Physician Assistant, Neurosurgery

Sciences

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SPEAKER: Would you please state your job title and the type of organization where you currently work?

SPEAKER: My job title as a physician assistant in neurosurgery and I work in a hospital.

SPEAKER: And how long has it been since you graduated from undergrad?

SPEAKER: I graduated from undergrad in 2008, so ten years, wow.

SPEAKER: Okay. And how long has it been that you’ve been working in your current field?

SPEAKER: I’ve been working in my current field since 2014, so about four four years now.

SPEAKER: Okay. And could you provide just sort of a brief description of your primary job functions?

SPEAKER: Yeah. Some of my primary job functions are to see patients when they first come into a hospital as a consult or directly. They are trauma patients so patients that have had head injuries, spine injuries, or spinal cord compression. I also take care of patients in the ICU, either before or after surgery, or to manage them medically, and also function in the operating room as a first assist to surgeons, and I help in discharging patients if they have had a complete hospital course.

SPEAKER: Okay, excellent. Could you estimate in an average week what percentage of your job requires writing of any kind?

SPEAKER: I would say that writing takes I’m going to say maybe 30 to 40 percent of my job. Documentation is pretty important in medicine.

SPEAKER: Oh great. What forms are types of writing does the documentation usually take?

SPEAKER: They are electronic, typed consultation notes or history and physicals. Also daily progress notes, so documenting events that have happened for the patient, anything pertinent, and physical exams. And for OR procedures, brief summary of the procedure itself.

SPEAKER: Okay. And who are the primary audiences for those?

SPEAKER: Primary audiences would be medical billing and coding specialists, hospital administration, other services – so for example, a medicine service – if we are seeing one of their patients, or other services and specialties, so other doctors, residents, PAs and nurse practitioners,

SPEAKER: I see. And the purposes it sounds like could range from anything from billing to just sort of like, what would other purposes be?

SPEAKER: The biggest thing is probably going to be documentation and billing for the hospital, and just as what is legally required in healthcare. But other purposes would be for helping the patient or their families themselves, so things like filling out sick leave or FMLA paperwork, disability paperwork. And then the other biggest is for social workers who are able to read our notes, so that can help them in giving patients support for services outside of the hospital for things like rehab or counseling.

SPEAKER: Okay I see. And could you just tell me a little bit about like the form that that documentation takes? How long are they typically, what are they typically include? How do you sort of approach writing them?

SPEAKER: Yeah. Most of our writing is actually in template form. So it doesn’t really take too much time, and most documentation will include a summary of the patient themselves and their background, specifically their past medical history and things that are pertinent to their hospital stay – a hospital course meaning day-to-day, if the patient has had multiple procedures or surgeries or events like low blood pressure. My writing is kind of like a concise but flow of a course of a hospital stay. They will also include a physical exam, so my exam of the patient and a plan. So plans for all of the diagnoses that the patient has, and documentation that my attendings and surgeons have agreed to plans that I’m making.

SPEAKER: I see. That’s very helpful. When it comes to writing those, is there– you know, we tend to think about writing often as having a process in terms of planning, writing, and then getting feedback or revising, but I would imagine this is sort of a one and done writing situation? You sit down to write it, you write it, and then it’s completed. Is that a fair assessment?

SPEAKER: Yeah just because we are required to document everything that we do and see. But at the same time every day we’re doing and seeing so much, so the writing for me is something that I do as quickly as I can. So it usually takes on a pretty specific flow. I always have it in my mind that I’m going to say like, for example, you know, “Patient is a such and such year old male or female, with this past medical history, who is coming to the hospital for, ” and then I’ll get into my story of the patient’s course.

SPEAKER: Gotcha,. okay So is it fair to say that you’re creating sort of – you’re writing the story, you used that actual word – even though is that a technical word, is that just a word that you use?

SPEAKER: It’s just a word I use. But what we actually call it is HPI – a history and present physical of the patient.

SPEAKER: Gotcha, okay. And how did you know how to perform these types of writing?

SPEAKER: It came when I was in grad school. So when I was training to be a physician assistant, we started to learn how to write these things, and then this is also something that if you were to read out loud, is also the way that we would talk to colleagues in presenting the patient.

