The Note Taker’s Dilemma

The year is 2020, or sometime in the future when the healthcare system is better, much better. Patients have access to their medical notes, are encouraged to read the notes regularly and ask physicians relevant questions. This is to facilitate patient-centered participatory medicine (PCPM), previously known as shared decision making. In fact, note reading by patients is now a quality metric for CMS.

The CEO of the Cheesecake Hospital Conglomeration, one of the hospital oligopolies, has set up a Bureau for Transparency and Protection of Patients from Complex Medical Terminology. The goal is to risk manage troublesome medical writing that could result in poor satisfaction scores, complaint or a lawsuit.

Mr. Upright (MU) is the Inquisitor General for the bureau. He has called the author (SJ), a repeat offender, to his office to discuss elements of his medical record keeping.

Disclaimer: Any resemblance to future events is purely coincidental. The narration is merely a reflection of the author’s paranoid affect and a tendency to believe in conspiracy theories.

MU: Dr. Jha, you’ve been summoned because your open medical notes do not meet the standards for empathy and compassionate care and seem devoid of a reflection on the complex interplay between social determinants of health.

SJ: Has a patient complained?

MU: No. But that’s what the bureau is trying to prevent. We protect patients from physicians. Actually, we protect physicians from their most dangerous enemy: themselves.

SJ: How do you know the standards were not met?

MU: Your notes were analyzed randomly by a panel comprising a diverse range of stakeholders who are experts in Humanism and Compassion.

SJ: How does one become an expert in Humanism?

MU: At the very minimum it requires a PhD. Most have done a post doc and served as Directors of Humanism in various parts of the world. I digress, there were five instances in which there was a high concordance between the experts that your medical notes risked confusing, alarming or offending patients. For the sake of transparency I should show you the kappa.

SJ: Don’t worry about the kappa. Just tell me about the cases.

MU: The first case is a 45 year old male with chest pain. You called his pain ‘atypical’.  Rather callous, don’t you think? It might seem atypical to you but it is quite typical for him.

SJ: By “atypical” I meant ‘not typical for angina’. This distinction is the difference between life and death.

MU: Then you should have said so. Bear in mind not all patients understand angina.

SJ: Should I say ‘heart attack’?

MU: Research has shown that patients whose open notes had ‘heart attack and other worrying phrases such as ‘tear in the aorta’ gave lower scores for satisfaction, even when they were eventually found not to have these diagnoses. Hospitals lose millions of dollars on bonuses for consumer satisfaction just by the presence of alarming words in medical records.

SJ: So I can’t say ‘atypical’ because it can sound trivial. I shouldn’t say ‘angina’ because it’s too technical. I might alarm the patient with ‘heart attack,’ even though it’s colloquial. Any suggestions?

MU: You’re the doctor, not me. I suggest you understand your patient’s unique culture and value systems and decide accordingly. Now let’s move to the next case, which is far more disturbing. The kappa is 0.95.

SJ: Did the patient complain?

MU: No, but that’s not the point. For a 28 year old female with right lower abdominal pain in the notes you said, and I quote verbatim: “Patient denies unprotected sex.” Denies! What were you thinking or were you even thinking?

SJ: That history is relevant in distinguishing between appendicitis and pelvic inflammatory disease or ectopic pregnancy.

MU: You still don’t get it. How would you like it if I said, “Dr. Jha denies shop lifting, denies tax evasion, and denies murder.” Sounds accusatory, doesn’t it?

SJ: If you put it like that, yes. But denying “change in bowel” habit is hardly the same as denying murder.

MU: But ‘denies unprotected sex’ makes you sound like a judgmental puritan. And not to mention a hypocrite. Remember prudes have no place in healthcare. Doctors that carry their moral and religious values on their sleeves are incompatible with high quality patient-centered care.

SJ: Quite frankly I couldn’t care less if the patient had unprotected sex recently.

MU: That sounds indifferent. You should care about your patient’s welfare regardless of your assumptions about their moral character.

SJ: What I mean is that I don’t pray for brimstone and fire to appear from the sky and shower upon the patient.

MU: Let’s move to the next case which is a 32 year old female with polyuria and polydipsia…

SJ: Ok maybe I should have said ‘thirst’ instead of ‘polydipsia’. Would you really prefer that I say “frequent urination” or “always passing the penny” instead of ‘polyuria’ ?

MU: Calm down, the experts were troubled not by your use of technical jargon but by something far more egregious. In the differential diagnosis you listed diabetes insipidus and diabetes mellitus, and that “p” word: psychogenic polydipsia.

Even first year medical students know that ‘psychogenic’ is offensive and a taboo. It makes the patient feel like a malingerer. Do you know what that does to the doctor-patient relationship? How would you like it if I accused you of lying?

SJ: Sorry, there’s an entity known as psychogenic polydipsia where patients drink lots of water. Admittedly, it’s a diagnosis of exclusion.

