Sunday, December 4, 2011

Making Medical Chart Notes Less Terrible

During my own residency in Greeley, one of the hospital's pulmonologists wrote notes in the hospital chart that were a delight to read. Yes, you read that correctly. His documentation IN THE HOSPITAL CHART was not only legible, but downright literary. It was not unusual to actually FEEL something when reading his chart notes--to chuckle at a patient's quirks, or to feel empathy, or to be seduced by the mystery of the diagnosis.

I have not seen anyone write notes like this since.

Now, with the rise of electronic medical records (EMR), our charting is usually done with computers. I am no Luddite. Electronic medical records have many benefits, including ability to extract and track data, reminders that improve care and templates that (sometimes) speed documentation. However, EMR has also devastated the readability of clinical notes. Every physician has tried to read a note generated by a colleague with an EMR, only to find a frustrating, poorly formatted jungle of lists, irrelevancies, incomplete sentences and poor (if any) punctuation.

But it doesn't have to be this way! Physicians should utilize the spectrum of benefits that follow from higher education, including the ability to think and write more clearly. Our notes can be scientifically accurate and readable, clinical and literate, informative and sophisticated. In the spirit of reversing the trend I've seen toward clinical documentation nearly indistinguishable from text messages, I offer the following remedies adapted from the classic book on quality writing, The Elements of Style by Strunk and White.

1. Use the active voice. Chart notes are frequently blighted by passive phrasing such as: "The cough was noted by the patient to become productive," or "the reason the patient increased her smoking was due to job stress." Not only is the active voice a stronger, more lively way to write, it is usually shorter and therefore more efficient! "The cough became productive." "Job stress prompted heavier smoking." Concise, complete sentences still say the same thing.

2. Put statements in a positive form. Another scourge of medical writing is the dreaded "the patient denies" some symptom or other. Oh, really? Is the patient accused? ("The patient endorses" is no better.) Why not say, as the skilled editors of the New England Journal of Medicine's case reports do, "She had no cough, dyspnea or hemoptysis"? Period. We know it is the patient we're reading about, after all.

3. Use definite, specific, concrete language. I often jokingly remind residents to "use your words." Medical language, like all scientific language, is ideally very specific and economical. "Having trouble breathing" can mean several things. "Dyspnea" is specific, and different than "wheezing" or "orthopnea." "Spitting up blood" can mean "hematemesis" or "hemoptysis" or even "posterior epistaxis." "Fatigue" may mean "sleepiness" or "weakness" or "abulia" or "lassitude." Use the most specific word that fits, and get a thesaurus app if you need one.

4. Omit needless words. Using more words makes the writer sound, not smarter, but more confused and confusing. "The chest pain is secondary to ischemia" should become "This is ischemic chest pain." "This is a patient with cirrhosis and pneumonia" becomes "He has cirrhosis and pneumonia." Simpler is almost always clearer.

5. Expand your vocabulary. Medical students are trained to write certain phrases and cliches while learning the basics of charting. Many of us, though, never move beyond this. Where is the holy writ that says we must write that a patient is "well-developed and well-nourished" (WD/WN) instead of muscular, brawny, sturdy, heavyset, corpulent (whichever applies)? Why must we use "disheveled"? Can the patient not also be unkempt, bedraggled, rumpled, even slovenly? Are patients only "pleasant"? No doubt we also see patients who are amusing, delightful, charming, joyful, genial, cordial, well-mannered.

The literate pulmonologist whose notes I so enjoyed reading was not following a list of rules, of course. I suspect he had simply mastered a core principle of good writing: write with the reader in mind. Unfortunately, as medical students we write lengthy discourses that no one ever reads, which teaches us to write, not to communicate, but simply to "document." It is high time to recover the skill of writing clinical notes to be read, not by hypothetical lawyers in some feared future courtroom, but by colleagues whom we can inform while simultaneously engaging in the patient's narrative.

Thankful Day #30

Thankful Day #30: Finally, I am thankful for consciousness. I am thankful that, for a vanishingly brief moment in the vast stretch of time and space, I was lucky enough to be awake and see a little bit of wondrous reality. Telomeres, dogs, nephrons, horseshoe crabs, music, the moon, indoor plumbing, history, anatomy...just a small sampling of opportunities for wonder.

Thankful Day #29

Thankful Day #29: I'm thankful for telomeres. These repetitious ends on our chromosomes get shorter and shorter with each generation of cell division. When the telomeres run short on genetic material, the cell either dies or becomes static. Why be thankful about this process? Without it, growth and development would be impossible, and every cell would be nearly immortal. Death is a necessary part of normal life.

Thankful Day #28

Thankful Day #28: I'm thankful for the germ theory. The gentleman pictured here, Louis Pasteur, helped to prove that little beings too small to see can make us sick. The germ theory replaced the miasma theory, that "bad air" caused contagious disease. Still, though, I think both should be taught in schools--it's JUST a theory!

