The seminar took place once a month in lieu of a weekly care conference. The central exercise involved two residents: one serving as a reviewer and the other as a treating physician (provider). The day before the seminar the reviewer would examine the chart of a patient currently under the care of the provider. The reviewer would then proceed to question the necessity of admission and/or continued hospital stay. The treating physician would defend both the care rendered and the necessity of the inpatient setting. The ward attending physicians (JC and VS) would facilitate the discussion and serve as arbitrators.
Before participating in the role-playing exercise, the residents and medical students were presented an hour-long instruction session on the origins and effects of managed care. (
+4,
+5). The concept was placed within the contexts of the doctor-patient relationship and the insurance industry (
+6,
+7). The mechanisms of concurrent and retrospective review, the role of hospital utilization reviewers, and the typical protocols for appeal were covered. Case illustrations were provided to demonstrate the criteria that must be met to justify inpatient treatment and to exemplify the crucial role of concise chart documentation. Two of the authors (JC and VS) provided cases that had been presented for appeal and had proven to be didactically effective for instruction (
+8). Literature and cases were cited to illustrate the legal and ethical obligations of physicians, reviewers, and payers (
+9).
As mentioned, the seminar took place once a month within the clinical setting of an 18-bed, open, adult, general psychiatric unit. The patient population is mixed with respect to diagnoses, socioeconomics, and demographics (including types of insurance coverage). The average length of stay is 12 days. The unit director (VS) and associate director (JC) served as the attending psychiatrists for almost all of the patients. Care is provided by a multidisciplinary team that included the physician, nurse, social worker, and creative arts therapist. The unit is a teaching service. It is worth noting that this seminar was open to all disciplines given the importance of documentation by each team member.
To evaluate the seminar, a postgraduate year (PGY)-5-level resident (KB) who had spent the entire year on the unit interviewed each of the 14 PGY-1 and PGY-2 residents and a group of 16 medical students who participated in the exercise by using a semistructured questionnaire (see Appendix). The items focused on what the participant learned, whether there was any change in attitude, what his or her reaction was to the exercise format, and whether there were any notable changes in behavior as a result of the exercise.
As seen in
+Table 1, most participants (the residents and medical students) had a positive response to the exercise and found it educational and particularly useful in its focus on documentation. While most of the response was positive, some participants felt that the format was stressful and that more didactic preparation was needed. Although there were no statistically significant differences between the groups (i.e., residents vs. medical students) on any of the questions, the medical students were twice as likely as the other residents to report a negative change in attitude toward managed care.
Qualitatively, the residents tended to report that they had learned how important it is to document their thoughts on the need for admission and continued hospital-based care. They tended to deny any change in attitude toward psychiatry or managed care or any change in behavior (i.e., although they felt their documentation might have improved), and they did not feel that the exercise influenced their decisions on admission or discharge. With respect to the format, the residents felt the session was an effective way to learn about managed care, and they felt it should be done on more rotations. However, a few felt stressed by the "audience," especially when they were defending a chart of a patient on their service.
The medical students were pleasantly surprised to learn that their notes play an important role in the patient's care, insofar as these notes were quoted to deny or defend a patient's need for hospital care. Furthermore, the medical students reported a change in attitude that the residents denied. While some reported a new found pessimism about the future of inpatient psychiatry and medicine, others were invigorated to challenge current trends and reassert the primacy of the doctor-patient relationship. A few of the medical students felt they would have liked to take part in the exercise rather than observe it. Others felt it would be useful on all hospital services.
Two of the authors (JC and VS) monitored the seminar's content and process. Regarding content, the weak points in the charts fell into one of three categories: lack of clarity, incomplete use of the biopsychosocial model, or lack of organization.
Charts would contain phrases like "patient doing better" without a specific description of the improvement or how the need for more improvement was linked to need for continued hospital stay. For example, a depressed patient's insomnia may have diminished but still persisted to a degree to warrant supervision. The phrase "to consider" as in "to consider antidepressant therapy" would make a chart vulnerable if not clarified. It would appear that there was an arbitrary delay in treatment. Once clarified (e.g., "to consider antidepressant therapy once detoxification completed, and previous history reviewed with outpatient psychiatrist"), the note would be much stronger. Last, the mechanism for reaching a treatment goal was often absent. For example, a note might cite the problem of noncompliance without linking it to the plan to discuss the problem in an upcoming family meeting.
