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Second Opinion: Speak Truth to Charting

Leap, Edwin MD

doi: 10.1097/01.EEM.0000419515.35479.a9
Second Opinion

Dr. Leapis a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, a member of the board of directors for the South Carolina College of Emergency Physicians, and an op-ed columnist for the Greenville News. He is also the author of three books, Working Knights, Cats Don't Hike, and The Practice Test, and of his own blog. (See FastLinks.)





I remember a short lecture I received in my medical officer's course when I joined the Air National Guard around 1988. The room was full of young medical students, physicians, nurses, and other health care folks who were beginning their service. The topic was appropriate documentation in the medical record.

Among the notable examples of what not to do was this gem, written by a medical officer about another officer's wife: “The patient is a contemptuous bitch.”

This was written in the medical chart for all to see. It is unclear if the young physician ever returned from his subsequent tours guarding airplanes in North Dakota, Greenland, and other points cold and bleak.

While the example was certainly a horrendous one, I am sympathetic. We spend so much time charting, trying to say and do the right thing, that often we subvert and disguise the truth. Or we cover reality in innuendo and medical code. “This patient, well known to this emergency department, presents with his usual and customary back pain for which he takes multiple prescription pain medications that do not seem to provide sufficient relief.” Translation: This guy is here all the time, wants pain meds, and is never, ever satisfied.”

Truth be told, verbosity does not improve communication. Just read some Hemingway. Furthermore, our current systems of electronic medical records are designed to capture lots of words but to hide meaning in catch phrases and required fields. Actual, honest description of what we see would dramatically cut the size of our too-expansive medical records!

In other words, we seldom chart what we want to chart. We don't actually say what we would love, with all our hearts, to say. I was thinking about this recently, and the ways I'd like to chart the things patients say.

Man, 25, otherwise healthy. “I have chronic pain from my degenerative disk disease, and I can't hold a job. I went tubing on the lake this weekend, and I think it flared up my degeneration. Oh, and I have a sunburn; can you give me something?

This patient is in active pursuit of disability, but appears far healthier than this aging, aching physician. Likelihood of narcotics or sympathy roughly zero.

Woman, 19, ongoing pelvic pain and discharge. May be pregnant for fourth time.

This young woman with crushingly low-self esteem and no evident support system has frequent unprotected intercourse with multiple partners and is at high risk for HIV and assorted other diseases, not the least of which is depression. She needs a real mother to care for her and a real father to kick the behinds of the various men who stalk her. She also needs antibiotics, which are administered and prescribed.

Man, 89, tearful and clutching chest, with no objective evidence of coronary disease.

This kind gentleman is desperately lonely, afraid of death, and fearful that his life will pass unremembered and without meaning. Even at his advanced age, he longs to carry on and do all of the things he could not do so far. Like me, he wants to see his children as they were again. Grief, especially for oneself, can be particularly painful.

Man, 35, intoxicated and experiencing 10/10 pain from superficial abrasion after wrecking moped.

This enormous whining man-child is drunk all of the time, lost his license, and is now playing the pain card to obtain yet more mind-altering substances, which he will either abuse or sell from his mother's basement until he is struck and killed by a large truck or slips into an Oxycodone/Xanax/moonshine coma and ceases all respiration.

Child, 7 months, “isn't acting right,” according to young mother, who is frantically hovering. Child is playful and smiling. Grandmother continues to suggest more tests.

After a thorough investigation for dangerous illness in this child, I find that he is well. His mother is simply terrified, and is being reassured. Her mother should leave the room, if not the town, and stop escalating her daughter's anxiety.

Woman, 57, complains to the patient advocate that her physician did not fully evaluate her chronic neck pain, did not give her adequate prescriptions, and did not give her the work excuse to which she was entitled. This is her 18th visit for this complaint.

I fully evaluated this patient, and found no emergency medical condition nor any sign of neurologic or infectious abnormality. She was instructed, yet again, to follow up with a family physician. She was encouraged to make some effort to pay her large outstanding (and as yet unpaid) balance, and she became angry and insisted on speaking to someone in authority. She will not receive any medication from me for visits like this one, which are abusive and manipulative.

Man, 19, complains of anxiety, tremor, and headache. He is incarcerated for armed robbery.

History and exam reveals no worrisome etiology in this young man. He is clearly shaken by the turn his life has taken. It is a pity that his father abandoned him, and that he was all but raised by wolves. He is encouraged to come and visit my church when he makes bail or finishes his jail time. He needs repentance, faith, and family not Xanax.

Woman, 78, is crying uncontrollably. Her husband of 55 years just died from massive MI. She has slumped to the floor in tears. She describes dyspnea and chest pain.

This patient lost her husband. Fully half, if not more, of her self has crossed over from this life. The breath sucked out, her heart crushed; her pain seems appropriate. I can only weep with her. There is no medicine for her pain in this life. I will, perhaps, slump to the ground by her side.

Man, 37, complains of shortness of breath, knee pain, and back pain with ambulation. He weighs 450 pounds. He denies chest pain, cough, fever, or trauma. He states his physician has ordered an MRI of his back, but he is too large for the local machine. Extensive testing has failed to determine an etiology for his shortness of breath with ambulation.

This very nice man agrees when I tell him that he must lose weight or he will continue to be at serious risk for diabetes, heart disease, and stroke. I explained that I feel short of breath and my knees hurt when I gain 20 pounds. He is roughly 200 pounds above ideal weight. He is directed to a weight loss clinic. He accepts this advice. No further testing deemed necessary.

Man, 98, is pleasant and charming, and is brought from the nursing home at his family's request. He has been having severe chest and abdominal pain for several days, and now has a low blood pressure in the 70s. His family wants “everything done.” The patient is lucid, and despite his pain is telling me about the time he felt the same at Guadalcanal when he was gravely wounded. He tells me he does not want tests or surgery, and is “ready to go.” Family is tearful, as I would expect, but desires that if anything needs to be done he be transferred to the teaching center in the next town.

This man likely has an aortic dissection. He has pulse deficits, and now has developed neurologic deficits. He is unlikely to survive any surgery. I have explained to his family that a man who lived heroically does not want to die pathetically. I will observe his wishes and keep him comfortable. I have spoken with him at length, and he has told me several stories I will never forget. The world will be poorer, but I will not subject him to anymore intrusion. His family will have to accept his wishes.

You see, it wouldn't be that bad, would it? To speak the truth. To document the truth. To do otherwise, and write otherwise, is a kind of terrible malpractice. A white-washed coating on the real world of human suffering and human folly.

That's not what we trained for, is it? So let's try to stop pretending so that we can actually get down to the healing.

(Leap is a great windbag who thinks he has something important to say about everything.)

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