D epartment
of
M edicine
Con ne c ti ng T e c h n o lo g y , Ed uca t i o n a n d D i s cove ry w ith H um anis m in Me dicine
Vol. 3 Issue 4 October 2014
Healing the Medical Record
Through his writing, Charles Dickens is credited with creating a tidal wave of social change in England regarding child labor, the care of orphans, public sanitation, and more. While few can aspire to being as influential as Dickens, our words are powerful. What we say and how we say it may influence others’ attitudes about a person, group, or particular situation. Careless use of words may send a message that is not intended. In his article, “The Language of Medical Case Histories,” published in the Annals of Internal Medicine several years ago, Dr. William J. Donnelly listed several maladies in medical documentation that either reduce the patient’s problem to a biological puzzle or cast the patient in a light that makes them appear to be of inferior intellect or not trustworthy. For example, supplanting the chief complaint with a clinical term such as “gallstones,” hijacks the only place in the history where the patient is allowed to speak for themselves. “I hurt in my stomach, under my right ribs after every meal” is cause for concern regarding the gallbladder, but preserving the patient’s own words leaves an opportunity to explore other possibilities, including their concerns regarding the origin and implications of these symptoms. Introducing the patient as “This is a 45-year-old white male” reduces the person to a biological specimen and his symptoms to little more than a biological malfunction. “Mr. Jones is a 48-year-old professional golfer” is an introduction of the man and the person, and we automatically worry that his illness might jeopardize his career. The history of the present illness is riddled with phrases such as “the patient claims” or “the patient denies,” which create a threatening image of the physician conducting an interrogation on a person he believes might not be telling the truth. “The patient refused her sleeping pill” sounds as if there were a heated argument, when it is far more likely that a good-hearted night shift nurse offered an elective sleeping
aid and a grateful patient said, “No thanks.” This destructive dialect has winnowed its way into every form of medical communication. It permeates our medical histories, progress notes, and discharge summaries. It appears at morning report and grand rounds. It creeps into hallway conversations when we curbside our colleagues about a perplexing patient. Competent, compassionate physicians and nurses talk and write this way without realizing that a lay person hearing or reading our words might think that the patient was an adversary. The damaging effect of words can be countered by writing in a way that does not cast doubt on the patient’s credibility or insight. Preserving the patient’s presence and documenting their perspective in our communications would project a more accurate reflection of the mutual trust and respect that exists in a healthy physician-patient relationship. Healing the medical record might go a long way toward changing the perception that the medical profession has become cold, impersonal, and uncaring. Let the healing begin.
Points of View
Rajiv Dhand, M.D., Chair
Academic medical centers, “teaching hospitals,” serve a vital role in our complex health care system. The primary purpose of such centers is to provide training for medical students and resident physicians to become competent, independent practitioners who are comfortable using the most current technology and treatments. Physicians are groomed under the guidance and direct observation of skilled physicians and teachers,
while they also have the opportunity to manage patients and learn the best practice for a wide variety of diseases. This system of rigorous training is meant to achieve a high standard of excellence and to uphold the skills expected in the physician workforce. Over time, academic medical centers have emerged as “safety net” hospitals that provide care to the indigent, the homeless, and the uninsured and underserved segments of our population. Academic medical centers bear the responsibility of caring for patients with the most complex illnesses and serving as the primary centers for research and scholarly activity. At these centers, new ideas are generated, new science is created, and new technologies and the latest continued on page 3
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