From Scribbles to Scribes: Newspeak and Foma in the Medical Record

“In George Orwell’s Nineteen Eighty-Four, the fictional language Newspeak attempts to eliminate personal thought by restricting the expressiveness of the English language.”

In my youth, I read George Orwell and Kurt Vonnegut, Jr. I remember thinking that “1984” seemed very far into the future – I would be over 30 then!

Well, 1984 came quickly; it was the year I started practicing medicine. I did a lot of thinking about language around that time. I was refining my use of English, my second language, and working on striking a balance between medical jargon and newly learned Maine colloquialisms.

In my residency, our progress notes were transcribed and cosigned by our faculty, but things were different among practicing physicians. Medical records at that time were handwritten in most offices I had contact with. Our notes were brief and to the point with word choices and symbols that conveyed nuances that made sense mostly to the writer and other medical colleagues. Few outsiders ever read our office notes. Specialists usually had their consultation notes transcribed, and there was often a richness and literary grace in their language. Here also, the notes often contained a metatext of subtle meaning that illustrated impressions and opinions without seeming blunt or offensive to uninitiated readers.

Our notes were our working tools for documenting our observations and our thinking. In my practice we often wrote down contingency plans and differential diagnoses for our benefit and our covering partners’, like “consider X” or “switch to Y if ineffective”.

We rarely elaborated the obvious. I remember my awe at the brevity of Rick and Dave, two pediatricians at the hospital where I trained. Many of their office notes simply read: “LOM. Amox” (Left Otitis Media. Amoxicillin). It made sense; what else was needed? The dose followed the child’s weight, and most ear infections were straightforward medical problems. No wonder they could see more than forty patients per day without getting bogged down.

Over the years, office notes became interesting to “outsiders” who had claimed a central spot in the doctor-patient encounter: insurance companies sought to control cost and quality, and we had to start writing our notes so that lay people would find them useful.

Writing mostly for non-physicians meant stating the obvious, so chart notes became much longer. This forced physicians to start using transcriptionists, as typing your own notes seemed a waste of time to most of us.

Now, with electronic medical records, we are finally doing our own typing. However, in order for the EMR to be really useful to the organizations we work for and for the government and insurance companies, we are discouraged from free texting our own words. Instead, we are choosing standardized, built-in words from click boxes or drop down menus. The industry jargon for this is “discrete data entry”. It is more quantifiable than allowing doctors to choose their own words or quote colorful descriptions by patients, but like George Orwell’s Newspeak, it reduces human experience and expression to a color-by-numbers exercise.

Even with the power of today’s EMR’s, click boxes, drop down menus and text macros, many busy physicians find the documentation process too cumbersome. Transcriptionists don’t seem to be the solution for most, because each EMR is different and entering the “discrete data” differently in each product isn’t the same skill set as speed typing and knowing how to spell medical words.

Enter scribes, the latest category of support staff in the medical office; a non-provider (now, there’s some Newspeak, as Orwell would have said) who listens in on the conversation between doctor and patient and documents it in the EMR by choosing the right preloaded words in order to translate the visit into computerspeak.

I read rave reviews about scribes, but shudder at the thought of having one more layer of possible distortion between what is said and what is documented. The patient says one thing, the scribe chooses the closest thing from the computer menu, and the doctor or a colleague, insurance reviewer or malpractice attorney later reads the non-medical person’s chosen word and concludes something totally different from what the patient and doctor had understood in the visit.

The whole concept reminds me of the parlor game “whisper down the line”, where people get to laugh at the change in meaning a message can go through as it is relayed from one person to another and another.

Kurt Vonnegut Jr’s spirit, like Orwell’s, thrives in today’s medical records, whether typed, clicked or still transcribed.

Not only did the increased readership of medical records among non medical “stakeholders” (more Newspeak) lead to documentation of what used to be obvious and understood by and between physicians. It also made room for what Vonnegut called “foma”, harmless untruths; lies that, if used correctly, can be useful (quoted from Wikipedia).

Medical records routinely contain the acronym “PERRLA”, which stands for “pupils equal, round, reactive to light and accommodation”. Yet almost no doctor actually tests whether the pupils change size when the patient focuses on a close object. The acronym is just too handy to resist, as it implies a thorough exam of the pupils was done with almost no effort in documentation.

Another white lie is “cranial nerves normal”, as only neurologists seem to carry a vial of ground coffee for testing patients’ sense of smell. The rest of us at most only check cranial nerves II through XII.

EMR’s make it irresistible to pump up chart notes with foma; one simple click can elegantly declare that a patient was counseled on this, that or he other.

The sad result of the proliferation of Newspeak and foma in modern medical records is that it is harder to find the salient points of medical history, exam, assessment and plan. Maybe the back-end users, those who pull statistical reports of how many heart attack victims have crushing versus squeezing chest pain are having an easier time, but busy doctors reading each others’ notes often secretly reminisce about the days when medical records only said “LOM. Amox.”

4 Responses to “From Scribbles to Scribes: Newspeak and Foma in the Medical Record”

  1. 1 Peter Elias January 25, 2014 at 3:24 am

    I continue to enjoy what you write. Thank you.

    • 2 acountrydoctorwrites January 25, 2014 at 3:54 am

      Thank you, Peter. I keep thinking back to my residency days and how they influenced me. Show this to Rick and Dave if you have a chance.

  2. 3 Lucy February 6, 2014 at 6:48 pm

    This really seems geared to standardizing symptoms and treatments, which would make research and studies a lot faster and easier – and accelerate sculpting health care to a symptom-drug paradigm. The pharmaceutical industry must love it as much as the insurance companys. But will anyone think of the patient?

  3. 4 steveofcaley March 3, 2014 at 11:16 pm

    I appreciate Lucy’s observation above. But really, nominalism reigns in the clinic. The patient can’t care a fig whether (s)he has classic, common or variant migraine. They define the migraine as the type that they have, and variants as they type others might have. Some of the single best path and Best Practices studies really act to remove the actual medical care from the theoretical.
    Once, the “Medical Note” was, well, a medical note; a prompt that would ease the recollection of the course of care of the patient. Now, it is worshipped as some datavistic idol of the dialectical materialist – the “law of the transformation of quantity into quality.” More data does not inherently improve anything. An infinite amount of data cannot stand in for Reality; that is a fallacy of our time, sadly.

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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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