SPEAKER: Oh interesting. So it really does translate exactly how you would say you would write it.

SPEAKER: Yes exactly.

SPEAKER: Gotcha, okay. Has there ever been a time in your career that you felt unprepared as a writer?

SPEAKER: Probably in the very beginning, like when I was a student and doing my rotations, and also in the first month or two of my first job. Only because, you know, it was new, and it is a pretty specific style of writing and you’re using so much medical terminology And so sometimes it’s actually a little difficult, if I was to go and talk to a patient’s family I would have to think about that note and translate that into everyday terms. But this writing, I think when you’re first learning in the medical field, you’re having to use such specific language. So that’s probably the time that it was most challenging.

SPEAKER: That’s interesting, yeah. Was there anything that you did to specifically overcome those challenges, actual strategies or steps that you took to improve?

SPEAKER: Yeah I did that when I was a student where I would practice what I was going to say to whoever was training me. And again that would translate from my notes. So I would take that time to write down what I wanted to say aloud in presenting my patient and then I would turn around and be able to write that down as my note. So practicing really helped in that.

SPEAKER: Gotcha. That makes a lot of sense. Does anybody oversee your writing?

SPEAKER: At this point no, no one oversees my writing but my surgeons do co-sign my note but they also, if they feel they need to, they will write something else in the note but never a change to what I’ve written. They would write something at the end for example to say you know, “I’ve seen and examined this patient and agree with the physician assistant’s. assessment Additionally patients said, ‘X Y and Z’ to me personally and for that reason I would also do this as a plan. ” But I think my writing was more so overseen when I was in grad school where we would have to write out example HPI and notes on patients and it would be graded.

SPEAKER: I okay se, e, okay. And was the feedback that you were getting in any way about writing style, or was it more about the content that was in there?

SPEAKER: It was I think both. It would be about content and style. So having something very long- winded is not very accepted in medicine just because again, everybody’s you know trying to also see their patients face to face, or do procedures, or be in the operating room. So sometimes it’s actually a little frustrating to have the requirement to write everything down a certain way, so I think pairing things down is the biggest thing that’s emphasized of how do you make this as brief as possible but still having as much information as possible.

SPEAKER: Got it. How do you do that? That seems extremely challenging with such technical writing.

SPEAKER: Yeah the way that we do it in medicine is for example, if you have a patient that’s there and they’re seen for a gunshot wound to the head, you would write out their past medical history so for example to say you know, “Patient is such and such year old female with a past medical history of hyperthyroidism, six weeks pregnant, diabetes, hypertension. ” And then you would get into your specific story, so how the patient was injured, how they appeared when they came in, what their blood pressure was, and then get right into a plan. But then if you were to see that patient, you know, five days later, you’d have a little bit of leeway and you can just touch very, very briefly on what brought the patient in. So at that time you wouldn’t say “Patient came in at such and such time, ” in this note you would say, “It’s been hospital day five since this happened and here’s what’s happened since. “

SPEAKER: I see, I see, okay. That’s really interesting. And I’m just thinking about like, if you’re writing these notes as someone is in there with a gunshot wound that puts a certain added pressure I would imagine!

SPEAKER: Yeah. So that goes back to, you know, we do have to see patients, you know, face to face and you’re spending time with them, sometimes every hour, to make sure that they’re doing the same things that they were doing an hour ago. Like for example, this patient was talking an hour ago and now they’re not. So what’s changed? What do I have to do? Is something happening in the brain? And then of course you do have to remember to go back and write that down, so that the hospital knows, that other people that may get involved in in the care know that these were the events that happened.

SPEAKER: I see. I see. And how long do you typically take to write up one of these notes?

SPEAKER: When I first started, that would take much longer so I would say, I would think about this for you know 15 minutes, 20 minutes, take maybe five or so to write it down. Now it sounds a little surprising, but you know you might just kind of write down little blurbs on a piece of paper for when you get to a computer. So sometimes it doesn’t take as much thought just because it’s become muscle memory and it would take maybe two minutes to write the actual note.

SPEAKER: Gotcha. Okay, okay. When you think back – this asks you to sort of look way back to undergrad – when you think back to the kinds of writing you were asked to do, what kind of writing were you asked to create as a student? And do you think that those college writing experiences prepared you at all to do the kind of work that you do now?