Thankful Day #27

Thankful Day #27: I am thankful for my nephrons. Each kidney has about a million of these amazing structures that do the work of filtering and chemically balancing our blood--our entire blood volume every 5 minutes. After eating movie popcorn nightly for a week, I'm thankful that my nephrons kept me from swelling up like a water balloon.

Thankful Day #26

Thankful Day #26: I am thankful for the Sumerians. Around 6000 years ago, this civilization developed year-round agriculture, a legal system and cities in southern Mesopotamia (modern Iraq). I'm most thankful, however, for their development of written language, which allowed humanity to graduate from solely oral communication.

Thankful Day #25

Thankful Day #25: I am thankful for dogs. Obviously, I'm biased. Nevertheless, fascinating research suggests that dogs evolved from less-human-avoidant wolves, probably used by early humans for assistance in hunting given their superior sense of smell. Dogs read human faces like humans do. They can understand symbolic gestures like pointing (chimps can't). And, of course, they're our best friends.

Thankful Day #24

Thankful Day #24: I'm thankful for all those who have to work today. Somebody has to fight the fires, enforce the law, care for the sick, rescue the injured, guard the borders, occupy foreign lands, guard the nukes, keep the power on, purify the water, screen travelers, fly the planes, drive the buses, engineer the trains, feed the animals, gather the intelligence, play the football, officiate the games, provide the commentary, run the TV and radio stations, update the Internet, stock the shelves, drive the trucks, unload and load the ships, work the open retail stores, clean up our garbage, unlock our cars, fix our plumbing crises...and fix our Thanksgiving feast.

Thankful Day #23

Thankful Day #23: I am thankful for statistics and probability. These sciences have opened up deeper and broader understanding of our universe by giving other sciences a robust mathematical language with which to work. Probability theory has led to better understanding of phenomena as diverse as the behavior of subatomic particles, genetic mutation, biological evolution and the formation of galaxies. At the same time, better understanding of probability and randomness has helped reduce (but, of course, not eliminate) superstition by showing how seemingly miraculous rare events are...well, inevitable. After all, a royal flush is no less likely than any other hand in poker. It's only our way of seeing that makes it special.

Thankful Day #22

Thankful Day #22: I am thankful for bipedalism. Walking upright freed up our hands, allowing our ancestors to start making tools like this Olduvai chopping stone 1.8-2 million years ago. Walking upright came with a trade-off, though--the pelvis evolved with a smaller outlet, necessitating earlier birth and a longer period of dependence on parents. Given the prevalence of 30-year-olds living with their parents, the process evidently marches on (so to speak).

Thankful Day #21

Thankful Day #21: I am thankful for sexual reproduction. Now, now...calm down. It's not all fun and games--for example, this poor Australian jewel beetle gets tricked by the super-stimulating features of Australian beer bottles (which share features considered very sexy in female jewel beetles) into humping the beer bottle until he dies. However, in general, sexual reproduction gives a species much greater genetic variation and adaptability.

Sunday, November 20, 2011

Thankful Day #20

Thankful Day #20: I'm thankful for oxytocin. This pituitary hormone keeps civilization together. It is best-known for its role in labor, delivery and breastfeeding; however, it also plays a large role in pair-bonding (secreted during orgasm, for example), parent-child bonding (even fathers have a surge of it when (allegedly) their baby is born), and probably in less-intense interpersonal relationships. Abnormal oxytocin production has been linked to sociopathy, narcissism and general manipulativeness (i.e., assholism).

Thankful Day #19

Thankful Day #19: I am thankful for stereopsis. First described by Sir Charles Wheatstone in 1838, this is the perception of depth resulting from two slightly different images from distant objects being projected on our two retinae. It is not identical to the colloquial sense of "depth perception," however, since one-eyed people (yes, you, Cyclops) still have many cues for relative distance (e.g., overlap, size, light diffusion).

Thankful Day #18

Thankful Day #18: I am thankful for my microbiome--the bacteria that live in and on me, making life possible. In my colon alone, there are 100000000000 bacteria per cubic centimeter, and these little friends comprise 90% of my stool mass. They break down indigestibles, they keep pathogenic bacteria in check, they produce and liberate vitamins from food. And they ensure I'm never really alone.

Thankful Day #17

Thankful Day #17: I am thankful for vaccines. We have forgotten, in the affluent Western world, what it is like to suffer epidemics of polio (which paralyzed children), diphtheria (which choked victims to death) and measles (which caused brain damage, seizures and death). In my career so far, epiglottitis, a killer of infants, has become rare due to vaccination. The hero pictured here is Jonas Salk, who developed the killed polio vaccine, rendering this once-common disease almost unheard of.