MU: Have you not updated yourself with the recommendations of the 22nd Taskforce for Repeated Renaming of Disease? In their last report they banned terms such as ‘psychogenic’, ‘idiopathic’ and ‘uncertain’, particularly ‘psychogenic’.

When you do not know the cause of your patient’s symptoms and you have excluded common diseases you are supposed to say, “No cause found yet, but the search continues until we find a cause which we will.”

DJ: Can there never be a psychogenic basis to a patient’s symptoms?

MU: Only when the patient says so. The patient knows best. Always. Get rid of this paternalistic mentality that belongs to the Stone Age. You’re the patient’s coach not an independent espionage service.

The next case. You wrote in the notes of a 52 year old male with distended abdomen “cannot assess for the presence of hernia because of abundant adiposity between the skin and peritoneal surface”.

SJ: I was looking for an abdominal wall hernia as a cause of bowel obstruction…

MU: Never mind the hernia. What were you trying to be by writing ‘adiposity’? Clever? Showing off your medical vocabulary?

SJ: Sorry, I was once reprimanded for writing that the patient was morbidly obese and now you reprimand me for using a politer medical synonym.

MU: You risk appearing patronizing. How long do you think it will take the patient to perform a web search for adiposity and see what it truly means? Not only could the patient be offended but a little deceived by you.

SJ: What should I have written?

MU: You should have explained that because of his body habits it may be difficult to assess for a hernia. You should have stressed repeatedly that his habitus was no fault of his. The panel was divided on whether they thought you harbor inherent malice towards people not as slim as you. This would not have happened if you documented the explanation and reassurance in the notes.


SJ: Yes I remember: If your thoughts are not documented they have not taken place.

MU: Good. Now to the final case where you made a few errors.

The panel was disturbed by your questioning of a 55-year-old female with difficulty breathing. You asked the patient whether she had been near a dead parrot, sick parrot or kept a bird as a pet. How bizarre.

SJ: I can explain. I was thinking of psittacosis; parrot fever. It’s a cause of pneumonia. I was also thinking of an allergic reaction to birds; hypersensitivity pneumonitis.

MU: Did you convey your thought process to the patient?

SJ: I believe I did.

MU: It’s not documented. Remember: no documentation, no happen. How do you think the patient might have felt? One moment asked whether she gets breathless climbing stairs and the next about dead parrots. Remember patients can post medical notes on social media. Do you want your notes to appear as if straight out of the script for Monty Python?

SJ: I see your point. You said there was another error.

MU: You asked if the patient had family history of heart disease. She told you that her father died of a heart attack at the age of 94. Then you go on to say “no family history of heart disease”. The panel wondered whether this was an oversight on your part. Why did you contradict the patient?

SJ: This was not an oversight. Having a heart attack at the age of 94 doesn’t count as family history, 45 yes, 90, no.

MU: You are not making much sense, Dr. Jha. Whatever convoluted reasoning you have you must explain your thought process and document that explanation. Although the patient did not complain the panel felt that this was a category 5 mistake, the worst type of mistake in which doctor disregards what the patient says. Your reports will be under heightened scrutiny for the next month. A member of the panel will accompany you to see whether your communication is adequate.

For the record can you summarize what you have understood from the meeting?

SJ: This was a useful meeting and I’m honored that I was selected to be protected against myself. My notes should contain medical terminology but not when it confuses the patient. I should use simple phrases unless they frighten the patient. I should not appear judgmental, accusatory or insensitive. I must not hide under sophisticated but patronizing medical terminology. I must explain my thought process particularly when it appears to contradict the patient’s. If it’s not documented it did not happen in my mind.

MU: Very good. Don’t forget to be very clear when asking patients about birds and animals.

SJ: Understood.

Saurabh Jha, MD (@RogueRad) is an Assistant Professor of Radiology at the University of Pennsylvania. His scholarly interests include the value of imaging and dealing with uncertainty in clinical decision making. Jha views most problems in medicine as problems of imperfect information. He trained in the UK and migrated to USA for more predictable weather and a larger yard.

7 replies »

  1. Please correct the misprint in the first sentence. It should read “2014”. This dystopian vision is actually here in the present!

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  3. Lol, legacy!

    If Swift were alive today he’d probably be writing a “modest proposal” to save healthcare.gov!

    Satire is policy and policy is satire!

  4. Well done!

    And remember, poor children – if well cooked – can be very tasty! – J. Swift

  5. If by “navigate and work with notes…” you are referring primarily to understanding unfamiliar medical terms as one reads:

    I’m not as familiar with Windows, but on a Mac, in nearly any program (including all browsers), one need only highlight and right-click any word or phrase to launch a dictionary/thesaurus entry for that word or phrase.

  6. Amusing. Point taken. Yet there HAS TO BE a solution. Maybe somebody needs to develop a brilliant technology that helps patients navigate and work with notes ….