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Resident Forum
September 2, 1998

PATH Audit Effects on Medical Education

Author Affiliations

Edited by Charlene Breedlove, Associate Editor.

JAMA. 1998;280(9):766E. doi:10.1001/jama.280.9.766

The words PATH audit can strike terror in the hearts of hospital and clinic administrators, a reaction that I shared during my family practice internship in 1995. Although Medicare patients constituted only 17% of the clinic's billings, the institution chose to apply a stringent interpretation of the Health Care Financing Administration's (HCFA) requirements to all patients out of fear of a PATH (Payment for Academic Teaching Hospitals) audit. Because HCFA's contracted carriers interpreted HCFA's physician supervision rules differently than HCFA itself, academic medical centers have been investigated and, in some cases, fined for not complying with HCFA's interpretation. The broad application of these rules has had both positive and negative effects on residents' clinical training, without either quality of training or patient care being the focus of this change.

On the positive side, during the first 6 months of my internship and before the new rules were implemented, I reviewed every clinic patient with an attending physician, who would then see every patient about whom either of us felt "uncomfortable." At the end of the 6-month trial, the physician remained present to discuss patient care, as required by the physician supervision rules in place at the time, but we had more responsibility and discretion in discussing patients than would exist today. Having no notes to write on patient charts, the attendings could focus on teaching and on reviewing the charts. Medical students had autonomy to generate patient care notes under the close supervision of residents and faculty members, which gave them a sense of responsibility for their work, for the patient, and for self-directed learning.

Three years and $42 million in PATH audit settlements later, family practice interns now must have their own attending. The strict interpretation of HCFA's physician supervision rules requires that this "physical presence" attending see each patient and write a comprehensive note, an additional "exception" attending attends only for residents in their second year or above. Because attendings must spend their time writing notes, they have limited time available to teach and to discuss patient care. They must repeat a large portion of the physical examination for patient billings above a specified amount and must be present for all procedures no matter how small. Medical students, having no way either to write or dictate clinic notes, are restricted to observer status.

To learn the experiences of others in my program, I informally surveyed those who had trained under both interpretations of the oversight rules. Of the 23 residents surveyed, 16 indicated that their ability to discuss patients with an attending was the same or better under the current rule interpretation; however, they felt their procedural training had suffered, as they often had to forgo performing clinic procedures because attendings did not have time to be there. Four residents said that changes in the clinic environment had influenced their decisions not to pursue careers in academic medicine. Because complying with the latest HCFA interpretation requires more time, fewer patients are scheduled with residents, especially in the specialty clinics. Anecdotally, residents complain of having less time to spend with patients and spending more time completing documentation; attendings admit feeling frustrated at having to spend their interactive time with each resident writing patient-care notes rather than focusing on teaching.

While the effects of HCFA's new rulings and PATH audits are not entirely negative, concern with improving residents' training and patient care are not driving the changes in education. The American Medical Association had been very vocal in defending academic teaching institutions, but only 1 resolution, submitted by the AMA-Resident Physicians Section, has addressed the subtle encroachments made by the latest interpretation of the HCFA supervision rules on education in the clinical setting. The recent dismissal of a lawsuit filed by the AMA, the Association of American Medical Colleges, and 45 other groups against the Department of Health and Human Services' Office of Inspector General may give the AMA pause. In that pause, the AMA has an opportunity to examine the other effects of PATH-audit fear and defend against the further erosion of our profession's control of its own educational standards.