Off The Record

Gwen and Dan Olsen were a handsome couple with a stunning blonde eight-year-old daughter, Trina. They had just moved to the town where I did my residency and over the course of their first six months there I saw all three of them for routine health care needs.

One day Gwen came in for nausea. She didn’t look well and I could see in her facial expression that something was dreadfully wrong. Thinking unplanned pregnancy and morning sickness, I glanced at her problem list, where her husband’s vasectomy was listed, in my own handwriting, as her method of contraception.

“I’m pregnant”, she burst out, tears suddenly streaming down her cheeks. I sat quietly for a while. She didn’t say anything.

“Dan had a …”, I started.

“He’s not the father”, Gwen said.

Wiping her tears she described how she had gone back to her parents for a visit, run into an old boyfriend and found herself doing the unthinkable.

“Does Dan know?” I asked.

She nodded.

“What do you want to do?” I didn’t say the A-word, but she understood.

“We’ve talked it over and we’re going through with the pregnancy as if it were Dan’s baby”, she began. “He’s promised me he will love us both just as much as if he were the father. We’ll just tell people the vasectomy must have failed.”

“Those things happen”, I said.

“Will you be my doctor for the pregnancy?” she asked.

“Of course”, I nodded.

“And please don’t put anything in my medical record about it not being Dan’s.”

“Of course”, I reassured her.

That fall I delivered a beautiful baby boy to two of the nicest, proudest parents I know. I was able to see him, his parents and his sister through two years of well baby visits, shots and minor childhood illnesses during the last two years of my residency.

Several years later I happened to run into the four Olsens again. Little Brad looked just like his mother.

Today I read in a journal that a large percentage of patients won’t tell their doctor sensitive information if they believe their information might be shared electronically with other doctors, hospitals or insurance companies.

Some things are better left off the record.

5 Responses to “Off The Record”

  1. 1 cathy April 18, 2010 at 8:04 pm

    That is a very good point. There are other issues that cause concern with EMRs as well.

    For instance…what if there comes along a doctor that you have a big personality conflict with? It happens. So what if he then puts only negative things about you in an EMR that all other doctors will read and form an opinion from? That could be very unfair.

    Also, What about us who have family members who may be doctors or other medical professionals that have access to medical information. Would they be able to access our medical records even though they would not be our doctors?

  2. 2 Elizabeth@ OBcookie April 19, 2010 at 2:03 pm

    I just found this blog–what an eloquent writer you are. I am a 4th year medical student about to start OBGYN residency. I think this topic is really important because sometimes facts about patients are milled around that don’t effect the medical outcome of their care, but can effect how a provider views a patient. Thanks!

  3. 3 isaac April 23, 2010 at 1:57 pm

    I hope the biological father doesn’t have any medical history problems that can cause the child problems later on life.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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