness. And again, I do not accept the idea that Jane reliably catches mistakes everywhere else. Not if she doesn't even read the name and CC of a patient.

    And if reading said useless and time-wasting notes cuts into your study time, don't you think it also cuts into the junior's study time to write them? You know, given that writing takes longer than reading? If they're so unimportant that you all agree they don't need to be read, not even their first sentence, why the hell are they written in the first place then?

  6. The notes are important not to people who are currently seeing the patient, but to people who may review the chart in the future to find out what's going on with the patient. I generally skim my resident's notes, but since I already know everything going on with the patient, I don't feel the need to basically act as a proofreader. (Plus I write my own brief notes.)

  7. Snarky - I'm still going to respectfully disagree. In taking on trainees I'm not agreeing to review every single thing they do with a fine-tooth comb, but rather to review the aspects of their performance that I feel are most important to their development as a physician and to their care of patients. If I wanted to ensure 100% that everything my trainees did was perfect and didn't harm patients, I would need to repeat every physical exam and review of patient data that they did - something that isn't feasible when I have 30-35 patients and 4-5 trainees under my care. As I said before, I have to prioritize my time and focus on the sickest patients, the weakest trainees, and those aspects of patient care that I believe have the biggest impact. On other things, I need to trust that my trainees are doing what they tell me they are.

    With respect to the utility of reading patient notes, what I think is useless is making it mandatory for a supervisor to read every single note on a daily basis. If a patient is medically stable and awaiting disposition planning, it doesn't do me or the patient any good to be reading the same note to that effect every day. I think it's still absolutely essential for trainees to be writing those notes on a daily basis though, for a number of reasons. 1) They're the primary person involved in care, and therefore it's their responsibility to communicate to the rest of the team what's going on medically with the patient. 2) Note writing is a skill that takes significant practice to perfect. Learning how to efficiently write notes both on complex patients with multiple issues and stable patients who are awaiting discharge is part of the whole learning process. 3) Other members of the team (nurses, PTs, OTs, dietary, etc.) rely on those patient notes to know what's going on with the patient. Even if I don't pick up on a note about a cat with a fur ball, one of them will. 4) When a patient's status changes, I will often go back and review the daily notes to find out what's happening. If a trainee hasn't written the notes because they view it as a waste of time, then I'm impaired in my ability to figure out what has happened with the patient.

  8. This reminds me of something I did in high school ... we had to do these mini essays in physics every couple weeks about a topic of our choosing, but everyone would always get 100% on them, so we suspected our physics teacher did not actually read them. So when I wrote one of my essays on wormholes, I added a paragraph on earthworms in the middle. Still got 100%! I don't think the resident should have circulated it around ... he must have known he would get Jane in a lot of trouble. Would have been better to talk to her privately first.

  9. Silverwhale: Actually, same here. In high school, we had a history teacher who never looked at homeworks, so people would hand in, like, their Spanish homework and still get a check. One day she decided to actually read them all and got really pissed off.

    I think the resident mostly thought it was funny and wanted to prove a point. I doubt he really wanted to get Jane in big trouble because she's really nice and actually got a lot of "attending of the year" type awards because she was a good teacher. She really didn't deserve that.

  10. Now we're getting somewhere... so the notes have a utility after all. Someone, some day will rely on them, so I guess we all agree they have to be correct after all. I agree that it's busybusybusy to be reading all of them, daily, into infinity. But guys. We all agree that notes might be useful to someone some day and should be correct, and yet she did not even read the very first sentence of a note in clinic, where she has not seen the very same patient in the very same shape for the last week or two. How the hell is the resident supposed to communicate the patient to her in a written form, as Solitary rightly says, if she didn't read the bloody first sentence? Busy or not, she was in the wrong here, the resident just had a very harsh way of pointing it out. Though I agree it would have probably been better if he had her actually read it as soon as she signed it, the point would have stuck just as well.

    Alternatively, if you all agree that residents are/should be capable of writing proper and useful notes all on their very little own (and we are), what's the point of 'reading' and signing them? Legal? I don't think you are legally all that well served if you sign it and therefore take responsibility for it, without knowing what's in there. Educational? I don't think we're all that educationally well served if someone accepts a note by signing it, and doesn't notice that it's pure and utter crap that should be corrected. Other services read it? Really? What if there's subtle mistakes in there, but because it was signed by the attending, it must be right, so they go along with it? Bottom line is... if you're going to sign it, know what's in there. If you don't, you personally and the resident and the patient are way better off, if you don't pretend to have read it and sign it off as acceptable.

