American College of Physicians: Internal Medicine — Doctors for Adults ®

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Wednesday, August 28, 2013

Crazy ideas

A patient calls or e-mails me with a problem. I talk with them over the course of a few days, using whatever form of communication works best. Eventually, they need to come to the office to be seen, either for something needing to be done in-person (examination, procedure, or lab test), or because of the advantages of face-to-face communication. At the visit, I not only deal with one problem, but there are other issues needing to be addressed. Finally, after the visit, follow-up on the problem continues until it is either resolved, or at least is not causing much trouble.

So how do I document that?

In the past I would’ve had a clear structure for the “office visit” and separate “encounters” for the documentation of the communication done outside of the office. The latter would be done largely with narrative of the conversation, and some direct quotes from the patient. The former, the “office visit” would include:

• A re-telling of the story of the “chief complaint” and what’s been happening that caused this encounter to be necessary.

• A sifting through other symptoms and past-problems to see if there is any information hidden there that may be useful.

• A documentation of past problems (already in the record) to support the thought process documented later in the visit.

• An overview of the physical exam, again to support the decisions made as a result of the visit.

• A discussion of my thoughts on what I think is going on.

• A telling of my plan on how to deal with this.

• A list of any advice given, tests ordered, medications changed, prescriptions written, and follow-up as the details of that plan.

• A signature at the end, attesting to the validity of what is contained in the note.

But here’s the problem: it’s not real. I don’t make all of my decisions based on the visit, and the patient’s story is not limited to what they tell me. Details may be left out because they are forgotten, questions aren’t asked, or things just haven’t happened yet. This signed and sealed unit of care, represented as a full story, actually represents only fragments of the story, of many stories actually, and only as a moment on the continuum of the patient’s care.

But there it stands, the office visit, the center of the patient’s medical record. It is what my past life defines as “health care.” But for me now, it is an anachronism: an old-fashioned idea that has nothing to do with my present reality. My care is no longer episodic, so why should my records be? I no longer need “visits” as units of commerce, and no longer need “problems” as the goods for which I am paid. This took me quite a while to figure out, and has me making some radical (crazy?) changes to how I think about care.

1. Stop artificially defining units of care from my perspective.

The “office visit” is a unit defined from the physician’s perspective. This may actually undermine a clear thought process, though, fooling me into believing I’ve finished something that isn’t complete. Instead of breaking care into a temporal unit, why not define it another way:

1. The narrative – what is going on with the person. The patient narrative goes over their lifetime, some of which happens in my office. Narrative would best be a combination of patient input and my observations as a third-party. My job is not necessarily to do the narration, but to guide it by asking questions and to prioritize that which I think is most salient. Each “problem” may have its own narrative, but those lines often blur, as the chronic disease causes depression, and both the chronic disease and depression lead to fatigue and increased pain. How do you divide those? Do you need to?

2. The investigation – both through my questions, examination, and through tests I order, I work to solve puzzles. The patient wants me to make sense of confusing parts of their narrative, so I step in and investigate. Tests are ordered for a reason, and exams are generally problem-driven. One of the most important “tests” to do is to wait and see what happens. Sometimes stories only become clear as they unfold, and it is my job to know when it’s best to do nothing other than wait and observe.

3. Interventions – medications, lifestyle changes, education, and procedures are what most people think of when they define “health care.” Yet these are entirely driven by the narrative and investigation. They add to the narrative and often become part of the investigation, but they never stand alone. Well, they shouldn’t stand alone, despite the fact that they are what doctors are largely paid for in this country.

4. Destinations – what are our goals? What is the goal of the patient in the bigger sense, and what are our goals for individual narratives? The destination is the entire purpose of the doctor-patient interaction. The patient doesn’t like their destination and I am called on to help them go somewhere else, or they just want to be sure they are not inadvertently going to a bad locale.

Can I do a record based on these categories? If I do, would it end up as a crazy jumbled mess?

2. Find strings to tie the pieces together.

Each part of the record of care is tied together in different ways, with different things that they share with the other pieces of information or narrative.

1. Diseases – these were referred to as “problems” in my past life, a euphemism if there ever was one, but part of each record is usually devoted toward the prevention, treatment, or management of disease. Narrative, investigation, intervention, and destination could address these aspects of disease.

2. Symptoms – these also (perhaps more appropriately) were listed as “problems” in my past life. They are how health directly impacts the patient. Symptoms may or may be related to a one or many diseases, or may be mysterious.

3. Risks – These are sometimes determined by choices of the patient (smoking, drinking) or not (family history). The reason we at all care about smoking or family history is the risk they confer.

4. Events – Big events, such as heart attacks or motor vehicle accidents can result from or cause disease, but they are tied together in a temporal way. In the same way, an office visit is a temporal way to tie together interactions with a patient on a given day. (I didn’t say it’s entirely bad to consider visits as units; it’s just bad to only define them that way).

5. Situation/Environment – What’s going on in the other areas? Is the person getting a divorce? Is it allergy season? Is there a flu epidemic?

6. Population factors – some narratives, investigations, interventions, and destinations can transcend a single patient. My ability to see the population as a whole will help me to give better individual care.

Where does this lead?

What does a record in such a world look like? I can’t say I’ve come to a clear idea, but there are some things I’ve started doing:

1. Treating narrative as a separate entity – Whether communication happens via secure message, on the phone, or via email, narrative is narrative. It is the fuel that propels good communication (my listening to it) and by which proper care is given. Lumping narrative with the other areas tends to artificially categorize it. The result is a separate documentation of narrative from exam, intervention, etc. in the record.

2. Tying narrative and the other areas together using things they have in common. I have started using diseases, symptoms, risk factors, and events as tags, tagging narrative, consults, lab results, medications, and anything else with these fathers (so I can see all conversations, examinations, lab tests, consults, hospitalizations, etc. related to a person’s diabetes, for example, or seeing all other parts related to a specific medication).

3. Allowing free-flowing use of tags to give me different views of the same parts of the record. In general, the more perspectives one has when looking at something, the more accurate the picture. This means tagging needs to be simple (perhaps automatic) and robust. It also means that I need to be able to quickly get those views when I (or the patient) need them.

4. Working with the patient to come up with a destination – an overall plan of what they expect to get out of my care.

5. Going over the progress toward those destinations on a regular basis.

6. Making all of this fully available to my patients. This assures the accuracy of the information and keeps it focused where it should be: on the person for whom this whole system is built.

Sounds crazy? Sometimes I wonder. But then I look at what my past life as a doctor involved, and what “care” was defined as, and I begin to grin. That was crazy. This is simply being myself, which, for once, doesn’t seem so crazy.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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