This article is more than 5 years old. Information may no longer be current.
The story line of medicine
Click Here to Manage Email Alerts
How can I walk with this ball and chain?
How can I land in this hurricane?
Or, is this part of man’s evolution:
To be torn between truth and illusion?
— “Forbidden Fruit,” The Band (Robbie Robertson), 1975
But if thought corrupts language, language can also corrupt thought. William T. Gerson
— Orwell G. Nineteen Eighty-Four. London, England: Secker and Warburg; 1949.
Beyond its roles as illustration, affirmation, hypothesis-builder, and low-level guidance for practice, storytelling can act as a modest counterbalance to a straitened understanding of evidence.
Kramer PD. Why Doctors Need Stories. The New York Times. Oct. 19, 2014:SR1.
While the first rule of clinical medicine is always to listen to the patient, its most important corollary is that the story must be accurately written. And while the minute detail of the clinical narrative, absent of preconceived bias until reaching the proscribed area of the clinical note under the heading of medical reasoning, has often been equated with the exquisite detail of the portrait painter (and thus, also seen as antiquated). The analogy seems to me to be false, as if the painter could tell the story with words why would she paint? Painters and historians aside, the critical importance of the medical narrative — the word, the story and its ultimate impression in the mind of the physician — embodies the essence of medicine. Unfortunately, that very story in all its beauty and form is endangered and at great risk of being sacrificed at the altar of efficiency.
Is our acquiescence to the electronic health record (EHR) a truth or an illusion? Whose words become part of the patient’s record — yours or the EHR’s coders? What is really at risk?
The substitution of words for thoughts and data for discernment, whether driven by efficiency, billing concerns or hour limits, places our professional identity in jeopardy. In doing so we accept an ever-expanding bureaucracy whose prime interest is not the individual patient, and we create a landscape where eye contact with the patient is limited, let alone human touch, and the only free text available is that which is nonbillable — critical thought and reasoning. Even our clinical note is now a product of that bromidic remedy: “team work.” Though it is 2014, I appreciate a whiff of Nineteen Eighty-Four.
William T. Gerson
Adapting to the EHR is one of the hardest things I’ve had to do in practice; my personal ball and chain. Transforming from a paper chart to an electronic is reminiscent of my internship, when seven volumes of the paper record would arrive on the floor associated with the admission of a well-known patient. Beyond the immediate care needs of the patient, my responsibility was to review and extract all relevant information from the multitude of clinical notes, lab results and consult notes. Here though I could treasure (no time limits to my day) previous generations of house officers’ clinical impressions about the individual patient. No problem lists, no graphic displays of lab results over time — just thoughts.
Now I have the pleasure to review my own notes to transfer “data” from my old paper chart to the new EHR before every first electronic visit of my patients. While being previously scanned into the EHR, it exists in no more useful form than the previous hospital system of record warehousing paper charts. Certainly much less accessible than my office paper records where all I needed was instantly at my fingertips. I could open the chart and find information on the entire family — parents with occupation, list of siblings, problem lists; in my office all siblings’ individual charts were included in one family folder so it was very easy to answer the inevitable question about a sibling at any visit. What a waste the new record is — sterile, limited and without texture. The new refrain has become, “The information is only a few clicks away.” Who do I talk with to create time? Will I have time to listen?
It is the patients’ words that become our story. It is that narrative that triggers our judgment and hopefully wisdom in the discernment of the necessary evidence to support our medical reasoning. Despite all current teaching, to me this process is a solitary event whose location is the sacred ground of the exam room. Of course, once obtained it can and should be shared, tested and even overturned. But at the beginning, it is exchanged in the personal context of patient and physician. Learning this requires opportunity, time, experience and critically, at some level, an obligation to accept responsibility.
Individual responsibility and ownership — an idea created in medical school, nurtured in residency and fruited in practice — is a lost approach. Just like parents who use the ubiquitous smartphone to take thousands of pictures of their newborn and in doing so fail to actually play with them, residents are often now trained as bystanders in the practice of medicine. What will they take away from residency? Will they share a passion for the narrative, an empathy for the patient as an individual, as represented by the critical role of the anecdote, and cherish the importance of judgment layered above evidence in the hierarchy of care?
In a brighter future, as pediatricians in general practice we need to play to our strength. If clinical excellence is our goal, we owe our patients, ourselves and our profession a commitment to encompass improving quality in care for all children. We can do this by not only valuing stories, but also by building quality improvement collaboratives of our own as we pursue excellence in clinical care and share practice and outcome data. Distinct from randomized controlled clinical trials, such collaboratives can provide a fitness landscape of clinical practice differences that can be harvested for potential better practices. In this goal I can see the importance of an EHR. However, its purpose and reason for existence would not be efficient care or billing, but better care. And its user interface would value the human narrative.
For more information:
William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.