Dr. Francis Peabody’s well-known quote from The Care of the Patient states “the secret of the care of the patient is in caring for the patient.” I would like to think about this quote in a little more depth in the context of the increasing modernization of medical records. A few weeks ago, my department “upgraded” our electronic medical record (EMR) system to better use standardized templates and check boxes. While that process has been exactly as much fun as it sounds, I will try to curtail the ranting about EMRs. What this upgrade brought to mind, however, was the stories I have heard from “the good old days” of symbols, notes, and abbreviations doctors used in paper charts as little reminders about who their patients were. As we move ever farther from these handwritten notes, I hope we can keep their spirit alive.
While I never experienced true handwritten paper charts, in training, I learned to dictate notes in clinic that were transcribed. It seemed many of my attendings had ways of dictating their notes to highlight this important personal information. “Mrs. Jones is a pleasant 68-year old retired school teacher.” “I had a long discussion today with Mr. Smith and his wife (who works here as a nurse) regarding treatment options for carpal tunnel syndrome.” I have since carried this habit into my own practice. “Susie is a 13-year-old level 9 gymnast.” “James presents today with his mother and 5 siblings.” “I had a nice thorough discussion today with baby Rowan’s parents, grandparents, and maternal aunt about Rowan’s polydactyly.” These little reminders help me to remember who my patients are and what is important to them. Certainly it is good customer service – our patients remember us and expect us to remember them. But understanding the patient’s hand condition in the setting of their real life also helps us guide their treatment. Caring about the patient – who they are, what their goals are, what their life is like – helps us care for their hand condition in the way that is best for them. This is the art of medicine – going beyond documentation requirements and clinical practice guidelines to tailor our care appropriately for the person sitting in front of us.
There are many very real benefits of moving beyond our illegibly scrawled notes and haphazard dictations. However, the personalization of our relationship with our patients is in danger of being lost in our efficient, templated notes. Templates and check boxes make it difficult to distinguish one patient’s note from another’s. My favorite example is the templated note I received from a referring physician in which the infant patient was documented as “single, denies smoking.” I had a good time wondering how the infant might have denied smoking, but that documentation certainly did not help me understand the patient’s situation any better. The task of the hand surgeon today is to find a way to maintain the patient’s personality and thus the art of medicine in the midst of the check boxes. So how do we do this?
- Look at your patients, not the screen. Reposition the chairs and computer in the room. Use a laptop or tablet and face the patient. Employ a scribe to do the typing and clicking so you can do the talking. Learn to type without looking down. Whatever it takes! Physicians who use EMRs in patient rooms spend much more time looking at the screen than physicians with paper charts spend looking at the paper, potentially missing out on the nonverbal cues that are important to learning about our patients.
- Designate a consistent place in your EMR to leave notes to yourself. Use the “chief complaint” box to describe symptoms in a patient’s own words. Use free text in your social history to add information about the patient that helps you, not just the information that fulfills the regulations. Use the first line of your assessment and plan to record an assessment of the whole patient. Wherever it is, having a consistent place that will be easily accessible at your next visit is essential to quickly cut through the mass of information now present in formatted notes.
- Resist the temptation to cut and paste. Just because more information is now easier to add to notes does not mean you need to include it. I like to think about what I would have included in a handwritten note, before templates and meaningful use. Certainly I never would have written out a radiologist’s interpretation of an MRI in my note. So why include that now just because I can? While we can’t ditch the requirements, we need to find ways to allow what is truly important to the patient’s visit to take center stage in our documentation.
Sir William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” Guidelines, templates, and check boxes can help us decrease variation in care so that all physicians can be at least “good”. But moving beyond good to great requires the human, not technological, aspect of medicine. No matter how many technological advances arise during our careers, we must continue to find ways to connect with our patients, and remember those connections, in order to serve them best.