Speak the truth, document the truth: To do otherwise is malpractice

I remember a short lecture I received in my medical officer’s course when I joined the Air National Guard around 1988. The room was full of young medical students, physicians, nurses, and other health care folks who were beginning their service. The topic was appropriate documentation in the medical record.

Among the notable examples of what not to do was this gem, written by a medical officer about another officer’s wife: “The patient is a contemptuous bitch.”

This was written in the medical chart for all to see. It is unclear if the young physician ever returned from his subsequent tours guarding airplanes in North Dakota, Greenland, and other points cold and bleak.

While the example was certainly a horrendous one, I am sympathetic. We spend so much time charting, trying to say and do the right thing, that often we subvert and disguise the truth. Or we cover reality in innuendo and medical code. “This patient, well known to this emergency department, presents with his usual and customary back pain for which he takes multiple prescription pain medications that do not seem to provide sufficient relief.” Translation: This guy is here all the time, wants pain meds, and is never, ever satisfied.”

Truth be told, verbosity does not improve communication. Just read some Hemingway. Furthermore, our current systems of electronic medical records are designed to capture lots of words but to hide meaning in catch phrases and required fields. Actual, honest description of what we see would dramatically cut the size of our too-expansive medical records!

In other words, we seldom chart what we want to chart. We don’t actually say what we would love, with all our hearts, to say. I was thinking about this recently, and the ways I’d like to chart the things patients say.

Man, 25, otherwise healthy. “I have chronic pain from my degenerative disk disease, and I can’t hold a job. I went tubing on the lake this weekend, and I think it flared up my degeneration. Oh, and I have a sunburn; can you give me something?

This patient is in active pursuit of disability, but appears far healthier than this aging, aching physician. Likelihood of narcotics or sympathy roughly zero.

Woman, 19, ongoing pelvic pain and discharge. May be pregnant for fourth time.

This young woman with crushingly low-self esteem and no evident support system has frequent unprotected intercourse with multiple partners and is at high risk for HIV and assorted other diseases, not the least of which is depression. She needs a real mother to care for her and a real father to kick the behinds of the various men who stalk her. She also needs antibiotics, which are administered and prescribed.

Man, 89, tearful and clutching chest, with no objective evidence of coronary disease.

This kind gentleman is desperately lonely, afraid of death, and fearful that his life will pass unremembered and without meaning. Even at his advanced age, he longs to carry on and do all of the things he could not do so far. Like me, he wants to see his children as they were again. Grief, especially for oneself, can be particularly painful.

Man, 35, intoxicated and experiencing 10/10 pain from superficial abrasion after wrecking moped.

This enormous whining man-child is drunk all of the time, lost his license, and is now playing the pain card to obtain yet more mind-altering substances, which he will either abuse or sell from his mother’s basement until he is struck and killed by a large truck or slips into an Oxycodone/Xanax/moonshine coma and ceases all respiration.

Child, 7 months, “isn’t acting right,” according to young mother, who is frantically hovering. Child is playful and smiling. Grandmother continues to suggest more tests.

After a thorough investigation for dangerous illness in this child, I find that he is well. His mother is simply terrified, and is being reassured. Her mother should leave the room, if not the town, and stop escalating her daughter’s anxiety.

Woman, 57, complains to the patient advocate that her physician did not fully evaluate her chronic neck pain, did not give her adequate prescriptions, and did not give her the work excuse to which she was entitled. This is her 18th visit for this complaint.

I fully evaluated this patient, and found no emergency medical condition nor any sign of neurologic or infectious abnormality. She was instructed, yet again, to follow up with a family physician. She was encouraged to make some effort to pay her large outstanding (and as yet unpaid) balance, and she became angry and insisted on speaking to someone in authority. She will not receive any medication from me for visits like this one, which are abusive and manipulative.

Man, 19, complains of anxiety, tremor, and headache. He is incarcerated for armed robbery.

History and exam reveals no worrisome etiology in this young man. He is clearly shaken by the turn his life has taken. It is a pity that his father abandoned him, and that he was all but raised by wolves. He is encouraged to come and visit my church when he makes bail or finishes his jail time. He needs repentance, faith, and family not Xanax.

Woman, 78, is crying uncontrollably. Her husband of 55 years just died from massive MI. She has slumped to the floor in tears. She describes dyspnea and chest pain.

This patient lost her husband. Fully half, if not more, of her self has crossed over from this life. The breath sucked out, her heart crushed; her pain seems appropriate. I can only weep with her. There is no medicine for her pain in this life. I will, perhaps, slump to the ground by her side.

Man, 37, complains of shortness of breath, knee pain, and back pain with ambulation. He weighs 450 pounds. He denies chest pain, cough, fever, or trauma. He states his physician has ordered an MRI of his back, but he is too large for the local machine. Extensive testing has failed to determine an etiology for his shortness of breath with ambulation.

This very nice man agrees when I tell him that he must lose weight or he will continue to be at serious risk for diabetes, heart disease, and stroke. I explained that I feel short of breath and my knees hurt when I gain 20 pounds. He is roughly 200 pounds above ideal weight. He is directed to a weight loss clinic. He accepts this advice. No further testing deemed necessary.

