{"id":33882,"date":"2015-04-14T11:26:27","date_gmt":"2015-04-14T10:26:27","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=33882"},"modified":"2015-09-22T14:24:12","modified_gmt":"2015-09-22T13:24:12","slug":"william-cayley-who-are-you","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2015\/04\/14\/william-cayley-who-are-you\/","title":{"rendered":"William Cayley: Who are you?"},"content":{"rendered":"<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-31912\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg\" alt=\"bill_cayley_2\" width=\"178\" height=\"220\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg 243w, https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2.jpg 551w\" sizes=\"auto, (max-width: 178px) 100vw, 178px\" \/><\/a>\u201cThe Patient\u201d 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. \u201cThe Patient\u201d is that anonymous moniker that gets plopped, intentionally or not, into clinical documentation of our medical care.<\/p>\n<p>This struck me today as I signed a procedure note. For some time, I have been working to deliberately refer to my patients <em>by name<\/em> when writing or dictating office notes and procedures, yet today I found that once again my dictation was \u201canonymized\u201d by the transcriptionist, with the patient\u2019s given name removed and replaced with \u201cthe patient.\u201d<!--more--><\/p>\n<p>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, <em>by name<\/em>?<\/p>\n<p>Much has been written about the importance of personalized care, and both <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/11597295\">narrative medicine<\/a>\u2014and the use of <a href=\"http:\/\/www.stfm.org\/FamilyMedicine\/Vol47Issue3\/Bradner182\">reflective writing<\/a> and <a href=\"https:\/\/www.wisconsinmedicalsociety.org\/_WMS\/publications\/wmj\/pdf\/106\/8\/486.pdf\">journaling<\/a>\u2014focus on the importance of story in understanding our patients.<\/p>\n<p>One small way I\u2019ve tried to keep myself focused on my patients\u2019 stories, beyond just the \u201ccomplaints\u201d and the \u201chistory of the present illness,\u201d is to both ask about, and incorporate in my clinical documentation, some small tidbit of each patient\u2019s 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?<\/p>\n<p>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\u2014not just referring to \u201cthe patient,\u201d or \u201ca case of a 52 year old man with chest pain,\u201d or \u201ca pleasant 30 year old woman.\u201d<\/p>\n<p>Each time I walk into an exam room, beyond wondering \u201cwhat is wrong?\u201d I also need to be concerned with \u201cwho are you?\u201d<\/p>\n<p>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\u2019s story\u2014name and all.<\/p>\n<p><em><strong>William E Cayley Jr<\/strong>\u00a0practices\u00a0at 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.<\/em><\/p>\n<p><strong>Competing interests:<\/strong>\u00a0I 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!<\/p>\n","protected":false},"excerpt":{"rendered":"<p>\u201cThe Patient\u201d 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. [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2015\/04\/14\/william-cayley-who-are-you\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1357,14769],"tags":[],"class_list":["post-33882","post","type-post","status-publish","format-standard","hentry","category-us-health-care","category-william-cayley"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>William Cayley: Who are you? - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2015\/04\/14\/william-cayley-who-are-you\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"William Cayley: Who are you? - The BMJ\" \/>\n<meta property=\"og:description\" content=\"\u201cThe Patient\u201d is everywhere. 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