Capturing the patient's story, or capturing a billing code?

Capturing the patient's story, or capturing a billing code? Is the duty of the physician to capture the patient’s story or capturing a billing code?

In July 2018, the Centers for Medicare and Medicaid Services (CMS) proposed revamping Medicare payments for office visits. CMS plans to collapse Medicare fees for levels 2 through 5 office visits into a single price beginning in 2019, as explained in this NEJM Perspective article.

In theory, this is to help reduce the documentation burden on physicians. In practice, it seems unlikely to do so.

For further insights and opinions, I refer you to the full NEJM article, and this nicely titled article in Annals of Internal Medicine, When Centers for Medicare & Medicaid Services Treats Throat Cancer Like Pharyngitis.

Don’t get me wrong, I loathe the burdens of charting and documentation as much as any one of us. I lament the ways the EMR’s (electronic medical records) have altered the way we chart and the appearance of our notes in the medical record. But I also think part of what we do as physicians, is to document the story. Because to learn the story of the patient is to participate in an act of human connection.

When we listen for the story, we listen to the patient.

A corollary: caring about the patient’s story equals caring for the patient.

And maybe it’s only because my brain is wired to write, but I often find that it as I finish my chart notes (and yes, I still type my own notes — I can type as fast as I can dictate), the patient’s story takes shape. I often improve on the plan in this step and will reach back out to the patient after this.

I also find a satisfaction in the completion of this task of documenting the patient’s story, because I feel we have a responsibility to get it right. And not the “fill-in-the-blank” of the EMR, but a true narrative.

Because I believe that to be healers, we must understand the patient’s story.

Another corollary: When I feel I’ve failed to make a connection with a patient, it’s often because I never learned their true inner story. There can be many reasons for this, but they usually boil down to just two: not enough time and not enough presence on my part. Sometimes it’s because I thought I would get another chance to spend more time with them that never materialized — because of disease, or circumstances, or both. And even though I fulfilled my role as their doctor, something still feels incomplete.

It occurred to me while I researched and pondered this topic, that perhaps those of us drawn to the cognitive specialties are drawn to the human story.

I have heard it said that for writers, there is only one human story, but infinite variations on how characters react to that story.

The writer’s job is to capture those variations. It is the same in illness. Every single one of us will react differently when our health is challenged or threatened. And it is the physician’s job to capture that unique story. It is not about the billing code.

I can never know exactly how the next person in the next exam room is going to react to the same diagnosis, and I must be prepared for all possibilities. I think all of us learn at some point, whether in training or later in practice, that one shouldn’t have any expectations about what is waiting on the other side of the exam room door. No matter how prepared you think you are, there will always be something you haven’t seen before –– something a patient says that you’d never expect. It could also be a manifestation of the same disease that one hasn’t seen before or a way the disease has impacted the patient and family one had never thought of.

Perhaps we need to look back at the history of medicine and the chronicling of illness before we adjust how we document based on billing rules.

This article, From Papyrus to the Electronic Tablet: A Brief History of the Clinical Medical Record with Lessons for the Digital Age, covers the history of the evolution of the development of an organized medical record. First out of a concern by physicians for quality improvement, and later to the development of the EMR stemming from a concern by regulatory agencies for billing and coverage (or denial) of medical services.

This blog post, As hospitals go digital, human stories get left behind, explains:

a medical record that abandons narrative in favor of a list does more than dehumanize our patients. It also hampers a clinician’s diagnostic abilities…For centuries, medical information has been documented by clinicians in the form of case reports, narratives that are similar in structure to other kinds of stories. Like stories, case reports include a protagonist (the patient), a sequence of events leading to a crisis (the illness), a backstory (the past medical history), and a resolution or denouement (the clinical outcome). The important role of stories in medicine is increasingly being recognized — there’s now even a discipline called narrative medicine that helps train clinicians to better gather and interpret their patients’ stories.

In Dr. Rita Charon’s words:

Stories are complicated things. They do not relinquish their meanings easily…By teaching clinicians how stories work, what happens to their tellers and listeners, and where stories hide their news — in form, in metaphor, in mood, in time and space — we enable them to enter the narrative worlds described by their patients. So clinicians can receive what their patients reveal about their lives and health, leading to accurate clinical diagnoses and personal recognition. They hear in depth what their colleagues report about their patients. They even come to be more forcefully aware of their own interior voices in self-awareness.

In conclusion, while steps to reduce onerous and tedious requirements in the EMR that waste physicians’ time and energy are more than welcome, I submit that the CMS proposal is not going to accomplish this.

We should remember when we still viewed the one-on-one interaction with the patient as a sacred rite, armed with that core tool that we carry across specialties, the history of the present illness. I think instead, that by risking the taking away of the story and even creating actual regulatory disincentives to capturing the patient’s story (the one that we are all taught to seek as medical students), not only do we risk missing a diagnosis, but we lose the story, the chance at connection, which is what leads to physician burnout.

Do you have an opinion on the CMS decision? You must let it be known by September 10th.

Instructions for sending individual comments on Medicare’s Proposed Physician Fee Schedule:

All correspondence must have the following for the Subject of letter — CMS-1693-P. address letter to Sema Verma. Start letter either as Dear Administrator Verma or Dear Director Verma-both are correct.

Electronic letters should be addressed to sema.verma@cms.hhs.gov

For traditional mail, please send letters to

Sema Verma, Administrator

Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1693-P,
P.O. Box 8016,
Baltimore, MD 21244–8016

Letters must be received by September 10, 2018 5pm EDT.

Originally published at The Hopeful Cancer Doc.

Dr. Jennifer Lycette, MD is a medical oncologist in community practice for 11 years. She works and resides on the North Oregon Coast, where she lives with her husband and 3 children. Her personal blog, The Hopeful Cancer Doc, includes her writings on practicing oncology, maintaining hope in medicine, work-life balance, and various other musings.