Man, 98, is pleasant and charming, and is brought from the nursing home at his family’s request. He has been having severe chest and abdominal pain for several days, and now has a low blood pressure in the 70s. His family wants “everything done.” The patient is lucid, and despite his pain is telling me about the time he felt the same at Guadalcanal when he was gravely wounded. He tells me he does not want tests or surgery, and is “ready to go.” Family is tearful, as I would expect, but desires that if anything needs to be done he be transferred to the teaching center in the next town.

This man likely has an aortic dissection. He has pulse deficits, and now has developed neurologic deficits. He is unlikely to survive any surgery. I have explained to his family that a man who lived heroically does not want to die pathetically. I will observe his wishes and keep him comfortable. I have spoken with him at length, and he has told me several stories I will never forget. The world will be poorer, but I will not subject him to anymore intrusion. His family will have to accept his wishes.

You see, it wouldn’t be that bad, would it? To speak the truth. To document the truth. To do otherwise, and write otherwise, is a kind of terrible malpractice. A white-washed coating on the real world of human suffering and human folly.

That’s not what we trained for, is it? So let’s try to stop pretending so that we can actually get down to the healing.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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  • http://www.HealthcareMarketingCOE.com/ Simon Sikorski MD

    Would exposing the truth, or your true opinions, influence how the rest of the staff treats these patients after they see the information in the charts?

  • Kevin Hu

    This article brings up an interesting question because what makes some of the “truthful” entries colorful is a value judgment, and opinion about the patient. On the one hand we seek to provide health care that is not infused with our own biases and opinions, but on the other hand a huge part of health is recognizing that these biases and opinions actually illuminate many important determinants of health. Also, while some of these records might be useful for the physician’s own evaluation of the patient, I am prompted to ask, like Dr. Sikorski above, whether these opinions are a good way of communicating with colleagues and co-workers.

    Of course, the examples you provided above were meant to demonstrate a need for a more succinct way to document the dynamic presentation of a patient. But what is more useful?
    1. “He needs repentance, faith, and family not Xanax.” OR 2.”Frail support network. Consider referral to social worker.”

  • http://www.facebook.com/profile.php?id=1536821513 Edwin Leap

    Gentlemen, I’m not actually suggesting we chart this way (not that I wouldn’t if I could…) I’m just offering a way to see behind and beneath what we’re saying and feeling. Can anyone chart or provide care entirely aloof from their opinions and biases? Did you read this and evaluate it separate from your own value judgments? In fact, we are a composite of our upbringings, our ideologies, our training and our personal life events. The best we can do is try to love and act professionally through it all. As for ‘inadequate support network and social services,’ if you haven’t noticed, social services are strained to breaking and out of money, and the support network in communities of faith can be remarkable!

  • Bhai_Mian

    What an interesting piece. I see a lot of backpain patients in my PMR practice and many of them do fit in the description narrated above.
    But unfortunately the ground reality is that we are unlikely to speak our hearts out or document it in the right way ( as described here)

  • http://www.facebook.com/naturegirlfromny Linda Wheeler Weigel

    I am not a Dr. but play one on TV. No seriously, as a patient of many Dr.s due to breast cancer and other problems, I always secretly thought my Dr. used to think of me as a hypocondriac. I don’t think it is appropriate to chart medical findings using one’s own feelings or assumptions about someone. Personal opinion should be kept out. I’ve had the same Dr. for my aches and pains for about 21 years now and have been treated well but not with what I would call compassion until I presented with a huge lump in my breast. I feel our patient/Dr relationship changed after that. I hope she isn’t writing her own biased opinions in my chart anyhow! I have always wanted to see my charts.. I should ask someday.. Ha!

  • http://www.caduceusblog.com/ Deep Ramachandran

    Funny article, I think some part of all of us doctors wants to document such things on certain occasions (particularly an ER doc), but of course we can not necessarily do that. I always try to document as if the patient is going to read my note, and I would not write anything there that I would not feel comfortable telling to their face (barring certain exceptions like psychiatric diagnoses, etc.).

  • EmilyAnon

    Is it OK to not document an error in the OR such as accidentally knicking an intestine, organ or whatever, even though caught and repaired with no chance of the patient every finding out?

    • http://www.facebook.com/profile.php?id=1458060542 John Lace

      No.

  • http://www.facebook.com/josh.hyatt Josh Hyatt

    I found this very enjoyable and entertaining, while understanding the underlying message. As a risk management and bioethicists professional, I relate to the tight rope of documentation that all professionals who document have to walk. When presenting on clinical documentation, I always ask people to imagine that as they are writing, it is being projected above their heads in a courtroom and they have to be able to defend everything they write to 12 people, who are not medical professionals, and one very adversarial, non-physician, person questioning them. Unfortunately,I have seen examples similiar to the ones’ used in this article and worse in medical malpractice cases.

  • StephenModesto

    …Yes, the post does contain many elements of ironic paradox, yet there is indeed an underlying thoughtfulness within the intent of the composition. There is a very real difference between assessment and value judging. Identifying the non-empirical variables behind the statements and presentations of patients are valid. The dyad of human interaction is intinsically subjective. I do think/feel it is valid to include those subjective self-asssesments of the qualities of the dyadic interaction within the `notes’…Just identify that process as a Husserlian `bracketing’. As with any artistry, it just requires a developed skill in keyboarding/writing as it does with a graphic artist using a brush with `colors’. At some point along the health care chain of bureaucracy, the social service crew and disharge planners always review the `notes’. They are just trying to glean info for their side of the job. These added colors help them adjust the`bigger’ picture they are trying to see as well.