How to be an Authentic Doctor #26: Tell a Story

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A patient’s chart should reflect their visit.  In fact, it should be a story.  Just as a book or a movie, there is a beginning, a middle and an end.  The beginning is their complaint and the story behind it.  The middle is your exam and possible work-up.  The end is your assessment and plan.   Now that is out of the way, here is my point. In that assessment and plan there should be….a f%cking assessment and plan!  That is why they call it that.  I can’t tell you how many times I see the diagnosis in patients’ charts with nothing else.  Nothing.  It will just say “Headache” and maybe a lab.  That is all.  Unbelievable.  Other times I may get lucky and see a cryptic note with something like “bw done.  F/u if no better”.   I have seen that last one many times.  Why?  Because I wrote it!  And I hate myself for it!

Why is it like this?  With the advent of the electronic medical record came shortcuts.  These shortcuts have ruined the chart.  Most of the crap in there is useless or plagiarized. The filler is the biggest part because that is what enables the doctor to upcode and optimize his or her billing.  The problem is that no one really reads this garbage.  The reader or moviegoer wants to know the beginning of the story and then see how it ended.  Most EMR records (trust me, I have become more and more guilty of this too) have no narrative.  There is NO story.   In the old days I would dictate and then give a whole paragraph on my thoughts.  I would give my opinion of what I thought was going on and why.  Do you see that today?  Rarely.  I would outline what I was going to do and why.  I would give a differential diagnosis.  I would detail what I told the patient and why.   This is not happening anymore, it bores the reader,  and it is bad for medicine.

My former medical partner said that when he saw an old dictated assessment and plan of his recently a tear actually came to his eye.  I would say this about ALL of medicine but I get his point.  Unfortunately, I don’t see this changing. The new guard is comprised of “click-happy” kids who have lost this art (or never had it).  They are treating numbers and not patients and all they worry about (because that is what the insurers worry about) is getting the clicks done.  Their notes suck!

My recommendation is to take the time to at least give a story in the “HPI” and the “A/P”.  Think about someone reading your visit and wanting to know what you were thinking.  It is so important.  Your job is to give your thoughts and help the patent and not make insurance companies happy.  If you are practicing Direct Primary Care, however, then you know what I mean because you have the time to document in a meaningful way because your only employer is the patient.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  11 comments for “How to be an Authentic Doctor #26: Tell a Story

  1. Anatoly
    August 25, 2014 at 1:17 am

    I don’ t think it is a problem of the medical record. Doctors are making a chart. But they do not have neither time, nor desire to change the record, that based on financial requirements of the insurance, and not on real values of thoughts so important to maintain high quality in the profession. We just simply loosing a battle and transforming from the doctor profession to service.

  2. Tom
    August 22, 2014 at 1:51 pm

    Amen! I have used Epic for 2+ years. Notewriter allows for completely “accurate” but totally useless descriptions of the HPI. One of my partners and I cannot stand this and take our PC home to complete the notes in a way that actually tells the story. If I read another “a 10 point review of systems was obtained and was negative except for the HPI” from an orthopedist, when the patient has diabetes, CHF, hypertension, angina and chronic kidney disease” I am going to vomit, and then they upcode the charge for a ROS that was not necessary in the first place. For heaven’s sake, make you notes tell a story that explains what has happened and why!

  3. Ray
    August 21, 2014 at 8:57 pm

    Hey Dougie! Could not agree more. The EMR was supposed to improve efficiency, save time, improving coding and documentation. This really…….is BS. This is a control issue. Doctors don’t know what is best for patients. The government or the insurance company or the hospital does. If you type your own notes and you are seeing 3-4 patients per hour with 10 active medical problems each , you need to be able to type 150 words per minute to accurately portray for your medical colleagues and yourself (that is the point of the documentation right?) what you were thinking…and why you did what you did for this patient encounter. I type 10 words per minute, my medical transcriptionist was with me for 15 years, survived 2 different hospital positions and was sh#tcanned for cost concerns. The result is yours truly typing my own notes. Horrendous. A series of bullet points. A terrible synopsis of the visit with “death by a thousand clicks” documentation thanks to the wonder of the EMR. Watch the movie “Planet of the Apes”, when Charlton Heston comes upon the Statue of Liberty in the sand. “You finally really did it!, you maniacs!, you blew it up!, oh damn you!, Goddam you all to hell!…. We let the monkeys decide our fate. Dr Zaius……paging Dr Zaius.

    • George Voigtlander
      August 22, 2014 at 6:20 am

      You nicely summarized problems with EMR’s. It is unfortunate that the office of National coordinator does not read this blog. It was his responsibility to make sure that the EMRs approved are functional and safe for patients. There was an attempt to make EMRs classified as medical devices and subject to review by the FDA. This way they would have to be both safe and effective.