+
Incomplete Use of the Biopsychosocial Model
While most of us subscribe to the biopsychosocial model, it was often not fully elaborated in the chart (
+10). Perhaps the psychological and social aspects do not carry the legitimacy of the biological. In fact it may be the environment, and not the patient, that requires change prior to safe discharge. For example, an alcoholic spouse may require treatment or the patient may not be able to tolerate living alone and resort to suicide. The latter is a good example of the paradox inpatient psychiatry faces; when this patient is in a stable environment (i.e., the ward) he or she improves, and the reviewer is eager for discharge. Yet this is the same patient who will predictably decompensate if discharge is not accompanied by a significant change in the patient's home environment. Similarly it is often useful to mobilize and educate all available family and peer support during the crisis so that the patient's life can be different, if not better, after discharge. This type of documentation and planning was often absent in chart notes.
Most charts did contain the data describing the acuity and the goals for hospitalization. However, the data are not compelling if they are scattered rather than concisely documented.
With respect to the process, the ambiance almost always evolved into one of friendly debate. This occasionally took some facilitation by the ward attending physicians. In some instances, the resident reviewer would "identify with the aggressor," opening the discussion with a flat denial of all services rendered. Other reviewers would try to circumvent the conflict by focusing on a discussion of pharmacotherapeutics. Treating residents might adopt a rigid style of insisting that everything done was necessary, without articulating why, while others felt intimidated by having their chart scrutinized. The attending physicians would assist the residents in their discussions by engaging in a debate with the residents or one another or by restating the arguments in a more neutral way. This progression was often mirrored by the physical use of the chart. At the outset, the reviewer held the chart, quoting from it to attack the treating physician. Then the treating physician would take possession of the chart to make a rebuttal. Soon they would share the chart, in a cooperative manner. The ability to confer with a reviewer, rather than argue, will certainly prove useful.
This combination of role-playing and case-oriented teaching seems ideal for the academic setting, where the "bedside" approach is familiar to all. By substituting the seminar for a weekly case conference, there is no extra burden on any of the participants. The ward attending physicians are prepared to hear a case presentation, and at least one is the doctor of record. The treating resident (provider) is, of course, familiar with the case. The resident who serves as the reviewer invests the time outside the seminar to read the chart, but this is roughly equivalent to the time involved in preparation for a case conference. An analogous message is conveyed to residents and medical students regarding documentation: keeping concise, clear, and focused notes need not be a burdensome or more time- consuming task.
The attending physicians running the seminar must remain flexible in their roles for it to proceed smoothly. Often one must play devil's advocate against one's own patient to assist the "reviewer" in assuming the role. The residents tended to be interested in the traditional questions of differential diagnosis and treatment without addressing the issue of the necessity of the hospital setting. In addition, the attending physicians would model the discussion and disagreement that might take place regarding treatment setting without becoming hostile.
Regarding the biopsychosocial model, if physicians are going to embrace this approach over the biomedical model, it must be clearly documented in patient charts. If psychological and social factors are to be afforded validity in the illness process, physicians need to safeguard that validity by documenting and including these factors in the assessment and treatment plan.
In retrospect, the course could have been evaluated more effectively had the questionnaire been administered before and after the exercise. Anonymous reporting of feedback might have been more candid than the interview format used. In addition, provision of a Likert-type scale for responses may have been more useful than simple yes/no categorical replies. It would be of interest to know more about the tendency of the medical students toward a newfound negative attitude toward managed care. The preclinical curriculum at Jefferson Medical College does address the health care system; however, this teaching exercise is unique in that it is imbedded within a clinical rotation, integrating the theoretical model with the practical application.
This approach was useful and educational to all participants and provides a fertile environment for further ideas and discussion on this important topic.