I write every day, but have not really considered myself a writer. I’m a physician, a surgeon. I take care of patients. I operate, I admit patients to the hospital, I consult. I order tests, labs, images; I do physical examinations, I take medical histories. And I write it down.
I gather all of this information, and more than simply recording a list of symptoms, physical findings, and results, I convey the narrative of what has happened, what is going on, the interpretation, the plan. So, maybe I am a writer. A biographer, of sorts, telling the story of every patient I see. Synthesizing the data, the history, the laboratory and test results, the imaging–into a narrative that not only explains how and why the patient got here, but also what I think is going on, what it means, and what we are going to do next. The original, and still primary, reason for the patient chart- the medical record – is Telling A Story.
This special “biography,” the patient history, is an extremely important piece of the story, of caring for patients. All of the testing in the world–labs and imaging and what have you–are really only in support of and augmenting what is learned in the history; it can not and does not replace it. My wise teachers maintained that about 90% of what was really happening with the patient could be ascertained from a skilled, well-done history.
Taking a good history is an art. Learning to take a patient history was when I understood why medicine is referred to as an art as well as a science. Taking a good history means you need to sit with your patient, ask questions, and listen to the answers. Listening to the answers, being attentive to demeanor and body language. Attending to the process. Teasing out the story and the details and nuance is the art of the interview, uncovering the history, the story.
Then we set ourselves to the task of telling their story. A narrative capturing the detail and nuance so that it explains to the reader– our colleagues and staff–what is happening, what is the impression or conclusion, and why; what the next steps are, what will happen, what the plan is. Telling the story. This isn’t easy, but this is rewarding. It’s how we take care of patients. This is what doctors do every day. This is what I do. So, I am a writer, a storyteller, just as I am a physician, a surgeon. This storytelling is the heart and the art of good patient care. The stories and their telling link the patients and physician; they are integral to care. Patients deserve to have their stories told and told well. Communication is a strong link in the chain of the physician-patient bond, vital to the trust that is forged by that bond. But, this link has been strained nearly to the point of breaking.
The history, the physical, the progress notes and the testing are combined in the medical record, weaving these threads together to form the narrative that is the story of the patient. The electronic medical record (EMR) represents a threat to that. The story unravels.
It is no wonder, and should come as no surprise, that many doctors in general, and myself in particular, buck and chafe with the imposition of EMRs that are nearly ubiquitous in hospitals, physician offices, and clinics. Most of these systems are unwieldy and do not integrate well into the work flow of an office or clinical setting. So either the physician continues on with the old processes, saving the charting for later after the completion of the visit (which has problems with recall, workflow, and time management), or the physician’s nose is buried in the laptop or tablet device, focused on clicking the right boxes, the right templates. In both circumstances, the narrative breaks down.
The heart of this narrative is derived from the communication between the physician and the patient, both verbal and non-verbal. This builds trust, the foundation of the physician-patient relationship. Trust that is built by the attention to their story, taking the time to listen. For all too many patients, this may be one of the only times and places in their life where someone does, in fact, listen to what they have to say.
Patients don’t like it if they feel that the physician is not paying attention to them. They see physicians focused on the computers, making eye contact with the screen instead of the patient, and feel like the doctor cares more about the computer than about them. Patient trust, patient communication are eroded, and so is the story.
When you find the nuanced and detailed narrative reduced to checklists and templates, a series of checks in boxes, the story gets further lost. It’s buried in a mountain of information that lends little to nothing to the story. All we see is a laundry list of conditions, of symptoms, of tests -pertinent and not, present or absent. We can barely tease out the details we need, if they are even there. No story, no narrative. Almost unintelligible and useless, pages and pages of tightly spaced words, important information buried like a needle in a haystack.
EMRs have been fantastic for insurance companies, billing services, tracking quality measures, any entity that needs to simply track data points. But the current state of EMRs, with few exceptions, is generally a disaster in communicating between colleagues and telling the story, telling it right. There are few people who have mastered or who even like their EMR, and even then, they usually use various add-ons like voice recognition software or “medical scribes.” But this comes at a significant (and to many practices and practitioners, unaffordable) price of time and effort, or money, or both. I don’t think any physician can say that EMRs enhance their work flow or ease of patient care; even in the best of circumstances they cannot see the same numbers of patients or spend the same quality or quantity of time with the patients they do see. The story suffers.
In this most human of human endeavors, a person caring for another person, we are risking our humanity, the humanity of attention and touch and connection. We risk our own humanity, as we feel like automatons and data entry technicians; and risk the humanity of our patients, reduced to check boxes, templates, and data points. We lose the humanity of connection with our colleagues and staff with stilted or ineffective communication. And we lose the story, a very human story.
Kathryn Hughes, MD, FACS is an experienced General Surgeon who has spent most of her career in private practice. She is active in organized medicine, serving on the Committee on Women in Medicine for the Massachusetts Medical Society, as well as other professional organizations. She earned her MD from the George Washington University in Washington DC, and completed her surgical training there. She blogs about her experience at the intersection of life and a life in surgery from Behind the Mask (behindthemaskmd.com).
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