I love stories. I like to hear them, read them, watch them, collect them, and tell them. I participate in stories every day. The story of my family is a beautiful epic. The stories I hear at work break my heart. One of my favorite stories starts like this, as told to me by an adult man in his 40s: “Me and my mama live with her boyfriend. The other night, her boyfriend had a cardiac arrest! When he had the cardiac arrest, he rolled out of bed, and crushed the Pomeranian.” I tell it better in person.
Story is essential to medicine. The history we obtain from patients is a narrative of whatever affliction they have. The medical record we generate is a larger version of the story, which includes past conflicts and resolutions, various antagonists and protagonists, symbolism, subtext, and conclusion.
The problem is that the modern medical record murdered the story. The EMR is designed to gather demographics, monitor (and modify) our behaviors, and generate bills. It must be easily interpreted by people or computer programs that look for clicks and checks rather than descriptions. After all, it takes time and training to learn to read and appreciate a well-crafted story but not long to do a word search.
I suspect it is also a generational issue because younger physicians have grown up with communication shared in short bursts, whether on television, in music, while texting, or on social media. I understand how we have evolved, or perhaps devolved, in our medical communications.
One can reassemble the story from click-boxes and dropdown menus; it just takes effort. It certainly requires more time than it would take to read a story. It's archeological in nature: Look at the nurse's notes and the time-stamps, the triage vital signs and the things ordered, the timing with which they were ordered and interpreted, the consultations, the disposition, the prescriptions, the outpatient tests. All of it, when properly put together, can give an approximation of the what, when, why, where, and how of the encounter.
But what we often do not have, particularly in times of crisis, is the luxury to put the pieces together again. This also proves difficult for the consultants, primary care doctors, and specialists who see our patients later and who very much want to understand what transpired. Yet, as I travel around, I look back on various charts to discern what happened on previous visits, and I see checkboxes, labs, findings, and diagnoses (often vague) but no description. The “Medical Decision Making” or “Emergency Department Course” are empty fields.
In years past, we were told that these were critical parts of the chart that showed the complexity of our thought processes. I suppose EMR has changed that. And we're worse for it. Looking at those particular blank spaces is like listening to crickets in a field. The absence of words doesn't help anyone, least of all the patient.
Let me encourage everyone to leave a note, even a short one, describing what happened in that patient encounter. Fine, if it's strep throat or an ankle sprain, I get it. But for anything with the slightest complexity, anything requiring several labs, studies, or consultants, please tell me a story.
It needn't involve a “dark and stormy night.” But it should have enough information to help the next person reading it. “This 14-year-old girl has had two weeks of intermittent cough, fever, and shortness of breath. She has a negative chest x-ray, but was noted to have scattered wheezes. She was feeling much better after an Albuterol treatment, and her parents agreed to arrange follow-up.” It's not For Whom the Bell Tolls, but it's a simple summary that helps everyone have a sense of what happened. And it did so in three — count 'em — three sentences.
Chest pain? Summarize and describe the plan. Trauma? Tell me why he was safe to go home. Headache? Explain why more workup wasn't needed. Make it a kind of micro-nonfiction. (Micro-fiction can be as short as six words.) Diligence at this craft makes us more effective communicators. And that can only be a good thing in the press of modern medicine.
When my children were little, bedtime was always accompanied by that question: Can you read a story? I'm asking a similar thing: Before you put the chart to bed, write me a story. If it involves a Pomeranian, all the better.
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