SPEAKER: Yeah. In college, you know, there was different kinds of notes based on what subject matter. So one of the things for me since I was a biology major was doing lab reports, and in those, the writing, you know, you have to have your grammar correct spelling etcetera, which I think is kind of lost now in medicine I think that if you see somebody misspelling something you just think, “Oh this was probably, they were just very busy had to get to another patient. ” And in the other sense, you know, you really are focusing on the grammar and you know, how your sentence flow is going more in college. And I think it was kind of taught to me after is, “No. Do the opposite. ” You know, get it as clipped and as fast as you can. So that is probably a challenge now, and I think to have been better prepared, maybe to have an assignment where you are having to be as concise as you can be with still providing as much information as possible, would have probably been helpful in undergrad.

SPEAKER: That’s really interesting. Going back to this, you mentioned – it’s super interesting to me – this idea that in a medical note now in documentation, if there’s a misspelled word or some sort of grammar issue it’s really unimportant because it’s assumed that it’s because of a time constraint. Could you talk to just a little bit more about that?

SPEAKER: Yeah I think, well not just that, but in medicine I think, you know, you’re seeing doctors or physician assistants etcetera writing notes, and I think that, at least for me, the assumption is that this person is definitely worthy of their credentials, so if they misspell something it’s not as detrimental as say, something misspelled on a resume, where, you know, you’re actually still trying to prove yourself and compete for a job or a position. And in medicine, we are all already established and we’re already doing our job, and to be honest sometimes medical terminology can, you know, the spelling and the words can be a little complicated. So I think we all give each other a little bit of leeway when it comes to spelling and grammar in those senses. I personally like to have my notes and everything spelled correctly, but I do see it in other people, and I also think it comes with just the diversity in medicine. There’s a lot of providers that have trained outside of the United States and come here to do their residencies or trainings, and then eventually establish themselves to work. So English is not always the first language for everyone in medicine. So I think that plays a little bit into it, and I think that most of us that are in the hospital setting, we know that and it’s just something that we see.

SPEAKER: That is fascinating. Yeah that’s great. Thank you for that explanation. Yeah. Could you talk a little bit about what’s at stake in your writing?

SPEAKER: Yeah. So all of us in medicine think, “Okay can our note stand up in court? ” Because if you don’t write it down, you can’t say that it happened. And you know, if you do write something down you cannot erase it, if that makes sense. So medical legal is a big thing especially in the area that I practice in this city, it’s very litigious is what, you know, kind of the common knowledge is. So again, like if you have a patient that had some kind of an event it involved an ICU and nursing there, and something that is missed, things like that, you always have to document and chronicle what happened the way that you saw it so that it’s almost as if to say, “this is my side of the story, ” for something like being in court. So that’s something that’s always kind of looming as well.

SPEAKER: Yeah, absolutely. This is my own ignorance, I should know this b ut – let’s say there is some issue and there’s a lawsuit. Do you get sued or does the hospital get sued?

SPEAKER: It depends. I think most commonly it’s the hospital or the organization that you’re with. But there are times where it would be a specific doctor that is named. Usually I have not seen anywhere where a specific nurse or a specific physician assistant etcetera is being sued, but there are times where they are named as a witness or a defendant or something.

SPEAKER: Gotcha. Okay. What would you say is the most difficult thing about writing in your specific position?

SPEAKER: That’s a good question. I think the most difficult is also the most fun part at least for me, is just being able to shape and write that story of why your patient is here or why you were called to see the patient in a concise and informative way.

SPEAKER: Yeah, how do you do that? I mean because it’s one of those things – I was really interested earlier to hear you use the word story because of course I think of medical writing as so incredibly technical – but of course after hearing you describe it, you’re telling the narrative of what happened So are there certain strategies or sort of ways of thinking that you approach writing that, and why do you think it’s fun for you?

