The medical record often doesn’t capture the care of the clinician team

While my forty-year parts warranty expired some time ago, leaving me with a snapped fibular styloid process not long after, the ensuing twenty-five years have not resulted in any serious medical encounters until last week.  Following a very pleasant early evening session with our Congresswoman and a sweet snack at home, abrupt abdominal pain progressed in under two hours to a clinical acute abdomen.  As I got dizzy and dependent on furniture for support, I thought it prudent to have the paramedics take me to the ER rather than my wife, who would likely panic if this were a dissecting aneurysm.  The pain eased as they put me on the stretcher for an efficient ride to the ER with my peritoneum noting the potholes as the tires crossed them, comforted by pleasant and capable attendants.

Medical care proceeded smoothly.  The young ER nurse who I only remember by first name got me settled, put me on the ER queue as patient #5 in sequence, and chatted to put me at ease while she attended to me and typed, explaining even why their urinals now come in disposable cardboard.  Then ER resident, ER attending, CT scan, surgical resident, transport to the floor where a very pleasant nurse got me settled and performed a more thorough hospital-mandated skin assessment than I would have anticipated, which is probably good since nobody previously had removed my suede slippers to check circulation even while discussing aneurysm.  My CT confirmed appendicitis, remedied by a surgeon with laparoscopic skills and the next shift of nurses post-op.  All went well progressing to discharge later that afternoon and the ability to fulfill my role as Torah reader in shul two days later.

If any of the many people encountered during my ordeal felt burned out, they kept that invisible to me, not only performing their professional duties but with a pleasant demeanor even in the wee hours and maybe even flattered by my respect for their skill reflected by the many rather technical questions I asked as the diagnostic evaluation progressed to surgical consent.

The following day I felt only slightly bruised but not beyond the reach of acetaminophen.  The people who worked on me gave me quite a gift, one meriting a full measure of gratitude, though how to express this in the best way posed as much a challenge for me as it did for a biblical Persian king: “‘What honor and recognition has Mordecai received for this?’ the king asked.  ‘Nothing has been done for him,’ his attendants answered.” (Esther 6:3)

Caring for patients has its own psychic dollars, perhaps compensated like no other activity, a reality that most of us figure out on our own.  Yet the work can be arduous with the satisfying elements of assessing a difficult presentation or getting the IV started without infiltration becomes subordinate to the stressors of typing data, following nursing protocols imposed by a director you never saw for a reason that seems not very purposeful, some surly patients or at least those whose pain unmasked their id.  A supervisor, administrator, or lawyer will inevitably pounce on infractions, ignoring the kindnesses as what the person was supposed to be doing anyway.  The people who took histories,  applied the healing hands, transported me, answered my questions or brought my wife a geri-chair so she could get more horizontal at 5 a.m. were nearly all younger than our own children, people at the beginning of their careers who haven’t quite passed through full spectrum of medical provider experiences.  Yes, they did what they were expected to do, but they each performed their part flawlessly and should be told that they did, or at least one experienced clinician thinks they did.

Nearly ten years had elapsed since I resigned my staff physician position there to take a job elsewhere, leaving me with few contacts but a close friend who had become a senior vice-president.  I sent him a note assigning him my spokesman, asking him to review the record to track down the ER nurse whose first name I remember and the overnight surgical resident whose name I did not but who distinguished himself by going back to the X-ray films themselves to clarify one of the unsettling parts of the report’s big print.  Being on the senior staff, he now thinks like senior staff, and forwarded my note to their who’s who of senior staff.  Undoubtedly, they will be pleased to know that the processes they put in place mostly worked flawlessly.  I am less confident that the people who distinguished themselves in my care will ever really know my personal appreciation.

As satisfied as I was, much of what frustrates us as quality assessment comes from the transcribed record which largely over-rides the personal contact.  I did not seek my record through the poohbahs on my friend’s copy list might.  For all I know, it records normal exam elements like peripheral pulses or oral exam that were not done.  They had an old medication list, including one stopped for side effects, which I amended both in the ER and on the floor intake, yet the old list was copied and pasted for me to resume on discharge.  When I changed my T-shirt the following day at home, I plucked off two lateral electrodes retained as unintended souvenirs.  I have become more than familiar with what the computer does to medical care.  Sometimes we need to set aside measures of that type, which can be recaptured later, and focus on the people who excelled and brought honor to our medical profession.  The window for doing that is much smaller, the benefits of making somebody proud of their superlative effort more important, though more elusive.

I did my best not to forget to share my appreciation to some very outstanding people in medicine’s future.  That matters a lot more than the accuracy of data entry, though our leadership may not quite appreciate it until it’s too late.

Richard Plotzker is an endocrinologist who blogs at Consult Maven.

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