On giving pearls rather than notes…
July 20, 2010 7 Comments
Shell-shocked. It is the only word I can use to describe the feeling I have coming off a 13 hour ED shift on a Monday in the critical care section, where the sickest patients are triaged. A 90-year-old woman in acute renal failure with laboratory values all out of whack, two possible aortic dissections, a woman in acute liver failure after a Tylenol ingestion several days ago – and this is only a drop in the bucket of all the ICU admissions who passed through my hands today.
Mondays are always sick days in the emergency department – after enjoying the weekend, people finally decide to come in to get checked out. And by that time they are usually much sicker. The truth is, they don’t come sicker than this. If they do, they’re dead.
An article published in The Wall Street Journal today, What the Doctor Is Really Thinking, discusses whether or not doctors’ notes should be available to patients. Although I believe that communication is an important part of medical care, I do not necessarily believe that there are benefits to distributing patient records to non-health care personnel.
A physician’s note is a compilation of evidence which leads to hypotheses, or a differential diagnosis. The “evidence” includes details of a patient’s chief complaint, medical history, and social history. It also includes more objective data such as vital signs, the physical exam, and laboratory values. The end of the note, the assessment and plan, is a conclusion based on all of the data, and a plan which includes objectives for both treatment and diagnosis.
The affects of these notes on patients will more likely be negative rather than positive, especially for people who do not work in a healthcare profession. I list the reasons for this below.
(1) The idea of a “differential diagnosis” would frighten some patients: the entire purpose of this exercise is to consider all the different feasible diagnoses, so as not to leave one out – but many of the fatal diagnoses that appear in this list would cause patients unnecessary anguish.
(2) Abnormal laboratory values or test results might also frighten patients unnecessarily. Only in the context of looking at hundreds of thousands of laboratory values and test results does a physician realize which findings are concerning and which are simply incidental. Patients do not have the experience to distinguish between the two and would be unnecessarily worried by any “abnormal” findings.
(3) The social history, which is often a very important part of a patient’s story, should be kept in the strictest confidence. People who are depressed, who use drugs, who have crossed the boundaries of the law, or who have other personal matters that affect their health are already reluctant to tell physicians the truth about these things – if they were provided with a written document openly stating such things, they may be less inclined to have intimate conversations with physicians. The act of sharing the document makes these things seem more “official,” and may give the impression to patients that their secrets are not safe.
(4) Although patient notes are the wrong form of communication, it is still important that we communicate with patients. They should be given their CT scan results or their laboratory values, and they should also be given these values in context so that they can be correctly interpreted. They should be given their diagnoses, or even their possible diagnoses, but again – only the most probable diagnoses should be discussed, rather than the laundry list with which the physician starts.
(5) There is an incorrect impression that the note is the be-all end-all of a physician-patient encounter that contains all the answers about a patient’s health. This is far from the truth. A physician note does not address any of the patient’s questions or concerns. It usually does not address prognosis, nor does it address the psychological or social aspects of illness. It does not address all of the “what ifs” which will be encountered along the way, depending on how the diagnostic or treatment plans play out. It does not address the side affects of medications, or how the patient will feel; nor does it address the benefits and risks of procedures or imaging studies.
I think there is a great risk that doctors’ notes will be erroneously viewed as the “final word” in a patient’s health care. They will be viewed as the answer to patients’ questions, when, on the contrary, they are exactly the place you do not want to look for answers to the most important questions.
I also believe that doctors should write candidly, without fear of retribution or misinterpretation, about their patients. A physician’s thought process, just like any other human thought process, is biased, flawed, and specific to the individual. Doctors should not spend time being careful of what they write in the charts for fear they will be misunderstood by patients. Instead, they should spend time communicating – both verbally and in writing – to the patient in the right way, after all of the data has been collected and analyzed. They should then focus on tailoring their words to each patient,depending on their level of interest.
Patient notes provide an illusion of transparency and communication, but in reality they serve as a very poor form of communication between patients and physicians. However, because they are “official” documents, patients would most likely take them far more seriously than they should. Just like the laboratory, each patient is an individual diagnostic “experiment” who must be examined thoroughly before any answers can be obtained – and the doctor’s note is simply the rough draft of a final, polished diagnosis and plan. It is a record of the process rather than the result – and this process is more a reflection of a physician’s own thinking than it is a reflection of a patient’s condition.
Words are powerful, and they should not be taken lightly. The language of physicians in their notes is stilted, enigmatic, and often difficult to interpret. Physician notes lend themselves quite well to misinterpretation. A good physician can use these notes as a thinking process, come to a diagnosis, and translate the final results for their patients. This is our job: to sift through a container of salt and distill out the crystals, so that our patients can focus on the most important aspects of their illness in a world of chaotic and overwhelming medical information.