Letters

"Off the Charts" is off-base

To the Editor:

The authors of "Off the Charts: Teaching Students in Compliance With HCFA Guidelines" [May 2000, page 37] are off-base with their recommendation that medical students' patient notes be kept in a separate "teaching" file.

Medical students play an active part in the patient care delivered by preceptors. They see patients, ask detailed questions, perform examinations and make observations. This role cannot be denied. In fact, students often enhance patient care by spending extra time with patients and providing more data than the preceptor could obtain alone.

Along with teaching the students, do the authors of the article suggest that the preceptor copy the students' valuable notes? If a lawsuit occurs and a medical student is involved, how are the sequestered "teaching" notes handled? Keeping students' documentation in a separate teaching file is impractical for this reality and for other logistical reasons of cataloging and space.

The Health Care Financing Administration's (HCFA) rules may make us play games to get paid for care, but let's not let HCFA contaminate medical education in the ambulatory setting. The care is entirely the preceptor's responsibility, but the record may be a team effort.

Joseph E. Scherger, MD, MPH
Irvine, Calif.

Author's response:

We fully agree with the spirit of Dr. Scherger's comments as well as his assertion that students play an important role in providing care to patients. However, while leaving students' notes on the chart is reasonable, it is also potentially dangerous if preceptors fail to do adequate documentation on their own.

According to HCFA documentation guidelines for teaching physicians and other professional organizations' interpretation of those guidelines, only the review of systems and the past, family and social histories may be drawn from students' documentation. So preceptors must document the history of present illness, physical examination and medical decision making.

HCFA guidelines truly are being allowed to "contaminate medical education." Physicians must encourage their professional organizations to lobby HCFA to acknowledge the role that the preceptor/student team plays in caring for patients. Until then, do your own documentation.

Kathryn Chappelle, MA,
Shawn Blanchard, MD,
Miguel Ramirez-Williams, FNP
and Scott A. Fields, MD
Portland, Ore.

A bygone era

To the Editor:

I enjoyed your June 2000 cover illustration by Mark Stutzman. Many might say this scene is too unrealistic, but they've probably never made any house calls.

Today house calls are an anachronism — a truly rewarding effort of a bygone era precluded by time, cost and defensive-medicine constraints. House calls are an example of a time when there was more artful caring in medical practice.

To me, this illustration ranks with Norman Rockwell's famous depiction on the same subject.

Thomas S. Lynch, MD
Tuckerton, N.J.

Corrections

To the Editor:

The article "Is Universal Coverage the American Way?" [July/ August 2000, page 33] incorrectly stated that the Oregon Health Plan includes an employer mandate. When enacted in 1989, the Oregon Health Plan did include a mandate that required employers to provide coverage for a benefit package comparable to that offered by the state for those on the Oregon Health Plan. The coverage was to be required for all full-time workers (and their dependents) with incomes above the federal poverty level. However, the mandate was repealed prior to its implementation.

Oregon Gov. John A. Kitzhaber, MD, informed us in a recent letter that although the Oregon Health Plan has not achieved its objective of universal coverage, "We've reduced those without health insurance coverage in our general population from 17 percent to 11 percent, and we've reduced the number of children without coverage from 21 percent to 7 percent. In the upcoming legislative session we will again attempt to achieve our original objective of universal coverage."

A credit line was inadvertently omitted from "Finding Success in a Capitated Environment" [July/August 2000, page 49]. The photos in the article were taken by A.A. Barnsley and reprinted with permission from the California Academy of Family Physicians. We regret the error.