Written Notes – Language in Medicine, Part 2

Insights into Medical Documentation

I wrote last month a piece intending to lightheartedly introduce some of the complexities of language in medicine, taking as example the initial patient-physician encounter in a hospital-based setting. I spoke semi-jokingly of a quest for “truth”, suggesting that the role of the physician is comparable to that of a detective seeking to establish the most important features that lie buried within the vast complex circumstances that have prompted the patient to seek medical attention. This month I wanted to take the conversation a step further, turning my attention to medical documentation, the written account of the patient-physician encounter.

There are probably three principle forms of physician documentation that track a patient’s stay in hospital. The “admission note” or “clerking”, the notes taken on daily ward rounds and patient encounters, and the “discharge paperwork”. The first is a record that seeks to lay out the pertinent findings from the initial patient-physician encounter. It is intended to be a relatively thorough document that conveys the physician’s overall impression to the consultant and team who will subsequently review the patient. The last represents the summary of the patient’s stay in hospital, typically encompassing the reasons that brought the patient to hospital, relevant examination findings and investigations (such as blood tests or scans), along with the team’s impression of the main issues and the treatment offered. It is intended to serve as a handover of care between the hospital and patient, along with their GP, as such it also contains the all-important discharge plan: the team’s recommendation of what should happen next to ensure that any outstanding issues are appropriately addressed and followed-up.

In my first post in this series, I sought to illustrate the way in which so much hangs upon the dialogue that takes place between the patient and the physician. It is not uncommon for the incessant to-and-forth to cause frustration: to the patient, who may perceive that they are being asked to answer the same question over and again; to the physician, who may feel that despite innumerable re-phrasings of the question at hand, they are not succeeding in clarifying the specific details that they would like to know.

The dialogue between patient and physician is a necessary tug-of-war that seeks to establish understanding. But once the conversation is over, the physician has the responsibility to put to paper his or her summary of that encounter. In the case of the ward round, that duty falls to a more junior physician, who takes on the role of scribe, interpreting and documenting as the conversation unfolds, often while simultaneously on the end of a phone call, or ordering investigations (- such is the level of (almost impossible) multi-tasking required in order for a ward-round to go smoothly). Within the surgical field, where the ward round often takes place at lightning speed before the consultant and registrars begin their operating list or head to clinic, many juniors use a printed template that simply requires them to tick a number of boxes. Thus for someone who has undergone ankle surgery and is recovering on the ward, the record of the daily round might read: Stable? tick. Wound clean? tick. Plan: physiotherapy. Tick. Weight-bear-as-tolerated. Tick. I often wonder what the patient imagines is written down – especially on those occasions when remarks are made which imply that a topic you are discussing should be “in my records”, as though every utterance they have made has been recorded verbatim.

Normal for Norfolk?

Medical terminology, often referred to with the pejorative term “jargon”, gets a lot of bad press. A consultant I once worked with, for whom I have the utmost respect, once asked me why so many doctors used it. It was a rhetorical question: his belief was that is gave them a sense of superiority. Periodically, there is outrage in the press when an article is published which purports to raise awareness about insulting abbreviations that may be found in patient notes, most classically (in the UK) along the lines of NFN – “normal for Norfolk”. See here for an example. But the embittered paternalistic physician with a black sense of humour is a trope in itself. In my years of practicing, I have come across no such insults in contemporary records. Returning to the question of obscure terminology, there will of course be people who do use language to intimidate and obfuscate, but I find the matter more complex.

Except in specific circumstances, such as that of obtaining informed consent from a patient for an operation or procedure, it is not expected of a physician to keep a word-by-word record of conversations held. When the patient is first reviewed by a consultant and their team (- known as “post-taking” or “post-acuting”), a long rambling document with no structure is of no help. The team will often have to see fifteen or so new patients in a morning, they are looking for a summary that is concise and clear. Thereafter, daily ward round notes need to be clear and brief. If a patient becomes unwell out-of-hours and an on-call doctor who has never met them before is called to review them, it is necessary to quickly gather the current impression and management plan from the notes. Wading through realms of paper is in no-one’s best interest. Finally, if a patient is being discharged, their GP does not have time read ten pages about the ins and outs of every single thing that happened during their hospital stay – nor does the team have time on their hands to draw up such a document.

This is where the question of language really comes into play. From the very beginning, the patient’s narrative has been subject to distortion and reformulation, as part of the very exchange that seeks to establish and confirm understanding. Having extracted what meaning they are able to find, the physician is now tasked with conveying the information to colleagues. Take the example of shortness of breath. Let us suppose that the patient came to hospital because, in their words, they’re feeling “puffed”. There are many things which might make them feel that way: their lungs, certainly, but also their heart, their muscles, their weight, or the amount of iron in their body. A vast number of questions will need to be posed in order to establish the context, but simply transcribing the answers to those questions is not necessarily helpful. What you are expected to do is to take the initial story, supplemented by the answers to your questions, and shape it into a coherent whole, into something which now carries your own spin, something which conveys your own thoughts and interpretation. In this context, judiciously used medical terminology allows you to abbreviate and condense meaning. For example: you might have established that your patient has a background of heart failure. They might have told you a lot of information about how breathless they get walking from their chair to the kitchen, or preparing their meals, how they don’t really leave the house at all any more. Some of these details will be relevant to state explicitly. But this whole picture can be summarised by referencing a common framework: thus you might simply write “baseline NYHA III”, meaning that your patient has marked limitation of physical activity and very easily becomes out-of-breath. Specific terminology also allows you to be precise about meaning and detail: saying that your patient becomes “orthopnoeic with fewer than two pillows” is different from saying that your patient “sleeps with two pillows” (Why? Comfort? Habit? Or because they can’t breathe if they lie flat? (- which is what “orthopnoeic” means)).

Clearly, this will change the formulation of the encounter significantly: you are essentially re-appropriating the information you have extracted and choosing how to present it on the page. And consider for a moment the complexity of this undertaking. The art of medicine is interpretation. Everything that you are told, every physical sign that you find, every blood test and scan that you perform: none of it makes sense out of context. Written notes are one person’s attempt at interpretation, one person’s attempt to create meaning. The extent to which this is possible depends hugely on experience: when you first begin, you don’t know which details you can leave out, or which questions you must ask. The extent to which it is well executed depends both on experience and aptitude for both language and writing, something that can be particularly difficult for physicians whose first language is not English, or for those who were never linguistically-inclined. Certainly, it is not uncommon to read documentation in which you feel that complicated words are being used pointlessly, but is that any different to reading the first paragraphs we wrote as schoolchildren or essays as undergraduates, as we grappled with the complexities of the new linguistic context in which we found ourselves, as we tried out words from our ever evolving vocabularies, feeling them out, testing them on people in order to fully understand their meaning. Rather than assuming that this is done out of superiority or exclusivity, it is kinder (and I would argue, more commonly the case) to view this as the best effort of a sleep-deprived time-pressured individual, struggling to do their best.

Many people will say that learning medicine is like learning a new language, but often that is a superficial nod to the Latin and Greek terminology at its core. Learning medicine does require the acquisition of new vocabulary, but the way in which it is truly like learning a new language is through its need for constant interpretation and translation, constant practice, constant willingness to try, fail, be corrected, and try again. As physicians we learn how to take a story and tell it again in a language that is objective enough to convey our impression and intentions while remaining true to the original, robust enough to withstand multiple re-tellings without losing or twisting that information, tender enough to remain human. And that is no mean feat. Authors and journalists may spend years learning how to write in such a way, physicians learn in the chaos of medical training, often with no formal teaching and conflicting (confused) feedback. It is a skill that we are forever honing.