Restoring the Clinical Note

A few years back, Abraham Verghese wrote “Physician as Storyteller” where he told a story of a patient of his who underwent a discectomy complicated by a rare infection at the side of the surgery. Verghese wrote a case report detailing the clinical situation which he later shared with the patient who was elated to be “a rare case.” Until he read the report: “Abraham, there is nothing about me in this paper!”

Disappointed and frustrated, the patient felt that the medical report failed to express who he was as a person, did not give voice to his personal struggles, and ultimately said nothing about his suffering. It was a collection of medical facts that contained no personal story.

There is a great divide between the Voice of the Patient and the Voice of Medicine. Some of it is naturally necessary, but the chasm can and should be less jarring.

With the pervasive ascent of the electronic health records, this dissonance has only gotten worse. The ability to cut and pace and include multiple pieces of information ballooned the clinical notes into a multi-page monsters cluttered with data points. What often is missing in these notes is a narrative that would succinctly capture the patient’s story, clinical observations and communicate the clinician’s thought process and the plan.

In the recent article published in the July issue of the Annals, entitled: “Restoring the Story and Creating a Valuable Clinical Note,” the authors write:

“There’s a critical distinction between documentation and communication: communication can document but documentation alone rarely communicates with matters most. Too often the welter of data loses the story of the patient.”

Now we have an opportunity to change it. As the authors report, new CMS requirements lift the requirement for specific bullet points that had been previously necessary.

Will we take advantage of it?

“…much of the physician’s work requires telling a patient’s story. This process—storytelling, captured in the clinical note—is (or can be) more than a record. With craft, it becomes a device with a voice, connecting the physician to the patient.”

Samuel C. Durso: “Chekhov on Epic”

Just a few days ago, August 30th marked the 5th anniversary of Olive Sack’s death. His writing – unique, detailed and combining clinical observations with deep scientific insight without loosing empathy for the patient – is one example of brilliant medical storytelling. Sacks credited Aleksander Luria, a Russian neuropsychologist, for the inspiration. (In this video, Sacks describes his 1958 encounter with Luria’s style of medical storytelling.)

“Each of us is a singular narrative, which is constructed, continually, unconsciously, by, through, and in us — through our perceptions, our feelings, our thoughts, our actions; and, not least, our discourse, our spoken narrations. Biologically, physiologically, we are not so different from each other; historically, as narratives — we are each of us unique.”

Oliver Sacks: “The Man Who Mistook His Wife for a Hat and Other Clinical Tales.”

Current medical notes, sadly, don’t capture our uniqueness.

Just to see how far we are removed from the tradition, I encouraged you to read another essay in the same issue of the Annals. In a lovely piece with a clever title: “Chekhov on Epic,” D. Durso borrowed clinical scenarios straight from Chekhov’s published stories and imagined them as if Dr. Chekhov wrote “not as a physician-storyteller but as Chekhov the busy physician scribe”. The effect is tragicomic. And we can easily see how, with the transition into the modern Voice of Medicine, full-bodied stories are flattened into soulless documents.

There are many barriers to changing medical notes. Some daunting, others less so. As clinicians, however, we have the power and the opportunity to “create an indelible picture of the patient as a person.”

Try it today.

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