The Narrative in the Dead Files

Dr. Edwin Leap’s blog in KevinMD http://www.kevinmd.com/blog/2015/04/in-medicine-we-have-murdered-the-story.html is so right on. But I think the murder he describes is more heinous than the picture he paints. In addition to the loss of story from the medical records we also see three additional faults in the trial records. The first is one immediately experienced when, as a patient, you are confronted with a check list that someone is going to enter into the computer. The choices you are given don’t include any answer that approximates your real experience. And you have been instructed to choose an answer closest to your experience. The second (not so obvious) is that these codified answers will end up in an insurance company’s computer as a diagnosis that will follow you for the rest of your life. And thirdly, most importantly, the story that is lost is not just what unfolded from the doctor-patient encounter but what was the true meaning of the patient’s request for help. Dr. Leap mentions the sore throat or sprained ankle as straight forward problems which he says “I can figure out.” But missing from this dismissal is the story of why the patient came for help in the first place. Is it because they have no job sick leave and they are anxious about missing work? Or they had a neighbor who was told he had just a sprained ankle and ended up in surgery because of a missed diagnosis? Or one of their children was diagnosed with a “strep throat” two weeks ago and didn’t get better until they were put on antibiotics. If they have had a flare up of back pain is there any clue to why they come in now? Is it a different pain? In what way? What has changed that makes this more upsetting in their life? Does the change make them worry about something else going on? What have they been doing on their own to try to manage the pain. What used to work and doesn’t any longer? These all important discussions don’t end up in any computerized record. And, contrary to other comments, improved software will not solve this problem unless…unless…the software includes an accurate rendering of a dictated narrative. And, of course, the narrative doesn’t generate ICD-10 codes and can’t be used to measure “value” under the latest pay-for-value scheme. As personal medical care is disappearing we may be witnessing, not murder, but genocide.

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