After having served a recent tour of duty caring for patients in the hospital, I was reminded by the hospital’s billing department that I hadn’t yet “signed off” on a handful of progress notes – the diaries of illness, updated daily, on the people my team of advanced practice providers and I cared for. Without my electronic imprimatur, the hospital couldn’t start hounding insurance companies to pay for the services we rendered.
Reviewing them, I was embarrassed by my spelling mistakes, desperate grammar, and uninspired prose that minimally encapsulated my patients’ experiences while hospitalized and barely communicated to my colleagues any thought processes underlying the decisions we had made that day. The patient was lost in a disorganized list of billable diagnoses, a comorbidity Tower of Babel.
It wasn’t always that way.
As a medical student, I entered my clinical rotations full of energy, committed to capturing my patients’ exact words in describing what brought them to the hospital. Allow them to tell their own tales! Let their words glisten under the “subjective” portion of the classic SOAP (Subjective description; Objective findings; Assessment; and Plan) note!
Instead of “Patient presented complaining of fatigue,” my patients described the challenge of walking “as if someone encased my legs in cement and tied a rope around my waist to hold me back.” Such imagery!
The downfall of medical notes may have been partially of my own making. I was the first medical student in my class to type a patient’s history and physical exam on a notebook computer. On my first internal medicine rotation, I helped admit someone with chest pain to the hospital and prepared to read my note to the medical team. After waiting five minutes for the computer to boot up, load its DOS-based programs, and search through a series of subfolders to locate the document, I presented the patient to my attending, a VA hospital-based endocrinologist who was well past retirement age. The enduring knowledge he conveyed to me that month was a mnemonic for the physical stigmata from the use of anabolic steroids, which build muscle but shrink the testes: LMNOP – Lotsa Meat, NO Potatoes.
“What’s this?” he wondered aloud, aghast at both my chutzpah, and at the foreign technology. “Is this HAL?” he added, referring to the computer that developed a mind of its own in Stanley Kubrick’s 2001: A Space Odyssey. “Are we being taken over by computers?”
He probably didn’t realize how prescient was his question.
I spent the rest of the day trying to connect my computer to a printer that would recognize it and debating with my resident preceptors the legality of printing what I had typed on an official, light brown VA progress note sheet. As if that’s all we would ever have to worry about.
During residency I became jaded and more efficient – both of which were reflected in my medical record notes. I recall one patient who was hospitalized for more than a year, not because she had any acute medical issues, but because her attending of record feared that her family would sue him if she were discharged. I cared for her for 30 of my 30 days on that particular rotation and realized quickly that, as she should have been an outpatient, nobody read her medical chart nor attempted to bill for her stay. I decided to dedicate a daily haiku to her rather than a wordy SOAP note, in hopes that the sparse verse would inspire her hospital release:
Another day spent
without notable events;
To no avail. She outlasted my entire residency class.
I’ve never been mean in a note, as I’ve always assumed that a patient might read my discourse about him or her, and I generally follow the principle of “If you don’t have anything nice to say, don’t say anything at all.” But I’ve known doctors who express their feelings in the medical record, in code. One surgeon told his team that when he writes “Thank you for this interesting consult…” the three ellipses stand for “you f***ing idiot.”
Was his anger really directed toward the team who requested his opinion? Or toward the dehumanizing electronic system that separated him from the patient, his colleagues, and the repercussions of his actions?
When I became a staff doc, I rededicated myself to the art of writing notes that could bring my patients alive, make their problems tangible, and provide rationale for their treatment plans. I included salient facts about activities that provoked symptoms (“He hurt his back while bending down to the floor to pick up a corn chip”) and recent trips or life events (“She danced at her son’s wedding last weekend in North Carolina”) to jog my memory for the next visit.
But the clicks, the alerts, the signature challenge question demanding my favorite flavor of ice cream (pistachio, but I can never spell it correctly), the follow-up signature challenge question demanding my childhood phone number, the staff messages, open encounters, laboratory results, letters, the orders under the orders tab, the orders under the oncology regimen tab, the orders under the nonchemo tab, the orders under the clinical trials tab – it all got to me after a while, and my prose withered alongside my soul.
I was recently chatting with another hematologist, who is also a poet, and someone I admire a bunch. He asked me how much creative writing I was able to introduce into patient notes.
I shrugged, ashamed, and didn’t meet him in the eye. “Really, very little. I essentially cut-and-paste most of my notes.”
He sighed and shook his head, sadly. “Me too,” he conceded. “With electronic medical records, the poetry of medicine, the songs we sing of our patients, is gone.”
Mostly. But as we pass the 50th anniversary of the release of Stanley Kubrick’s masterpiece, we can’t let HAL win.
Let’s all agree to include at least one interesting detail about every patient we see, every time we see that patient, to bring color to an otherwise bleak electronic existence. Let’s do it out of respect for the people whose histories we’re writing, even if we can’t bill for that detail.
Let’s do it to remind ourselves of how the stories of our patients are what attracted us to medicine in the first place.