A Country Doctor Writes:

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“Did You Read My Chart?”

Published February 28, 2017 Progress Notes 3 Comments

The patient, I surmised, was the one in the wheelchair, with nasal oxygen and an unhealthy red color of her cheeks. The younger woman in the room with her looked like she might be a daughter.

I introduced myself. I had been right about the other woman being her daughter.

It was Saturday clinic, urgent care at our country doctor practice, and the plastic holders with “express check-in” history forms and a scribble sheet for the doctor and the medical assistant were piling up in the pocket of my office door.

“So, what can I do for you today?” I asked.

The woman in the wheelchair gave me a sturdy look and said:

“Did you read my chart?”

My mind raced, thirty years into the past and back again.

As an intern and resident admitting patients to the hospital, I would routinely read up on the patient’s paper chart before entering the room. Each admission took as long as it needed, and the only time pressure I felt was usually my own. The emergency room doctors had already ordered the initial treatments each patient needed.

In practice before computers, I would glance at the problem list and flip through the last few notes, labs and imaging tests while pausing in my office or at the nurses desk, sometimes actually while walking toward the exam room.

Now, with computers that go black after just a few idle minutes, I’d have to log on in order to see any information, and the moments that takes feel like forever. Besides, I can’t very well sit in the last exam room I used and do this, since my nurse needs to room the next patient.

Also, now, with all the checklists we must complete in even the simplest visit, there really is no time during or in between visits to actually sit down and “read the chart”; our time is so pressured and the medical records have become so bloated that we end up just asking the patient, because the pertinent information drowns among the mandated minutia.

“No, there is seldom time to read the chart anymore”, I said.

My patient sighed and gestured to her daughter, who recited her medical history in a monotone voice as if she had done it too many times to count.

The woman had leg cramps, and it was probably because of low magnesium. Her exam was fairly similar to the last note by her own doctor. I did compare my findings and his.

So I prescribed magnesium and two days later we got a call that that had done the trick.

But I don’t think she will ever accept that when she sees a different physician, they will talk to her first, before deciding if it would be worthwhile to steal the time from someone else’s appointment to sit down and read her chart.

A Day in the Life of Sir William Osler

Published February 13, 2017 Progress Notes 1 Comment

Snowed in by a fierce Nor’easter, with our clinic as well as every other outpatient facility within 100 miles closed for the day, I stoked the fire in our wood stove, pulled up my high back chair and read for a couple of hours.

I returned to my treasured, signed copy of Harvey Cushing’s biography of Sir William Osler, the father of modern medicine. On page 431, under the subheading ’He Knew Not Idleness’, Cushing quotes a senior assistant’s account of Osler’s daily routine.

This description may be surprising to those who only know Osler by his famous quote, “Look wise, say nothing and grunt”:

“At 7 he rose; breakfast before 8. At a few minutes before nine he entered the hospital door. After a morning greeting to the superintendent, humming gaily, with arm passed through that of his assistant, he started with brisk, springing step down the corridor towards the wards. The other arm, if not waving gay or humorous greetings to the nurses or students as they passed, was thrown around the neck or passed through the arms of another colleague or assistant. One by one they gathered about him, and by the time the ward was reached, the little group had generally grown like a small avalanche.

The visit over, to the private ward. For the many convalescents, or the nervous invalid whose mind needed diversion from self, some lively, droll greeting or absurd remark or preposterous and puzzling invention, and away to the next in an explosion of merriment, often amid the laughing but vain appeals of the patient for an opportunity to retaliate. For those who were gravely ill, few words, but a charming and reassuring manner. Then, running the gauntlet of a group of friends or colleagues or students or assistants, all with problems to discuss, he escaped. How? Heaven only knows!