  4. Leslie
    August 20, 2014 at 7:57 pm

    I read charts, for insurance preauth or claim denial reconsideration, for a living. There is SO much nonessential information about what they don’t have, that what they do have is forgotten. Amazing how often they systems assessment has everything marked as no this or no that, yet there is a needed for custom KO, AFO, wheelchair etc. Sometimes there is a small narrative but it conflicts with the check boxed items. Yes, I would like to hear the story, with a problem and not read the 12 pages of what they don’t have. Example: respiratory assessment- no cough, no SOB, no cyanosis, no labored breathing, no accessory muscle usage, lungs clear in all fields….blah, blah, blah……

  5. Pat
    August 20, 2014 at 1:03 pm

    And yet, paradoxically, some of the old country doc’s who knew their patients the best would have a simple index card sight an entry like ” (vitals) Cough – bronchitis – penicillin.” Unless a referral was being made, it was far less important to tell the story, than to simply know it.

    All of modern health care is designed to depersonalize, and have turned hospitals and clinics into health factories, and us into keypunch clerks. Oh well patients, this is what you wanted…

  6. Maria in Oregon
    August 20, 2014 at 12:25 pm

    This is so true! Old chart notes actually told a story! The new stuff is so voluminous and yields far less actual information.

  7. August 20, 2014 at 12:19 pm

    We have somehow taken the cultural jump back to being pre-literate and pre-verbal. Medicine once required a certain skill with language, to write substantively and to speak exactly. Before the written tradition, there was a need for skill in oral communication. The mutual exploration of facts so as to ascertain truth, was simply called the dialectic, a word that now has lost any sense of meaning. A patient visit was a dialectic of healing, regarding disease and health.
    That’s all dead as a doornail now.
    We build machines that excrete crappage at a phenomenal rate, a tidal wave of poorly-formed ideas and poorly-observed phenomena.
    What is wrong with the elegance of the surgeon’s note?
    “POD#1 appendectomy. Afebrile. Patient comfortable, eating. Discharge tomorrow.”
    Every word there has meaning. That is an entire paragraph. Instead of the professional obligation to TELL a story, we hide behind the bureaucrat’s wall, “It’s not my fault!”
    Sad, ’tis.

  8. George Voigtlander
    August 20, 2014 at 11:16 am

    I share your concerns, these “data rich, information poor” charts are not in the patients’ best interest. I have heard these same sentiments from our pathologist who tries to get clinical correlation. An attorney who specializes in defending physicians hates these RoboCharts, they confuse the jury, and don’t give the physician’s thoughts when treatment is chosen.
    I had done a lot of chart review for our QIO, there would be poor rationale for treatment, but many pages of non-information. Often when asked the physicians had a good reason for their decision, it just wasn’t in the chart.

  9. Jill
    August 20, 2014 at 10:18 am

    I agree. How can you click a box that properly describes: “49 y/o male with hemoptysis and dyspnea for three days, in the setting of known metastatic melanoma felt to be progressing. Patient having pain in ribs on the R side due to fx from recentcoughing spells. Family present, concerned and supportive. We have discussed POLST form information and patient’s wishes are reiterated today to enter hospice and focus on quality of life as he awaits natural dealth.” (or something like that) What the heck box gives you this picture? We’re in the process of switching to Cerner, and at last night’s training, my ortho colleague (who’d’ve thunk?) was very upset that there was no place for the nurses narrative description of care. The answer? “Just look at the flowsheet where they check the boxes.” Useless. Use. Less. Not only have we boiled down human beings and the human condition into relatively few tiny boxes of discrete information, but patient care has become devoid of all flavor and nuance. Even more exciting, doctors are being asked to do more order entry and update charts with click boxes so some data miner later can use it to pay us less (I’m certain). Love it.

  10. Ed
    August 20, 2014 at 6:39 am

    I couldn’t agree more. Our EMR is so full of redundant data “Brought over” from other areas of the chart into all notes, it’s extremely difficult to parse through all of it.

    We, unfortunately, don’t have the ability to dictate directly into the EMR. So there’s a lot of typing involved. I am a two finger typer… So it takes me a while to get through chart entry. So, I, like you, you shortcuts.

    I’ve taken to dictating my notes at home into Microsoft Word using Dragon NaturallySpeaking. I then access the EMR from home and cut and paste those notes into the chart. That’s my compromise.

    I predict, that plagiarizing, cutting and pasting from other notes, drawing in data from other areas of the chart, will lead to a malpractice nightmare in the very near future, if it hasn’t happened already.

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