From: David R. Stoolworthy, M.H.A., M.B.A. <dstoolworthy@saintrectory.org>
Sent: Monday, 7:15 AM
To: Physician Interns, Residency Program
Cc: Medical Education, Attending Physicians
Priority: Standard Training Reference
MEMO XIII: Doctor Intern Questions — A Training Reference

XIII. Doctor Intern Questions — A Training Reference

Saint Rectory Memorial Hospital System's physician interns are, without exception, brilliant, exhausted, and one question away from calling the attending at 3am. Their questions are a diagnostic category all their own. Some reveal deep clinical reasoning. Some reveal that they have not slept since orientation. Both are valuable. Both are billable.

This memo is a mandatory reference for all internship programs, the DIO, and Medical Education. Each question below was asked by a first-year intern, usually over the phone, usually while standing very still in a supply closet. Each is real. Each was answered. Each was, eventually, coded.

Billing Note Every intern question occurs during a billable encounter. The question is free. The assessment, the workup, and the note are not. We bill the visit. We keep the story. The intern bills the hour. Everyone bills.

A. The "Is This An Emergency" Questions

  • "The patient's heart rate is 110. Is that... bad? For a human?" — Context: they are 22 and just ran here. For the patient, 110 is a footnote. For you, it's a sign you should sleep. We billed the reassurance consult.
  • "The leg is bent the wrong way. Should I... un-bend it?" — No. Document "gross deformity, aligned with gravity." Call ortho. Bill the reduction they will do.
  • "They said they're 'fine' but they're cyanotic. Fine, right?" — Cyanotic is not a flavor of fine. Activate. Intubate. Bill the resuscitation you just prevented.
  • "The monitor is beeping. Is the monitor okay, or the patient?" — Assume the patient until proven otherwise. The monitor is always okay. The patient is the variable. We bill the monitoring.

B. The Documentation Questions

  • "How much do I have to write? Like, a sentence?" — A sentence is a med student note. You are a doctor. Write a novel. Bill the complexity.
  • "Can I just say 'stable' and go home?" — You can say "stable, awaiting social work" and go home. Social work will bill. You will bill. Stability is a team sport.
  • "Do I have to mention the fart? It's in the note from nursing." — See Memo III-B. Yes. The fart is documented. The fart is coded. The fart is, God help us, revenue. Acknowledge it.
  • "What if I write the wrong thing and someone reads it?" — Someone will read it. That someone is the auditor. Write the truth. Bill the truth. The truth is billable.

C. The Existential Call Questions

  • "I don't know what's wrong. I just know it's wrong." — This is the most accurate physical exam finding in medicine. Trust it. Work it up. Bill the workup. Your gut is Memo III-A trained.
  • "Should I wake the attending? It's 2am and I'm 80% sure it's nothing." — The 20% is why we have attendings. Call. Wake. Bill the supervision. Sleep is not billable, but the save is.
  • "Can I discharge them if I'm not sure they're better?" — No. See Memo III-F. The F.E.C.E.S. review is a hard stop. So is your uncertainty. Admit. Bill the admission. Go lie down.
  • "Why does the nurse know more than me?" — The nurse has seen this patient three times today. You have seen them once. Listen. The nurse is also billable, separately, and correctly.

D. The Legendary Questions (Restricted)

These were asked by interns who are now our attending physicians. They survived. So will you. Do not post these; the GME office has feelings.

THE INTERN ARCHIVE
"If I chart 'patient appears alive,' is that defensible?" (Barely. We billed it.)
"The order says 'as needed.' How needed is needed?" (Clinically. Then bill.)
"Can I code my own confusion as a diagnosis?" (No. But the workup for it, yes.)
"Is 'sundowning' just being cranky or is it a real thing?" (Real. Billable. Do not become it.)
"When do I stop being an intern?" (When you stop asking. Please keep asking.)
Interns ask the things.
We hear the things. We answer the things.
We code the encounter. We bill the encounter.

The question was free. The care is not. That is the whole business model, and you're in it now.

Questions regarding this policy may be directed to:

David R. Stoolworthy, M.H.A., M.B.A.
Chief Operating Officer — Saint Rectory Memorial Hospital System
Email: dstoolworthy@saintrectory.org
Phone: Ext. 2800 (ask for "the poop guy" — they'll know who you mean)

For training questions:

Graduate Medical Education (GME) Office
Email: gme@saintrectory.org
Phone: Ext. 2750 (we have been where you are, call us)
Saint Rectory Memorial Hospital System
"We Save Lives. We Document Everything. We Bill Accordingly."