When writing medical notes, some clinicians include an appreciation of their patient’s personality and disposition in their opening line (the “chief complaint”), or when they’re wrapping up (in the “assessment and plan”), or in both locations.
You know — it goes like this:
“CC: Ms. Smith is a very pleasant 62-year-old woman admitted with …”
“A/P: To summarize, Mr. Jones is a delightful 89-year-old man presenting with …”
“CC: This lovely 74-year-old retired school teacher was in her usual state of health until …”
Yikes, not a fan of this practice.
Am I just being curmudgeonly and negative? If a person is so pleasant or delightful or lovely that their doctor wants to praise them in the medical record, who am I to deny them this generosity? Or deprive their patients of this honor?
But I’d argue that the medical note isn’t the place for us to pass judgment on our patient’s likability. What does this imply about those we don’t call pleasant?
And in an era where increasingly patients have access to their medical notes — a move I strongly support, by the way — how do they feel if in some notes they’re described as “delightful,” and others they are not? What if they’re having a bad day, reducing their loveliness? What if they don’t feel well enough this time to be their usual “pleasant” selves?
Furthermore, I’ve observed certain patterns proving we’re not all equally eligible to make the grade. First, women earn way more “praise” (ahem) than men:
- “Pleasant”: 60% women
- “Delightful”: 75% women
- “Lovely”: 90% women
(Data from a highly scientific review of several thousand medical charts. Really.)
Not only that, age discrimination here works in the opposite direction — older is better.
Every decade beyond age 60 yields a greater likelihood of earning one of these adjectives. Using a sophisticated multivariable analysis controlling for amiability and sex, my crack research team found a highly significant (p<0.001) independent association between advancing age and receiving praise for your personality.
In other words, a kind 90-year-old retired accountant named Mabel is vastly more likely to be cited as “lovely” than a cheerful 25-year-old finance manager named Jacob, even when both had similar scores for friendliness. Is that fair?
But — if you think about it for a moment, doesn’t this “lovely” imply something demeaning and patronizing about the label? Of course, it does.
Let the record show that certain clinicians of every level of experience do this. Ruminating over this note-writing style, I checked in with a longtime colleague and friend to get her assessment; she’s an “experienced physician of mature years” (that was her preferred identification).
In a twist, she wrote back the following:
Generally, I agree with you …
… er, except for this. Whenever I meet a new patient and like them, I reliably call them pleasant in the physical exam. (Note: I never called anyone delightful or lovely. That seems patronizing.) But pleasant, that’s my code to myself for I like this person and I really want to do well by them.
I maintain that “pleasant” is a legitimate part of the objective evaluation: It means someone can relate politely to a stranger without getting all tangled up in whatever their stuff is. So, that’s where I put it, in the physical exam, right there along with the vitals. Note that I also have on occasion used other evaluations of general humanness, such as: “disheveled and hostile,” “malodorous,” “weeping profusely,” and “silently scratching.” All germane, if you ask me.
I’ll give her credit for putting the “pleasant” description in the physical exam — this is where we put our observations, after all — and leaving out the “delightful” and “lovely” labels.
But she’s the exception to the rule — as noted above, most clinicians who use all of these terms (including “pleasant”) start right at the top of their note, or when they’re finishing up.
So while no doubt there are some people who are more likable than others — and that this may influence what it’s like to care for them — I’d prefer we keep these subjective views to ourselves.
Paul Sax is an infectious disease physician who blogs HIV and ID Observations, a part of NEJM Journal Watch.
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