SPEAKER: Yeah I think the way that I approach it is, how do I shape his story into something that’s going to catch someone’s attention? So most of us in medicine, like if I get a call of a consult to say, “Hey this patient has some kind of an issue and it looks like they have a fracture in a bone near the ear, ” I’m immediately checked out thinking, “Why are you calling a neurosurgeon for this? We don’t take care of this. I’m not interested. ” So same thing if I’m trying to talk to a medicine doctor. I’m trying to frame my note that would be appealing to them to say, “Hey this is exactly why we need you, and this is why we hope that you’re going to accept our patient, ” because there is still, you know, some procedure in the hospital involves once a surgical problem is managed and taken care of, you want to transfer your patient to a doctor that can better take care of their medical needs, things that I don’t really manage myself. So you want to try to kind of frame the patient of, “Oh this is a really interesting medical patient now that we’re done with the surgical part of things. ” So having to write something in a way that’s going to make it relevant to other people and catch their attention is a big challenge in writing and I think it’s a challenge that’s kind of fun to try to do.

SPEAKER: That’s fascinating. Yeah I never thought about it like that. So you’re sort of trying tell the story persuasively on behalf of your patients so that they get the best care.

SPEAKER: Yeah exactly.

SPEAKER: But you’re also sort of trying to appeal to these doctors because of course I guess what you’re saying is everybody gets bored, just like any other job at some point. Like Y you want something interesting.

SPEAKER: Like Y you want something interesting. eah I think bored too, but also protective of their workload because, you know, I’m maybe seeing 30 patients on my service and then I’m saying, “Oh my god, ” I’m having five other people try to give me other patients so I’m thinking, “Okay, do I really want this patient that’s not at all really relevant to me? Or do I want the ones that are specifically neurosurgery? Yes I can do something to help you, ” that kind of thing.

SPEAKER: That’s great. That’s really fascinating. Has anyone helped you formally or informally with your actual writing since you’ve been there?

SPEAKER: Yeah I want to say that, you know, just starting a new job at a new specialty in the beginning while I was training, I would write my notes and then of course ask people, “Hey does this look okay? ” And they would tell me things more informally of “Oh, you always want to mention this in a physical exam because in neurosurgery, this is what’s important and here’s why.

SPEAKER: Yeah that’s great. How do you believe you’ve evolved or improved as a writer if at all over the course of your career?

SPEAKER: I definitely think there has been improvement, especially from, you know, training to now, because not only can I write what I need to and have it be relevant and appropriate, but I can also then take what I’ve written and say it out loud to somebody to like collaborate and treat a patient. And I think that’s definitely improved since I started.

SPEAKER: Okay. And just a couple more questions – to what extent do you think writing is valued in this organization specifically, or in your field sort of as a whole?

SPEAKER: I think writing is valued in the sense that, you know, of course all hospitals or clinics etcetera you need to document things. But I think writing is valued in the sense that every medical provider is you know, going around seeing different patients. So when you have a note that is concise, well written, it flows properly, and it really is relevant to the patient and their illness, that’s pretty impressive in our fiel. So if I read a note that’s very relevant and you know, gives me all the information that I need, I tend to say, “Oh this is like a great note, ” versus, “Oh I’ve read this note but things don’t add up. Let me go dig through the patient’s files and charts and their note from two years ago that has something relevant in that note but wasn’t included in today’s note, ” that I think is what’s emphasized a lot in our field.

SPEAKER: Okay that makes a lot of sense. Yeah. And the last little set of questions – so first, how would you define successful writing where you are now as opposed to when you were a student?

SPEAKER: Yeah I think successful writing, it just goes back to being able to write exactly the way that you would speak it and vice versa. And I think in other fields I do acknowledge that it takes so much more thought. But in medicine a lot of it is muscle memory and flow and template, and you write things the exact same way, it just differs from patient to patient.

SPEAKER: Yeah right. And it seems like – I’m just sort of thinking out loud but – I think in a lot of different fields writing from a template, we start to think that oh the writing feels stale or it’s uninventive but here it’s like it’s necessary that you follow the same format, right?

SPEAKER: Exactly. Yeah it does really matter to have things in the same format because it’s, you know, probably at a level above my head. It’s been talked about and formulated and then dispersed out to “Hey use these kinds of templates, it gives us what we need. “

SPEAKER: Right, right. And then the last question – would you say you are a successful writer at work?

SPEAKER: Yeah I would say I’m a successful writer at work. I do think it could still get better obviously, as I become a better provider and have that experience. But I do think that I’m successful in my writing.

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