Thankful Day #16

Thankful Day #16: I am thankful for Lucretius (99-55 BCE). He wrote a long poem called "On The Nature of Things" which was virtually lost until its rediscovery in a remote monastery library by book hunter Poggio Bracciolini in 1417. The poem helped to launch the Renaissance and the modern world with its "radical" ideas (at the time) that the universe is made of "atoms," is controlled by natural laws (not the gods), and that death is nothing to fear. [Read More About It: The Swerve by Stephen Greenblatt (2011)]

Thankful Day #15

Thankful Day #15: I'm thankful for lenses. I'm looking through two of them, but the Assyrians invented the first one around 3000 years ago, probably to start fires with sunlight. Modern life would be almost unimaginable without eyeglasses, contact lenses, cameras, microscopes, telescopes, and the other uses of lenses in technology.

Thankful Day #14

Thankful Day #14: I am thankful for horseshoe crabs. Although they aren't really crabs (they're more closely related to ticks and spiders), the blood of this oldest living species has saved more human lives than any other animal. A product of their blood, you see, is used to ensure that injectable medications are not contaminated with bacteria, viruses or fungi.

Thankful Day #13

Thankful Day #13: I am thankful for this stern-looking gentleman's discovery and its derivatives. Edward C. Kendall won the 1950 Nobel prize in Medicine for his discovery of cortisone, a steroid hormone, while working at Mayo Clinic. Until then, there was no way to treat crippling, painful autoimmune diseases like rheumatoid arthritis and lupus.

Thankful Day #12

Thankful Day #12: As a shout-out to my dad and brother, I am thankful for petroleum products. Take a moment to imagine life without, not only gasoline, but also plastics (e.g., Styrofoam, plumbing pipes, packaging, bottles, toothbrush bristles, much of your car, nylon, on and on), diesel, waxes, and aromatic artificial flavorings and colorings that make food palatable.

Thankful Day #11

Thankful Day #11: I am thankful for music. Human beings are a musical species - more areas of our brain are dedicated to music than are dedicated to language processing! And although I think that scientific knowledge makes everything more beautiful, sometimes you just have to enjoy the music, as neurologist Oliver Sacks explains below:

"As one's mind becomes preoccupied with theoretical or scientific issues, one may have less attention, time or emotion available for other things. But there are lots of highest-power intellectuals who stay interested in music, like Einstein. Darwin may have been as absorbed in thinking about evolution as Freud was absorbed in thinking about psychoanalysis when he went to operas. All of us are apt to get a little desiccated if we don't make a point of holding on to the delights of art and music and landscape. It's very easy to become preoccupied with theorizing and the activities of daily living and stop noticing the beauties of the world."

Thankful Day #10

Thankful Day #10: Apropos of today's date, I am thankful for the Arabic numeral system. By inventing zero and the concept of place value, the Arabs made arithmetic and higher math possible (and therefore most of science).

Thankful Day #9

Thankful Day #9: I am thankful for the anal sphincter. Allow me to quote, in full glory, Dr. Walter C. Bornemeier's brilliant statement:

"They say man has succeeded where the animals fail because of the clever use of his hands, yet when compared to the hands, the sphincter ani is far superior. If you place into your cupped hands a mixture of fluid, solid and gas and then through an opening at the bottom, try to let only the gas escape, you will fail. Yet the sphincter ani can do it. The sphincter apparently can differentiate between solid, fluid and gas. It apparently can tell whether its owner is alone or with someone, whether standing up or sitting down, whether its owner has his pants on or off. No other muscle in the body is such a protector of the dignity of man, yet so ready to come to his relief. A muscle like this is worth protecting."

Thankful Day #8

Thankful Day #8: I am thankful for the moon, which originated with the impact of a Mars-sized proto-planet with the proto-Earth about 4.5 billion years ago. It's gravitational influence gives us ocean tides, but is also slowing down the Earth's rotation by 15 microseconds a year. So you get a little extra time each day!

Thankful Day #7

Thankful Day #7: I'm thankful for the Centers for Disease Control and Prevention (CDC) and World Health Organization - these government organizations successfully eradicated smallpox, the world's #1 killer. The last case occurred in 1979.

Thankful Day #6

Thankful Day #6: I'm thankful for indoor plumbing, flush toilets and waste water treatment facilities. These engineering feats have improved human life and health immensely.

Thankful Day #5

Thankful Day #5: I'm thankful for chlorophyll. This amazing chemical, discovered in 1817, absorbs most of the blue and red light spectrum, allowing plants, algae and cyanobacteria to convert CO2 to sugars and produce most of the O2 on Earth.

Thankful Day #4

Thankful Day 4: I'm thankful for 23.45 degrees. This tilt of the earth's axis gives us seasons.

Thankful Day 3

Day 3: I'm thankful for my DNA repair enzymes (e.g., DNA ligases, DNA glycosylase, etc.) that find and repair the approximately one million damaged sites in each cell every day.

Thankful Day 1 and 2

I've got to catch up with this Thankful Day stuff!
Day 1: I'm thankful for water's hydrogen bonding property. Without it, the climate on earth wouldn't be stable enough for life.
Day 2: I'm thankful for mitochondria. These little bacteria made a symbiotic pact early in eukaryotic cell evolution to provide us energy in exchange for a home.