Matt Morgan discusses how patient notes could be improved
One day, you decide to help your daughter with her physics homework. You open a textbook that claims to explain fundamental particle theory:
Page one tells you that everything is composed of atoms. The next page tells you that these atoms are indivisible, indestructible, and identical in mass. Page three says that actually that is wrong and that atoms are made of protons and electrons mixed together in a single mass. The paragraph later says in fact atoms have an impenetrable nucleus orbited by electrons. Oh no, not quite, page four explains electrons actually have quantized orbits. Whoops, wrong again, page five outlines the electron cloud model. Page six blows your mind as neutrons are made from two down quarks and one up quark. You give up, forgetting what is actually true and what is not.
Making sense of a story can be achieved in many ways. Having historical, temporal context can be very important but serves to solve a different problem rather than explaining the state of being at one time. Imagine viewing an article on Wikipedia as a stream of hundreds of corrections and edits rather than the current accepted state of knowledge.
My last piece (The ward round is broken) outlines how the mass of data presented during a typical ward round can be overwhelming. Leafing through a thick set of medical notes contributes towards this process too. They may read:
Page 1 – Admitted with chest pain likely myocardial infarction, treated with dual anti-platelet agents. Plan: troponin and in-patient angiogram.
Page 2 – New pyrexia, troponin negative, chest X-ray shows consolidation. Plan: antibiotics and consider CT scan.
Page 3 – CT scan shows evidence of cavitation likely TB. Plan: Bronchoscopy and triple therapy.
Page 4: Bronchoscopy shows malignant cells, likely lung cancer. Plan: Surgical referral.
This temporal journey has huge value, but is complex. Each new finding is added to an ever increasing series of iterations over time—disconnected and disarticulated in time and space. And this is over only a few days let alone weeks, months, or even years.
Would this be better?
Chest pain due to cavitating lung cancer according to CT and bronchoscopy. No evidence of myocardial infarction or infection.
Perhaps medical notes should move towards or add a Wikipedia style of continuously updated state of current knowledge. We can maintain the diary style running commentary for day to day communication. This may still help to explain the patient’s story. At the same time, the current state summary can allow us to focus on what we know is true rather than what we thought was true in the past. I better get back to my daughter’s homework . . .
Matt Morgan is an intensive care consultant, scientist, computer programmer, teacher and geek interested in machine learning, medical education and public engagement. Twitter: @dr_mattmorgan
Competing interests: I have spoken at a number of education events for which standard travel expenses have been reimbursed. I received a research grant from Heath Research Wales and the Medical Research Council in 2016. I am paid as the lead clinical editor for BMJ’s onExamination.