A cold luncheon, always ready, shortly after one. 20 minutes’ rest in his room; then his afternoon hours. At 4:30, in the parlor opposite his consulting room, the clans began to gather, graciously received by dear ’Mrs. Chief’, as lady Osler was affectionately known. Soon the chief entered with a familiar greeting for all. It was an anxious moment for those who had been waiting on for the word that they had been seeking with him. After five or 10 minutes he would rise, and perhaps beckon to the lucky man to follow him to his study. More often he slipped quietly from the room and in a minute reappeared at the door in his overcoat, hat in hand. A gay wave of the hand, ’Good-bye’, and he was off to his consultations.

Dinner at seven to which impartially and often, his assistants were invited. In the evening he did no set work, and retired early to his study where, his wife by the fire, he signed letters and cleared up the affairs of the day. Between 10 and 11 o’clock, to bed. Such were his days. Three mornings in the week he took at home for work. He utilized every minute of this time. Much of his summer vacation went to his studies. On railway, in cab, on his way to and from consultations, in tramway, and in the old ’bobtailed’ car that used to carry us to the hospital, book and pencil were ever in his hand, and wherever he was, the happy thought was caught on the wing and noted down. His ability at a glance to grasp and to remember the gist of the article that he read was extraordinary.

His power to hold the mastery of his time was remarkable. He escaped as by magic, so graciously, so engagingly that, despair though one might, one could hardly be irritated. No one could speak consecutively to Osler against his will. How did he do it? I know not.”

(W.S. Thayer, ‘Osler’. The Nation, N.Y., Jan. 24, 1920.)

It makes me reflect:

Time, my old arch enemy, is always on my mind. Over the years, I have managed to adopt a somewhat Oslerian persona, which tries to make every minute, and every brief encounter, count in the mind of my patients and in my own pursuit of forward movement in each clinical case I encounter.

But most days I don’t know that I am anywhere nearly as skillful as the old master in navigating through it.

He probably capitalized on his larger-than-life reputation and position in the world of medicine. I have only a local reputation and the position that career longevity and mature appearance bestows me, like my silver haired temples and my wrinkled hands and face.

But the one thing I know and sense every day in the clinic is: If for a single moment my love of my profession or the connection I feel with my patients and my coworkers is clouded or briefly forgotten, the pace of my workday becomes almost unbearable.

It is only when I am carried by the momentum of my greater purpose that I can make every one of my brief encounters with my fellow human beings count and be healing in any sort of way.

Dropping the SOAP Note

Published February 4, 2017 Opinions 5 Comments

The SOAP Note isn’t what it used to be, and what it has become needs to be scrapped, because it has made the office practice of medicine cumbersome and unsafe.

In simpler times, when medical records were written by and for doctors, the SOAP Note represented a significant leap forward in terms of expanding and organizing office notes, and also notes from emergency rooms and walk-in clinics. Prior to that, notes sometimes only documented the diagnosis and the treatment, not how those were arrived at.

With S for Subjective, O for Objective, A for Assessment and P for Plan, the reader could instantly find exactly what he or she needed to know from a colleague’s medical record entries.

These days, medical records contain a lot of data that is mandated by outside parties – CMS, ACOs, PCMH/NCQA, the Joint Commission, and now even local states, like Maine.

EMR vendors have inserted these mandated items in sometimes very illogical places in the medical record, and they have also infused bookkeeping items where they probably work best for billing purposes, but definitely not to document clinical thinking.

Some examples:

I see many ER notes that don’t clearly state the patients “Chief Complaint”. I see that they got there by private vehicle, gave the history themselves, didn’t need an interpreter, had already had all their baby shots and were not yet ready to quit smoking, but I’ll be darned if I can figure out what brought them out in the middle of a snowstorm to see somebody in the emergency room.

In the SOAP Note, anything observed during the visit instead of told to us, such as vital signs, heart sounds, blood tests and in-house X-ray findings would go under Objective. Tests ordered but not expected back until later went under Plan.

In the EMR I work with (or under?), there is no Objective and no Plan. There is Exam and Treatment.

