“The Patient” is everywhere. He is in consult notes, she is in hospital admission notes, he is in letters, and she is even in my daily dictations and procedure notes. “The Patient” is that anonymous moniker that gets plopped, intentionally or not, into clinical documentation of our medical care.
This struck me today as I signed a procedure note. For some time, I have been working to deliberately refer to my patients by name when writing or dictating office notes and procedures, yet today I found that once again my dictation was “anonymized” by the transcriptionist, with the patient’s given name removed and replaced with “the patient.”
Surely this is not a matter of life and death, and there are bigger fish to fry if we hope to fix all the ills of modern medicine. Nevertheless, this makes me a bit uncomfortable. Why is it that we expect, allow, or teach those doing or recording our documentation to make things so distant and de-identified? I understand the many concerns over patient privacy, yet when recording a private medical record of an individual patient encounter, why the resistance to naming the patient, by name?
Much has been written about the importance of personalized care, and both narrative medicine—and the use of reflective writing and journaling—focus on the importance of story in understanding our patients.
One small way I’ve tried to keep myself focused on my patients’ stories, beyond just the “complaints” and the “history of the present illness,” is to both ask about, and incorporate in my clinical documentation, some small tidbit of each patient’s daily life story. Where is he going this weekend? What family plans are in the works? Who is coming to visit? What joys or sorrows are currently front and center in daily life?
But each story is the story of a person. We all hopefully know that intuitively, but we can remind ourselves of this in each clinical encounter, by giving each patient their name—not just referring to “the patient,” or “a case of a 52 year old man with chest pain,” or “a pleasant 30 year old woman.”
Each time I walk into an exam room, beyond wondering “what is wrong?” I also need to be concerned with “who are you?”
It is one thing to record the facts of an illness in the medical record, but it is far richer to truly tell the patient’s story—name and all.
William E Cayley Jr practices at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.
Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare, but I do like a good story!