All doctors should be able to tell a patient’s story well

An op-ed piece this past summer by Verlyn Klinkenborg in the New York Times decried “The Decline and Fall of the English Major.” As I read it, I reflected on my own experience in medical school and beyond, and I think that Mr. Klinkenborg’s message is one that medical school admissions committees should be hearing loud and clear.

Despite the fact that doctors are faced with increasing mounds of paperwork and decreasing autonomy, medical school admissions are as competitive as ever. All handwringing about the state of the profession aside, young people still desperately want to be doctors.

Students who would vie for a coveted slot in medical school must start their resume building early in their college careers, and must complete with flying colors a standard premedical curriculum which with rare exception has not changed one iota since I applied to medical school in the fall of 1974. Students who major in the basic sciences — biology, chemistry and physics — have an advantage in the race for med school admission because they typically outperform other majors in their MCAT scores and because their majors allow them to get a leg up in scientific research.

In many cases, college students who are science majors apply for medical school with first author publications listed on their curriculum vitae.  And at the end of medical school, students who have taken the time to obtain a dual MD-PhD degree are the ones who are most competitive for those coveted specialties of dermatology, plastic surgery, orthopedic surgery and radiation oncology where the prize at the end of the road is a controllable “lifestyle” combined with high reimbursement.

But even in the rarified world of first author scientific publications in peer reviewed journals, there is that moment of truth, when push comes to shove, and a group of editors must decide whether to publish the paper of one author, or someone else’s.  No matter how brilliant the tables and graphs, in the end that decision will be made on how well the author explained the data, how compelling was the argument, and how explicitly the new data informs both the reader and the greater body of work on the subject.

In the end, this is where those former English, and history, and philosophy majors shine, and surpass their basic science background colleagues.  Just ask Dr. Harold Varmus, the current director of the National Cancer Institute, Nobel Laureate, and possessor of both undergraduate and graduate degrees in English from Harvard.

This week I worked with an excellent medical student.  He was bright, personable, and thorough and the patients truly enjoyed speaking with him.  We saw six or seven new patients together, and here is an example of the narrative on the physical exam on one: “ABD: SFT, sMS, NTDR, NABS, NHSM.”

Say what?  For the non-MD readers out there, that means that the abdomen was soft and non-tender with no masses, abnormal bowel sounds and no enlargement of the liver or spleen. In this fast paced world of texting messaging and abbreviation, this old English major would like to see her own life history and physical exam written in English, please!

Why does this matter?  Colum McCann said it well in Let the Great World Spin:  “Literature can remind us that not all life is already written down: there are still so many stories to be told.”

Very few doctors will ever win a Nobel Prize.  But all of us should be able to tell a patient’s story, tell it well, and make sure it’s worth listening to.  After all, it could mean the difference between life and death.

Miranda Fielding is a radiation oncologist who blogs at The Crab Diaries.

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  • azmd

    Unfortunately, outside of our own satisfaction in telling a patient’s story well, there is little institutional reinforcement for a well-articulated chart note. Our documentation work is valued based on other parameters such as whether it facilitates billing/coding/data-mining and whether it is completed instantaneously.

    I personally enjoy writing so my notes are well-written. But at the end of the day, what my department chief really cares about is whether my patient contact sheets were filled out and submitted promptly and whether I checked off the check boxes about whether a patient was on two antipsychotics on discharge. The fact that my notes are well-written and clinically useful does not earn me anything at all, other than my own satisfaction. It is much more important to the hospital that they have all of the check-boxes marked that allow billing at the highest possible level of complexity.

    • SarahJ89

      Which is all part of obfuscating medicine. Which, in the end, sows seeds of distrust towards the medical profession, benefiting no one–except the profit takers, of course.

    • Miranda Fielding

      Sadly, I agree with you. I do my own coding and billing, but I am at a satellite of a major academic center. There, I watch as the billing people check off the boxes in order to bill the highest level of evaluation/management codes. As if saying “I spent 90 minutes face to face with this patient” makes it true.

      • azmd

        Not only that, we are becoming a profession that values “efficiency” over almost all other qualities that a physician should also have. So getting your work done quickly is more highly valued than doing it thoroughly, or well. Naturally, if you could do your work quickly and also do it thoroughly, that would be great. But given today’s medical workloads and the complexity of medical knowledge, that’s not always a realistic goal these days.

        So physicians learn that getting something done fast, even if it’s done in a superficial way, is the desired approach.

        The problem is that our patients don’t really value us getting our work done fast. Not too surprisingly, they place a higher value on our taking more time and doing a good job. As well they should. So we have unhappy patients, and the doctors who would enjoy being thorough and taking their time, are also unhappy.

        • Miranda Fielding

          Again, I absolutely agree with you. And while some view multitasking as an efficiency, for me, it’s a distraction. I guess I am a plodder and a linear thinker.

  • Rob Burnside

    The more symbolic our language becomes, the less it means. The more meaningless language becomes, the less we communicate. The more our communication falters, the less we cooperate. The more we free-lance, the less we succeed. The more we fail, the more symbols we need.

    • Miranda Fielding

      I absolutely agree with you.

      • Rob Burnside

        And I salute your writing. Absolutely first rate.

        • Miranda Fielding

          Thank you very much! I will keep trying.

          • Rob Burnside

            We should all try so well.