Thread by @medicalaxioms

For some reason today of all days as I was writing my notes I was suddenly irked...
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I was writing “Acute Hypoxemic Respiratory Failure” and sufficient qualifying supportive verbiage and I considered the physicians who first tolerated being told what words to use in a patient’s note.

Surely they thought it was no big deal. Just standardize your words to help the people who pay you. Sounds so innocent. A minor request.

Followed by another. And another. And then how much family history makes a high level note. Simply add some family history, someone thought. It’s just one more requirement.

To a practicing adult doctor, family history is deeply irrelevant. When people are adopted, I don’t panic. When they don’t know their fathers, I don’t ask them to get on the phone and start trying to find them.

On December 28, 2019, the things I need to write in a note to convey the patient’s condition and my decision making might need 10 lines of text. Instead, this note was like about a zillion.

My ire was not rising about “the government” or CMS or hospital administrators. I seldom get irritated at people getting away with what they are allowed to get away with.

I was getting increasingly mad at the doctors who first conceded to this trash.

Doctors forced to choose their words to comply with some requirement dreamed up by some person who doesn’t even know what “Acute Hypoxemic Respiratory Faure” looks like.

When you give in just a little to being dominated by other people like this, there is no end. You lack cohesiveness.

The first doctors did it because they wanted to get paid.

The next doctors did this to compete with the first.

The rebels were squashed out of existence.

The compliers who complied with the best compliance were rewarded. Then dominated further.

The result is, on this day of 2018, is that my note is low on pathophysiology. It is not richly descriptive in terms of trends or changes in status...

... it is a mechanical billing spreadsheet that accurately reflects my patient’s diagnoses but not the actual doctoring performed.

It’s no surprise from notes like this that there are people who think AI could do my job.

A computer could certainly created such a dry and lifeless document.

What a computer could not do is mostly invisible in the modern US medical note—that is walk into the room and see that something is immediately wrong.

So back to my irritation. I’m mad at whoever gave up the first little bit. Once it’s gone you probably aren’t going to get it back. Ever.

You probably aren’t even going to get them to stop.

Use these words.

Now use these new words.

No. Those are the wrong words. You don’t get paid.

364.5 days a year I don’t care. I make a dot phrase and a autocomplete thingy. It’s effortless habit and I spend 1/4 of my day tapping away, compliantly.

Just not today.

Today I felt the weight of my chains. The unnecessary burden or dragging them with me around the hospital.

Got a few hours I imagined those old doctors had never given in to the first demand to “use the right words.”

“Measure something else!” They could have said. Minutes or heart rate of drops of sweat. Years of life saved or number of patients seen or anything.

Just don’t use the words I write. And force me to use the words you choose. When what I am doing is ministering to the sick.