That difference isn’t subtle.

The tests I do in-house are ordered and resulted under Treatment, after I have already stated under Assessment what the diagnosis is. That makes no sense. A chest X-ray doesn’t treat anything. The antibiotic I prescribe goes there, too, so at least that makes sense. But essentially, the logical and chronological order of my notes has been hijacked by non-clinicians.

More static items like past medical history, family and social history used to go on the inside left of paper records, where they could be referenced and updated on the fly. Now, just like in a hospital admission note where the patient is presented as if they had never been seen before, they are prominently displayed in every single office note.

That is one of the fundamental differences between a paper office note and an EMR note; the former is pertinent and the second is comprehensive, because the note presumably has to document that the doctor mentally went back over known historical facts and considered their possible relevance for the problem at hand with the speed of expertly trained thought and hard earned experience.

It didn’t seem enough to keep the background data separate and simply state “I considered the Past Medical, Surgical, Social and Family history in handling the patient’s issues in today’s visit”.

Even if someone I stitched up ten days earlier just comes back to have the stitches removed, the second office note reads as if a stranger just walked through my clinic door.

In such a case, a visit that lasts less than five minutes from the doctor’s point of view requires verification of all the data that isn’t likely to have changed in ten days, and the office note is just as long as the original note about the chainsaw cut or their first get-established visit – seven pages of 99% irrelevancy for a simple suture removal.

The mandated add-ons’ presence in every single office note has created a clear and ever-present danger that time-pressured clinical staff and physicians will miss critical information and put patients at risk for clinically incomplete care, even though I’m sure the non-clinicians’ intent at some point was to ensure the opposite.

All these additions have inflated and cluttered up the SOAP note to the point where I think it is high time we reclaim a space, however small, inside the office note for strictly medical documentation that is immediately pertinent.

This nugget notation needs to be near the top of our computer screen, so we don’t have to scroll, even to get from the beginning to the end of it.

We must accept that the office note serves the needs of many people and bureaucracies, but if we don’t make it serve us better, we’ll drive ourselves into the ground and at least some of our patients into their graves because we might miss critical things in the overinflated medical records of today.

Friday’s Lessons

Published January 22, 2017 Progress Notes Leave a Comment

My colleague, Dr. L.T. Kim, was off this week and I covered for him.

Friday afternoon I dealt with two of his patients and learned, or relearned, two important lessons.

I saw a man with thoracolumbar back pain. He had fallen off a ladder a few years earlier and suffered from recurring bouts of back pain, sometimes with tingling in both legs. He had been to the emergency room after a particularly bad episode. Dr. Kim saw him in followup and ordered an MRI of his thoracic spine.

I saw him to review the results. The MRI showed more or less garden variety degenerative changes, but nothing that would explain all his symptoms.

“I’m feeling much better, but this very sore spot is still here”, he said and asked if he could point to the corresponding place on my back.

I asked him to remove his shirt and palpated my way down his spine.

“Right there. You got it”, he said.

I marked the spot with an X, using my green ink rollerball pen, sat down at the computer and ordered PA and lateral lumbar spine films. My tech taped a metallic marker over my X and a few minutes later I saw on the screen that his pain centered on his second lumbar vertebra, just below where his expensive MRI had ended.

A call to Cityside hospital’s MRI department verified that they couldn’t just go back and look a little lower on their images, which only included a small fraction of L2. Our patient needed a whole new, lumbar, MRI.

In case I had any temptation to feel a little smug that I had realized something Dr. Kim hadn’t, I learned another lesson at 4:55 pm.

“I’ve got a sodium of 123 on one of Dr. Kim’s patients”, our lab manager said as she entered my office with a lab printout in her hand. “If he saw this he’d probably have the patient go to the ER by ambulance”, she continued.

“Well I don’t usually worry quite that much about sodium levels”, I said. “I’ll take care of it.”

