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 email@example.com
For traditional mail, please send letters to
Sema Verma, Administrator
Centers for Medicare & Medicaid Services,
Letters must be received by September 10, 2018 5pm EDT.
Department of Health and Human Services,
P.O. Box 8016,
Baltimore, MD 21244–8016
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.