A Chart Should Tell a Story.
My EM News column for March.
I suppose it is obvious that I am a fan of stories. I like to hear them, read them, watch them, collect them and tell them. I believe I am participating in stories every day of my life. The story of my family is a beautiful epic. The stories I hear at work can break my heart. One of my favorite stories starts like this, as told to me by an adult man in his forties: ‘The thing is, me and my mama live with her boyfriend. And the other night, her boyfriend had a cardiac arrest! And when he had the cardiac arrest, he rolled out of bed, and crushed the Pomeranian.’ I can tell it better in person.
Obviously, story is truly essential to medicine. The history we obtain from patients is a story, a narrative of the development of whatever affliction they are facing. The medical record we generate is a larger version of the story, which includes past conflicts and resolutions, various antagonists and protagonists, symbolism, sub-text, conclusion and all the rest.
The problem is that in medicine, we have murdered the story. But it isn’t a complicated mystery. The murder occurred because the modern medical record is designed to gather demographics, monitor (and modify) our behaviors and generate bills. Therefore, it must be easily interpreted by people, or computer programs, that look for clicks and checks rather than descriptions. After all, it takes time and training to learn to read and appreciate a well-crafted story. But not so long to do a word-search.
I suspect that it is also a generational issue, as younger physicians have grown up with communication shared in short bursts, whether on television, in music, while texting or using various forms of social media. So I suppose that I understand how we have evolved, or perhaps devolved, in our medical communications.
In all fairness one can ‘reassemble’ the story from click boxes and drop-down menus. It just takes effort. It certainly requires more time than it would take to read a story. It’s rather archeological in nature, in fact. One must look at the nurse’s notes and the time-stamps, the triage vital signs and the things ordered, the timing with which they were ordered and interpreted, the consultations, the disposition, the prescriptions, the out-patient tests. All of it, when properly put together, can give an approximation of the who, what, when, why, how and where of the encounter.
But what we often do not have, particularly in times of crisis when the patient suddenly returns, is the luxury to put the pieces together again. Nor do the consultants and primary care doctors and specialists who see our patients later and who very much want to understand what transpired. And yet, as I travel around, and as I look back on various charts to discern what happened on previous visits, I see check boxes, labs, findings, diagnoses (often vague) but no description. The ‘Medical Decision Making,’ or ‘Emergency Department Course,’ are empty fields. In years past, we were told that these were critical parts of the chart that showed the complexity of our thought processes. I suppose EMR has changed that, on some level. But I’m think we’re worse for it. Looking at those particular blank spaces is like listening to crickets in a field. Or staring into an empty room. The absence of words doesn’t help anyone; least of all the patient.
So let me take this moment to encourage everyone to leave a note, even a wee, little note, describing what transpired in that patient encounter. Fine, if it’s strep throat, if it’s an ankle sprain, I get it. I can figure that out. But for anything with the slightest complexity, anything requiring several labs, or studies or consultants, please tell me a story!
It needn’t involve a ‘dark and stormy night.’ But it should have enough information to help the next person reading it. ‘This 14-year-old girl has had two weeks of intermittent cough, fever and shortness of breath. She has a negative chest x-ray but was noted to have scattered wheezes. She was feeling much better after an Albuterol treatment and her parents agree to arrange follow up with her doctor next week.’ It’s not ‘For Whom the Bell Tolls,’ but it’s a nice, simple summary that helps everyone else to have a sense of what happened. And it did so in three, count ’em three (3) sentences!
Chest pain? Summarize it and describe the plan. Trauma? Tell me why they were safe to go home. Headache? Explain, however briefly, why it wasn’t necessary to do more work-up. Heck, make it a game! A kind of ‘micro non-fiction.’ (Micro fiction can be a story as short as six words.) Diligence at this craft makes us more effective, more succinct communicators. And in the press of modern medicine, that can only be a good thing.
When my children were little, bedtime was always accompanied by this question: can you read a story? I’m just asking a similar thing of my colleagues. Before you put the chart to bed, write me a story.
And if it involves a Pomeranian, so much the better.