I saw that this older woman had been discharged from the hospital a week earlier and she did run low sodiums there, about 130.

Dr. Kim is an internist by training, and he spent most of his residency years in a tertiary acute care hospital, where only the sickest patients went. In that setting, even small changes in lab values could be harbingers of deterioration, disaster and death. I spent most of my training in small town hospitals and outpatient clinics, where most people got better more or less on their own, and where small laboratory abnormalities often didn’t matter much at all.

I dialed the number.

“Hello, is this Mrs. Weld? This is Dr. D. calling from the clinic with your lab results. Dr. Kim is away this week.

“No, this is her daughter.”

“Her sodium is low so I’m calling to see how she is doing.”

There were several voices in the background.

“Guys, I’ve got the doctor on the phone”, she said and the voices went silent. She continued: “The ambulance is here, I’ll put you on speakerphone so you can talk with them.”

“Hey, Doc, what’s up”, the familiar voice of one of our local EMTs greeted me.

“Mrs. Weld has a sodium of 123, it was 130 a week ago when she left the hospital”, I said.

“What are the symptoms of that?”

“Weakness, lethargy, confusion…” I started.

“That would be it, Doc.”

“So she needs to go back to the hospital. I’ll call the ER”, I said.

“Thanks a lot for calling, Doc. Good timing!”

Indeed. And I thought this would turn out to be just an insignificant laboratory abnormality.

Not On Call

Published January 19, 2017 Progress Notes 2 Comments

“I am not on call”, Dr. Brian Stoltz said over a lot of background noise through what must have been the speakerphone in his car.

“I know”, I said. “Cityside ER said there is nobody on call for ophthalmology this weekend. I have a 54 year old woman with intense tearing, discomfort and only 20/70 vision in her right eye.”

“And she’s not a patient of our office?”

“No, she has only had to see an optometrist for glasses. I’ve called every hospital within 50 miles and there is no ophthalmologist on call over the long weekend. You helped me once before with a case of dendritic keratitis when you were on call.”

I also remembered Memorial Day weekend last year, I was in the same situation during my Saturday clinic. A young boy, whose mother had just joined the board of our health center, came in with eye irritation. He had a small rust ring very close to the center of his cornea. I had dug out plenty of them, with a special spatula or even with the tip of an 18 gauge needle, but this was a child, who might not have beeven fully cooperative, and the location was critical for his future near vision.

Cityside Hospital had no ophthalmologist on call for that long weekend either, and all my calls to ophthalmologists in the surrounding area were fruitless. He got in to see an eye doctor the Wednesday after the Monday holiday and it turned out that he actually also had a small metallic corneal foreign body. Everything turned out okay, but the wait was uncomfortable and at least a little risky.

A corneal rust ring, even a foreign body, can usually wait a few days, but if this woman had what I thought, acute angle closure glaucoma, I wouldn’t want her to wait that long to see an eye doctor.

“I think she’s got acute glaucoma”, I said.

He was silent. I continued:

“She’s got mixed injection, no foreign body, no fluorescein uptake and I can see her left fundus clearly but I can’t get a focus on her right fundus no matter what lens I dial in on the ophthalmoscope.”

He was silent again for what seemed a very long time. Then he said:

“I live an hour away, but I happen to be in town. If you have her walk out your door right now, I’ll meet her at my office in, what, 25 minutes?”

“She’ll be there. Thank you so much.”

I haven’t heard yet what he found, and I haven’t wanted to bug him, but I am anxious to hear what the final diagnosis was. I do know that an urgent slit lamp exam was necessary.

One postscript:

When I sent my emergency eye patient off with her office note and insurance information to see Dr. Stoltz, her husband said:

“You’ve done well by us. I came in and saw you once with a cauda equina syndrome.”

I didn’t remember him, but he must have had a critical enough pressure on his lower spinal nerves to also have warranted an urgent referral to a specialist.

Disease strikes at inopportune times.

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