Bag people, we’ve all seen them, pushing grocery store carts with what seems to be all their earthly belongings. That’s what I think of when I read some medical charts. Back when we were dictating office notes to be transcribed, I often read initial paragraphs summarizing a patient’s entire past history with smatterings of relevant information like most recent colonoscopy if they were in the office for constitutional or digestive or related conditions. That can make a certain amount of sense but often there are too many items quoted in that paragraph for readers to follow along and to grasp what the whole visit was about.
With electronic medical records , particularly written in the APSO format (which I detest, because it’s like putting the punch line before the joke, or revealing the murderer before telling the mystery plot. A better format, in my humble but well grounded opinion, is the aSOAP note.) In hospital APSO notes, I sometimes get the main diagnosis followed by all the other diagnoses the person ever had. Look at this example, for instance:
When I started practicing, clinical notes were brief and to the point. I have mused before about pediatricians with hand written sick visit notes that might read LOM. AMOX (left otitis media, amoxicillin). Before billing codes and malpractice concerns dominated our clinic days, that was all we needed. A little more information, I’ll admit, can be useful, particularly what dose you prescribed on your hand written script that wasn’t copied into the chart.
One interesting observation I have made is that emergency doctors at some hospitals create extremely malpractice defense focused notes with detailed differential diagnoses and why they appeared unlikely. And also the opposite, when somebody comes back from one of the top Boston hospitals, their discharge summary is impressively succinct.
To me the contrast between bag people and globetrotters is worth considering in our charting practices: Too much baggage bogs us down but just enough to fit in a carry-on makes us quicker and more nimble, and can still carry us through most situations we’ll encounter.
A BBC PASSWORD STORY
In all the years that I have been the primary physician for children and young families, especially as children start to become gradually more independent, I have promoted the idea of a family password.
A typical scenario would be that a teenager is with friends and starts to feel uncomfortable about what’s going on. In a telephone call to a parent, the teen would say a secret phrase like did you hear from uncle Sam? This would mean “I don’t feel comfortable with what’s going on, please come and get me“.
I just read an article on the BBC website saying that a secret password or pass phrase could be a weapon against scamming with AI voices.
The article suggests that if we get a call from what sounds like a family member saying they’re in trouble and need money or, worse, want us to talk to their kidnapper, we need to do something very quickly to verify their identity. Asking for the family password can quickly expose an AI imitation of our loved one’s voice.
https://www.bbc.com/future/article/20260804-why-your-family-needs-a-secret-codeword
Lately, in my social media scrolling, I’ve seen a lot of posts about how horses, who are animals of prey, are exquisitely sensitive to our energy and seem to be able to read our minds. There’s also more and more talk about how they synchronize our heart rates when we are together or even nearby. All this reminds me of something I wrote in 2014. I’m linking to it below.
“I Also Tame Wild Horses”
A 2017 post from A Country Doctor Reads (retired blog)
The reason dogs are friendlier than wolves appears to be a genetic one, according to an article in The New York Times:
“A group of scientists from Princeton, Oregon State University and other institutions combined behavioral and genetic studies of 16 dogs and eight captive, socialized wolves to pin down changes in two genes on a region of one chromosome that were associated with hyperfriendliness in dogs. The two genes, GTF2I and GTF2IRD1, are also associated with Williams-Beuren syndrome in humans.”
I found this interesting, because of my general love for dogs and my heartfelt memories of the three extremely affable beagles I have lived with over the years. Also, I know a boy, now in his early teens, with Williams Syndrome. I wrote about him in my first year of blogging in a peace called “All God’s Children”:
“Joey didn’t reach his developmental milestones; his eyes didn’t seem right and he had an unusual, broad grin, which he always flashed. By age two he was diagnosed with Williams Syndrome, a rare genetic disorder that affects one in 7,500 newborns.
Joey, in typical fashion for Williams Syndrome children, is extremely gregarious, even with strangers. He is a favorite with the nurses. He isn’t potty trained, cannot make three word sentences, and cannot make age-appropriate drawings.
His parents elected to give him the 4-6 year-old shots yesterday, and he protested loudly. Immediately afterward, he wanted to kiss the nurses.”
My 2008 piece concludes:
“We must all remember that our children are only loaned to us. We have a natural desire to see them grow up to be healthy and happy, and more often than not I think we hope they will be a lot like us. Our task and privilege as their parents is to see them for who they are, and help them reach their potential.
A youngster with Down’s or Williams Syndrome can be more capable of receiving and returning the love of their parents than a child without genetic challenges, and a healthy child can be killed in a freak accident in the matter of seconds. The wisest parents cannot protect their children from making their own mistakes, and even the elderly often have to grieve the loss of a child.”
I came across a post on a Swedish primary doctor Facebook page that mentioned a word I didn’t know existed. Eminence Based Medicine, at least according to some, is when there is no evidence to base your treatment plan on and you instead choose to trust experts. I guess in some cases, if we’re high enough or long enough into our careers, we might even venture to assume on our own what the best course of action is. “Expert opinion” is often used these days, but it doesn’t have the aura of eminence…
Intrigued by the expression itself, I started researching how new Eminence Based Medicine is, since it was all new to me. I found to my surprise that it was coined by Isaacs and Fitzgerald in 1999. They wrote:
Clinical decisions should, as far as possible, be evidence based. So runs the current clinical dogma. We are urged to lump all the relevant randomised controlled trials into one giant meta-analysis and come out with a combined odds ratio for all decisions. Physicians, surgeons, nurses are doing it; soon even the lawyers will be using evidence based practice. But what if there is no evidence on which to base a clinical decision?
They introduced a bunch of other terms in the same vein as Eminence Based. Some were more comical than others. So here is a table from that 1999 article:
A Country Doctor Writes: 
