A Country Doctor Writes:

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

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.”

The other day I received my copy of the periodic newsletter of our neighboring Canadian medical society. It made me realize that both countries’ primary care doctors, in spite of our entirely different health care systems, are facing some of the same issues.

The bulletin warned Canadian doctors not to enforce a one-problem-per-visit policy, but to offer more comprehensive care to their patients.

The way doctors and clinics are paid in most settings here, two short visits are reimbursed at a much higher rate than one long and complex visit that takes up as much or more time. When patients feel the pinch of copays, travel costs and lost time at work for doctors’ appointments, tensions between the agendas of health care consumers and providers are inevitable.

It can be challenging enough to provide a healing atmosphere in a busy clinic. When doctors feel so much pressure that they become mercenary about their time, any hope of healing is lost.

I never understood the logic behind the one-problem-per-visit way of rationing health care. I do accept that the time we have to spend with our patients is finite, but there is usually some wiggle-room. I tend to be upfront with patients about how much time they were scheduled for. Some patients require extra time for even the seemingly most straightforward problem, but I have many patients who can bring up several problems and allow me to address them in a fifteen minute visit.

A patient with abdominal pain and joint stiffness may have an inflammatory bowel disease that explains the two seemingly unrelated symptoms.

A patient with pneumonia and a raging grief reaction needs both issues addressed in that visit, most likely with early follow-up for both problems.

A person with uncontrolled diabetes never has just high blood sugars; there is always a multifaceted story behind the numbers. That story often touches deep seated issues like self worth and depression.

Doctors in today’s health care machines, not just in our country, seem to think of themselves too often as widget makers, and not as healers. If we deliver only cookie-cutter health care, perhaps every aspect of our work is measurable and more of a commodity than a unique, personalized service. But, by reducing ourselves to generic providers of mass market care, we breed discontent among our patients and burnout within ourselves.

My wife often points out that when I hurry to do things around the house, I become less efficient and actually get less done than if I just plod along and do what needs to be done without fretting about it. In my work, I have just that ability. I am blessed to most of the time be able to enter the exam room with a mind free from the clutter of busy-ness and engage with my patients in an unhurried manner. Sometimes, when I am running late, I will enter the room and literally sigh before sitting down with an apology about running late because of a tight schedule. Patients invite me to relax, and I show them that all my attention is on them at that moment. Not being scattered allows me to accomplish more in a short time.

We need to always think of ourselves as “selling” our expertise and experience, not just our time. An appointment of any length can be effective or ineffective. A brief but well planned visit, where we enter the room prepared and where our documentation in the medical record doesn’t detract from the patient interaction, is more satisfying to the patient and the doctor, and gives some room for connecting with the person behind the symptom.

If we don’t fully master our EMR technology, we will be distracted and ineffective during the visit, and we could fail to document our clinical thinking well enough to be effective in follow-up visits.

I also think we as physicians need to always value the personal aspect of the work we do in order to be of any real help to our patients. If everything about our care is ever so correct, but bland and uninspired, we invite demands for more, as patients feel unsatisfied. If we spend our allotted fifteen minutes delivering exceptional care, our professional satisfaction will carry us further. Our patients will not feel cheated the way many do when we are too stressed to even recognize their needs, let alone begin to address them with skill and compassion.