Doctors Speaking Accountanese

You have to think fast in medicine. Not that most doctors handle life and death emergencies all day long, but even seemingly mundane clinical situations require a lot of rapid gathering of data, processing of applicable information and attention to detail in formulating a plan.

I have always been bemused by the so called E&M (evaluation and management) coding that dictates payment by requiring documentation of how doctors think. Ironically, the AMA defines this work and thereby has been a major contributor to physicians now spending more time on documentation than on doctoring. The documentation, even with EMR templates, takes infinitely more time to complete than the thought processes that go into clinical work. Even our preliminary observation of a patient, before any history taking occurs, is something instant, that in a novel might fill a whole first chapter, or in a homeowners’ insurance inventory might go on for pages. We can take in details of a new face or a new place in the blink of an eye; this is something all of us experience. Doctors, by nature of their profession, hone this ability in Sherlock Holmes-like fashion.

Not that I follow sports, but I can imagine a pro golfer or star soccer player could go on for quite a long time describing all the millisecond judgments that go into every aspect of their game. But the difference is they don’t have to. It seems they get paid according to their results, and not by their stated mental work behind those results. In fact, most fans’ appetite for hearing all the details behind the action shots is probably rather limited.

In medicine today, unlike the worlds of Sir Arthur Conan Doyle or Sherlock Holmes, we don’t quite have the option of using the richness and nuances of our language to document our observations. Our words must be chosen from a dictionary of “findings” that correspond to numerical codes used as underpinnings of our EMRs. Our patients can’t be “uncomfortable”, “squirming”, “braced”, “forced”, “pensive” or even “vague”; we must choose between “in acute distress” or “not in acute distress”.

Our language is no longer ours; we must speak like accountants. But when we do, will accountants understand us any better than when we speak like doctors? I suspect that by speaking their language, we risk having our powers of observation, ability of analysis and skill of formulating a clinical plan reduced to something with less depth than what it is, regardless of the number of details we provide.

When we encounter patients we have seen a long time ago, our own notes can fail to give us the instant familiarity of past medical records, and when we see our colleagues’ patients, we struggle more to get to the essence of the clinical notes.

By accepting to describe our work in this foreign language, Accountanese, we have deprived ourselves of some of the tools of our trade, the shorthand that soccer teams might use to synchronize their game. We have lost the nuances of language we need to describe complex processes and multidimensional clinical scenarios involving patients of flesh and blood. So we fumble around, choosing more and more words from our pick lists, none of them quite the right one, while our notes get continually bigger and less and less precise.

We are more or less trusted to care for the lives of our patients, but we are not trusted to bill honestly for whether we just did an easy visit or a complex one.

Maybe I should ask my tax accountant for an itemized bill for his preparation of my income tax filing; all he sent me was a note, stating:

“Preparation of 2013 form 1040. $180″

I would never get away with anything that brief.

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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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