This video of Dr. Weed’s 1971 Internal Medicine Grand Rounds at Emory University should be required watching for all graduating medical students. Its message is as fresh and urgent today as it was in 1971–if not more so.
Thanks to his New England Journal articles and the series of grand rounds delivered at teaching hospitals across the country, Dr. Weed accomplished a transformation in medical culture: the widespread adoption of the “SOAP” note, or a systematic documentation of a patient’s problems and medical course.
The SOAP note made it possible for any physician reviewing a chart to quickly appreciate what the medical issues were, what the differential diagnosis was, and what tests and therapies were being undertaken to treat a patient.
Adoption of and respect for the SOAP note was the prevailing culture when I trained as a physician in the 1980s.
No more. Cue the EMR, or electronic medical record.
Now, when I review a chart at some institutions, I can find myself much in the same position as Dr. Weed in the 1970s. What is the differential diagnosis? What tests were done to sort things out? What were the results of those tests? I try to piece together the diagnosis and plan from all the tests and procedures that are ordered.
I told a pediatrician colleague of mine that instead of a diagnosis, I may see statements like: “Assessment/Plan: colonoscopy.” But a procedure is not an “Assessment” and it CERTAINLY is not a differential diagnosis. Why the colonoscopy? To diagnose what? That was not explained.
My pediatrician colleague laughed. “Funny you should say that – often, when I have referred a patient to a specialist and the note from the specialist comes back with a recommendation for a procedure, I wonder–but what are they thinking? What do they think my patient may have?”
The EMR, another medical colleague told me, really serves “as a cash register.” It is set up purely for financial reasons–not to help physicians and certainly not to aid in medical diagnosis.
What would Dr. Weed think of our medical records now?
In a 2008 interview, Dr. Weed asked his interviewer to imagine if our highway system were set up the way our medical record system is–as a cottage industry, where everyone was wandering around, defining his own game. Some highways would be paved, others not. Getting from one state to another would be extremely challenging. But that is what we are seeing in the medical system, he said. If you have the misfortune to get sick in Chicago and return home to Massachusetts–it will be very difficult, and sometimes impossible, for your physicians to access the record of what happened in Chicago.
In fact, it can be extraordinarily difficult if you are hospitalized right here in Boston, and then are seen at an institution across town. I recently heard a fellow physician present a case and mention, apologetically, that the patient had been hospitalized elsewhere in town, but she had no records for that hospitalization, so she didn’t really know what happened there.
Really?
When I was a physician in training, our systems were far more antiquated–but a clinic patient would arrive with a stack of medical records–and at the referral hospital in Denver where I worked, those voluminous records would come with the patient from all over the country. Now we have much better technology–but no records? How can that be?
Medical records as fiction
Moreover, the automated nature of the dictation system, where no human scribes check for errors, can lead to significant mis-statements of fact. Just like the practice of dictating notes three weeks after seeing a patient that Dr. Weed bemoaned in his grand rounds, the lack of a human editor can create a fiction out of the medical record.
When the medical record is wrong it can be difficult to correct
According to one patient I spoke to, getting the record corrected can be difficult bordering on impossible. She had had a carotid endarterectomy on the left–but the chart noted that the procedure was done on the right. The physician acknowledged the error–but said he was unable to change the record.
The lesson here: errors like this can have serious consequences and we need to have a way to prevent them–and rapidly identify and fix them when they occur.
One of my colleagues in Virginia concurred about the failings of the EMR. “What bothers me,” he shared with me, “is that when I review my patients’ records after they have been in the ER or hospital or to see a specialist– there is no narrative anymore. I don’t know what the patient looked like, what he was feeling or what the doctor was thinking about a differential.”
“I am old-fashioned, I suppose, but I still enter all of that into the record,” he said, “even though there isn’t really a place to do that. It’s the way I was trained.”
Discouraging clinicians from including a differential diagnosis
Another colleague weighed in: “It’s not just that we don’t include a differential. Including a differential diagnosis is DISCOURAGED. We are actively told NOT to do that.”
Take home from Dr. Weed
The medical record should be the cornerstone of patient centered care. As Dr. Lawrence Weed once said, “the way you handle data determines the way you think….the very structure of the data determines the quality of the output. The record cannot be separated from the care of the patient. This record IS the practice of medicine. It determines what you do….you are a victim of it…or you’re a triumph because of it. The record….is part of your practice. We do so much to a patient. We give them so many drugs and so many procedures and so much…confusion. You are a guidance system…a doctor has to be a guidance system–he is not an oracle that knows all the answers.”
“This is a crisis of major proportions,” Dr. Weed noted in his grand rounds talk. “We do not practice the art of medicine,” he said. “Chaos…. to a large extent, is what we have. The EMR just automates the chaos.” The problem, according to Dr. Weed, is that we don’t have a system that allows us to work as a team.
It is time for physicians and patients to reclaim the medical record. I should make clear: some institutions get it right. But in many places across the country, it isn’t serving patients well; it isn’t serving physicians well; it introduces error instead of clarity into the practice of medicine. The practice of medicine dies when procedures replace the differential diagnosis; when the perpetuation of error cannot be easily fixed by clinicians; when the medical record becomes a fiction.
The medical record is key to the art and practice of medicine. Physicians and patients can take it back.
Credits: Photograph by Irwan Iwe, from Unsplash.com