  11. Now I wonder what happened to the resident....

  12. An attending is more like a boss than a teacher, and NO boss worth his/her salt checks every single bit of work that his/her employees perform. That would be micromanagement, and completely counterproductive. I do think they should look at notes from time to time, in order to be able to provide feedback, but it's really not helpful to anyone to have someone picking every note you write apart every day. It's a total waste of time, and not especially helpful to anyone.

    Plus, at my hospital nursing and pharmacy staff follow orders that are input in a separate system from the chart. That's where errors happen, and where they (should) get caught.

  13. And this is how dogs get credit cards. :-)

  14. Not to start a fight or anything, but then why should a physican "supervise" the work of an NP then?

  15. I'm going to agree with Snarky on this one. I'm not in med school yet, but I work in a teaching hospital and some of the stuff the residents try to pull when the attendings aren't around is really surprising. I don't think that you need to review every single thing, but that trainees should be monitored more closely than what seems to happen at my institution, which I've heard from some residents is better at it than a lot of places. Including reviewing their notes. I'd like to think that people generally have good intentions but when residents know they aren't really being monitored quite a few start to take the easy way out or blow stuff off.

    From the patient side of things I found out after getting a copy of my records that Dr. very shy and anxious was documenting exams he hadn't done and questions he hadn't asked. He was polite and everyone liked him and trusted him, but apparently he was very afraid of looking bad so if he was questioned about asking the patient "do you have x or y" and he hadn't done it, he just said he had and made up an answer he thought would fit. Symptoms that other docs down the road said should have been followed up on weren't because he just told the attending things were going well. A colleague of mine told the desk she was leaving after waiting in the exam room for an hour after being in the waiting room for an hour as well. She got billed and figured it was because she didn't cancel 24 hrs in advance, but then when she saw her records her resident had documented an entire phony visit and physical exam rather than admit the patient got angry having to wait so long and left without being seen.

    These aren't all examples of things that could have been caught be reviewing notes, but do demonstrate that sometimes the level of trust is higher than it should be. The unintentional mistakes will be more common and the attendings might be the only one's in a position to catch these thing and prevent harm to the patient.

  16. I have twenty to thirty teaching patients to round on daily, there's no chance that I can oversee pre-rounding, residents' daily physical exams, lab results, follow-up from social services and so forth (not to say that I don't examine every patient daily).

    Once I establish a rapport with my residents, I know that I can trust them to provide me with truthful and accurate information and to convey that information in their notes. Conversely, they can trust that when I am teaching or lecturing etc, that I'm giving them truthful and accurate information.

    On rounds, when a resident says, "Mr. Smith is a 76 year old male with colon cancer post-op day three from hemicolectomy with persistent ventilator dependent respiratory failure," I trust the resident to write that in Mr. Smith's note...not Tabby is my foo foo kitty cat who eats cat food. Because honestly, WHY WOULD HE WRITE THAT, HE'S A DOCTOR FOR GOD'S SAKE! And I trust that his note will also have a plan which is reflective of what we decided on rounds. There is no reason that a resident should document or order the wrong medication if during rounds, we decide on cipro and flagyl. Once I know that the resident can read, write and follow simple directions, then I trust that these things can get done properly (college and medical school tends to weed out those who can't). I haven't had any major problems yet.

    To the folks who say that residents need to be watched like little kids, remember, they're doctors; intilligent ~30 year old people. Being in the health care profession has an inherent level of responsibility, sure there'll always be one or two bad apples in the bunch. Successful housestaff interactions require two-way trust (once it's been established that both parties are trustworthy). And for all those who don't know, especially at night, many teaching hospitals run with residents making major decisions.

    To the story at hand. As I recall from residency, a resident sees the patient in clinic, then will immediately precept with the attending. Based on this, my perception of the situation is that this resident saw a patient and presented this patient to Jane. Obviously, the resident didn't present a patient Tabby the cat, but instead presented a normal patient and had incorrect documentation.

    Question #1: Where's the note from the real patient he saw? Did that patient receive healthcare that ended up undocumented? I would consider that dereliction of duty to be as bad as pulling the rug over the attending's eyes.

    Question #2: What kind of moron thinks he can do this without drawing the ire of all the other attendings in his program? Total lack of foresight on his part.

    Question #3: Should Jane have recognized this? Maybe, maybe not. Like mentioned above, when you're signing off on so many notes, it's impossible to go through each with a fine-toothed comb. After all, in the grand scheme of being an attending, proof reading resident notes isn't at the top of your list of priorities.

    On a somewhat unrelated note, to Old Squid: Couldn't agree with you more.