Is it the Devil or God in the Detail?

“We must bear in mind the difference between thoroughness and efficiency. Thoroughness gathers all the facts, but efficiency distinguishes the two-cent pieces of non-essential data from the twenty-dollar gold pieces of fundamental fact.”

Dr. William Mayo

The practice of medicine involves a lot of details, but details without the big picture are meaningless at best and distracting at worst.

The expression “The Devil is in the Detail(s)” implies that the details can trip you up, whereas the original, older, idiom “God is in the Detail(s)” conveys the importance, even beauty or virtue, of paying attention to the details when trying to do good work.

I think medicine has lost sight of the big picture when it comes to its thoroughness and its pursuit of efficiency. And I don’t see much beauty or virtue in today’s medical charts.

This was going on before electronic medical records, but quantum leaped with the switch from transcribed dictation to click boxes and copy-and-paste functionalities.

The root of this problem lies with the Evaluation and Management (E&M) coding that literally gives points for how many questions a doctor asks about a symptom – onset, character, duration, severity and so on. Points are also given for documenting which symptoms a patient doesn’t have. In earlier times, we used the phrase “pertinent negatives” for items a reasonable physician would want to know in order to work through the possible differential diagnoses for a particular symptom

With the reimbursement system we now have, the number of questions and physical exam items, regardless of whether they are relevant or just filler material, drives physicians’ income and practices’ bottom line.

It was often possible when reading an old-fashioned, dictated, narrative to relatively quickly sort through the irrelevant items, particularly if the style and grammar were used to provide emphasis. For example, when dictating, you had the option of grouping all the negatives together and of keeping the positives separate and emphasized. With an EMR, the items in structured data entry fields tend to come in a predetermined order, making it much harder for the reader to find the relevant items.

The forest of details in today’s medical record serves purposes other than the efficient documentation for doctors to remember their own inquiry and thought processes. It also isn’t primarily designed for doctors to communicate to each other what they have observed and how they propose to treat it.

Today, under the new Government edicts, medical records have to contain hoards of details doctors never thought were relevant, but politicians and insurance actuaries do and future generations of researchers might. Plaintiffs’ lawyers and medical boards might need them, and patients need to be able to read them, so we can no longer create notes that efficiently document our findings, conclusions and plans. It is as if the conductor’s sheet music at the Symphony could no longer have musical notes, G-clefs and technical terms like “mezzo forte”, in case a non-musician wanted to follow along with the orchestra.

It is a bizarre situation: Imagine the Ministry of Culture requiring that all poetry contain certain elements about the beauty of America and the threat of global warming. Similar things have happened in countries that shall not be named here.

This is where the religious analogy really plays out: Which higher power decides the relative importance of what details in medical records? I have a theory.

Details, details, details…

2 Responses to “Is it the Devil or God in the Detail?”

  1. 1 David Felker MD FACP August 17, 2014 at 5:07 pm

    Say more with less and document your time spent. I found this the only eloquent solution.

  2. 2 Dennis Gannon March 16, 2020 at 11:43 am

    To answer your question, the man Jesus, our current Lord, has permitted the Devil to do some damage. Eventually, he will be turned back, but meanwhile, we all suffer some for neglecting who is in control of all.

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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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