Going Live

All doctors are writers. We write about providing medical care and about our patients over and over, every day, in the form of history and physicals, progress notes, and consultant’s letters. These writings, for the most part, tell other health care providers what is “wrong” with the patient, and what it is we plan to do about it.

Of course, we take a “social history,” usually informing us about smoking, alcohol, drug use, and other behaviors. But the format we use for these communications falls short of giving us the essence of the person inside the patient.

Many of us have much more to say than what goes into a medical note. Someone once said that “medicine is a front row seat to the drama of life,” and those of us in practice know that we experience much more in caring for patients than our charts would indicate. We talk to each other about these experiences, both good and bad, all the time. It’s what keeps us sane, and keeps us human. And then, there are those of us who feel compelled to write about those experiences.

That’s what happened to me when, as a young internist right out of residency, I was diagnosed with a serious illness for which only experimental treatment was available. I became a patient and an experimental subject, but I was still a doctor. I started to record my impressions, my feelings, what I saw and what I heard, during that difficult period. I learned a lot about myself, the medical system, and about how I wanted to care for patients from that journey. Eventually I came to publish a memoir from those writings.

I was surprised by my own ability to write that book. When I first considered writing it, I told a writer-friend that I didn’t think I could do it, because I didn’t know how to write. I missed that part of my college education, eschewing the humanities for the sciences. She told me to just use my own voice, and to write down what I thought and felt, what I heard, saw, smelled, and tasted. Writing was both challenging and cathartic for me, and it became my second passion.

Narrative medicine has become, over the last two decades, a popular genre, though doctors have been writing literature for many years (think Oliver Wendell Holmes and William Carlos Williams). Medical narratives can be about the experience of providing care, receiving care, or really any aspect of being part of the medical community. We need to share our stories and understand our experiences. Writing beyond the chart gives us a chance to do just that.

In Consultant, the column “Doctors’ Stories: ‘My Most Memorable Patient’” was previously an opportunity for readers to share their thoughts about caring for patients. We are now relaunching that series as “Doctors’ Stories: Tales from the Trenches,” and opening it up to a broader range of experiences from practice. Stories and essays about any aspect of practice, from patient encounters to the business of medicine, will be considered.

One of the many wonderful things about being a physician is that it is a lifelong learning experience. There is much to be learned from the real, human stories coming from medical practice. We hope you’ll contribute to, and benefit from, this opportunity. 

It’s 7:30 PM on a Tuesday. I finished with my last patient at 5:15. I sit staring at the computer screen in my office. It stares back at me maliciously, daring me to click my mouse, to take the risk of making yet another mistake, one that would cost me God-knows-how-many precious minutes to back-track and correct. Yet if I continue to sit here and take no action, I will never finish my patient notes.

So I take the plunge and click on “Find New Symptoms.” “Leg Pain,” I enter. No response. Not one of my options. I can add it in, a three-step-process, or I can find another option. “Pain.” Nothing. “Lower extremity pain.” No. Okay, I hazard a guess and try “Sciatica.” It comes up. But the patient doesn’t clearly have sciatica. And isn’t “sciatica” a diagnosis, not a symptom? Symptoms are what the patient tells you. She told me “leg pain,” not sciatica.

Okay, what if I just free-text? Yes, that’s an option. I can do that. But then the system won’t pick up “New Symptoms,” and the billing for the visit will be down-coded. Oh, wait: I know how to get around that. Sort of. I can add a phrase about how much time I spent, or override the code. But somehow that feels like cheating. . . . Oh, WHATEVER!!!! Stop obsessing, I tell myself, and just get this done!

I am three days into using the electronic medical record system (EMR) that we have implemented, after a 20-hour blitz training. “Implemented.” It’s an “implement.” Isn’t that something that is supposed to make a task easier? Clearly it hasn’t, at least not yet. After writing in paper charts for 25 years, using the EMR seems insurmountable. But I must persevere, because, in tech speak, we have “gone live” on the system.

“Don’t worry,” everyone tells me. That is, everyone who has been using an EMR for at least a year. “It gets easier.”

“I use my own templates,” a friend tells me.

“I use smart phrases,” my husband says.

“I use Dragon Dictation; you should try that,” a colleague states.

If only I knew how to access the templates without causing some kind of note-destroying disaster, or how to add Dragon Dictation to the system, or what the heck a “smart phrase” is. Did I miss something during the training? I’m usually a good student, and I felt like I was paying attention. . . . Also, despite my status as a “dinosaur,” having avoided this technology for a long time, I am pretty computer-savvy. Not a tech geek, but facile with many other uses of digital technology. So, is there something wrong with me when it comes to the EMR?

“It’s taking me an hour to write a simple note. It would take only three minutes in a paper chart!” I whine to my husband. He tells me this is normal at this stage, that I just have to survive the transition, and I will adjust. I don’t believe him. I am suspicious of everyone who has surrendered to the EMR. They are all part of some evil plot.

“Who thought this was a good idea?” Julie, my work partner, walks into my office, a look of sheer defeat on her face.

“I think it was you,” I answer.

“No, I’m sure you were more enthusiastic about this than I was!”

I try to be pragmatic, though I certainly don’t feel rational at this moment. “Well, we decided that if we were going to stay in practice, we were going to have to do this. EVERYONE is. Otherwise we lose Medicare money . . . and besides, now we’ll have the problem lists and updated med lists and all the labs and reports in order. Haven’t we been wishing for that for years?”

“Yeah, I know.” She doesn’t sound convinced.

We both fall into a contemplative silence. The computer blinks at us. I am sure it has complete disdain for us.

I gaze longingly at the abandoned paper chart of my leg pain patient. The chart in which I would have written “aching pain in the posterior right thigh and back of knee, with swelling and tenderness in the popliteal fossa for the last three days.” Pen to paper, the way I have always written my notes.

Despite the EMR’s dubious promise of perfect organization, I am mourning the move from black ink on a clean, blank page to a frenzy of clicks and the filling in of blanks, the words of a living, breathing being compressed into a “problem list” and sent to a server in the digital clouds.