Goodbyes were confusing during my third and fourth years of medical school. Even on my way to a 28-hour labor and delivery call, I tended to say, “I’m leaving for school.” Rather quickly, my wife trained me to say, “I’m leaving for work.” I was never quite reconciled to this, as I couldn’t forget the upcoming exams and tuition costs around $30,000 per year.
For the uninitiated, “work” as a medical student on clinical rotations takes many forms. Talking with and examining patients, participating in team rounds, sewing up skin lacerations in the ED, assisting with various surgeries, contacting outside facilities to obtain records, and occasionally performing invasive procedures under supervision (lumbar puncture, paracentesis, central venous line, etc.) In my mind, this was the role of an apprentice. Often, the only difference between my “work” as a student and that of a trainee physician (resident) on the same team seemed to be the expectation for the resident to learn at a more rapid pace.
As we’re undergoing a shift toward the use of medical student documentation for billing purposes, I’m wondering about the definition of medical student labor, as well as its value.
Sarah is a third-year medical student on a busy oncology service. She has heard from classmates about the heavy workload, but she’s surprised to find that two PAs and a scribe have recently been transferred off of this service “since students write all of the notes for free now”. The one resident on service hands her a long list of patients to see. She feels nervous since she has had no training on the relationship between documentation and medical billing. A nurse on the unit reassures Sarah that student notes won’t be scrutinized by staff, since “We all just call the attending if we really want to know what’s going on”. The students are unsure if this is true — they assume their notes are perfect since no one has given any feedback. Their attending physicians consistently attest their notes without changes. Sarah is eager to learn more about oncology, but she’s not sure when that will happen. Her friends in the year ahead emphasized that writing all her notes would be the key to getting good grades and recommendation letters for residency. Right now, she can’t even remember the attending’s name. Where did he go?
Fiyin is a third-year medical student in the midst of his otolaryngology rotation. It’s a busy service with high expectations, but he knows he can handle it. Near the end the last school year, a group of residents trained his class on documentation, requirements for medical billing, attending attestation requirements, as well as institutional policies on rights and responsibilities of the student on clinical rotations. They even practiced documentation after simulated patient encounters. During rounds, the junior resident makes sure Fiyin is oriented on a student-dedicated, rolling laptop stand. The chief resident and attending quickly clarify the plan with Fiyin, the intern and the bedside nurse before moving onto the next patient.
Occasionally, they give Fiyin a phrase or sentence that needs to be verbatim in the note — he immediately types those in. He is able to finish his batch of notes in time to make it to the second case of the day. The chief resident is eager to discuss this case with Fiyin so that he’ll be ready to write the note tomorrow — and ready for his exam in a few weeks! This year has been a little easier outside of school since the College of Medicine made a 25 percent tuition reduction for students in clinical rotations. Billing for student notes took a few years to catch on, but it soon became obvious that learner labor was increasing hospital productivity.
Many institutions will transition students into new documentation workflows without approaching these extremes, but at least one will settle as the least common denominator in regulating student labor. Resident physicians may find themselves in messy transitions — will they be responsible for revising every student note? Will residents end up spending more time with patients when students are writing notes? Perhaps the increased importance of the student note will lead to higher student engagement by all team members.
The average starting salary on completion of an undergraduate degree at my state university is $43,800. Let’s consider this as an opportunity cost — in this case, income a student could have generated if they were employed full-time instead of continuing in school. In my case, the opportunity cost was formalized in a restriction against medical students working outside of school. The combination of in-state tuition and opportunity costs for professional students is illustrated below:
In formalizing students’ contribution to productivity, we must recognize the value of their labor is nonzero. Unlike other graduate students, medical students are not eligible for an “assistantship” stipend for work in the hospital. We do not supply health, disability or life insurance. We do not enroll them in retirement matching programs. We don’t give them a contract detailing duties and expectations.
Now that changes are taking place, I want you to go all in. Teach your students to write notes that matter. Work them hard, and keep them seeing as many patients as possible. Make the student the team’s contact person, except in emergencies. Give students the IT support they need for their new role. The best educators will redouble their efforts to prioritize high-quality medical education throughout this transition.
Here are two options:
1. Treat your students as employees and pay for their health insurance. Give them benefits that are at least as good as those of your housekeeping staff.
2. Recognize that the labor of students will save money for your institution (once they are trained appropriately). Give them a 20 percent tuition discount for clinical rotations.
We are increasing students’ responsibilities — will your institution be the first to recognize their rights as workers?
Thad Salmon is an internal medicine-pediatrics physician.
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