Duly Noted

If Kurt Vonnegut had been a physician, would his phrase “and so it goes” have ended each section of his clinic notes? Would a patient history written by Charles Dickens wax poetic and verbose over the orphan’s plight, no matter what the patient’s chief complaint? Perhaps Ernest Hemingway’s charting would be spare with impeccable narrative development.

No, they would have wanted nothing to do with medical documentation—bastard child of the biography and the legal brief. Like the physicians who author them, medical notes are hobbled by too many conflicting functions, both banal and profound. Yet they also reflect a physician’s voice, and, under the technical jargon, a story always hides.

I suspect most notes sit forever unread by anyone except a brief glance by the billing and coding department. They remain lowly receipts of services rendered. Someday one of my notes may be dissected in a court of law. The malpractice lawsuit is a statistical probability, but I prefer not to dwell on it. At its best, the note communicates with other physicians to smoothly coordinate and transition care without dropped beats or stuttering. These are the utilitarian functions: business, legal, medical science.

When reading a chart, I can frequently identify my colleagues’ style without looking at the author’s name. Many editorialize, using words such as “unfortunate 42-year-old man” or “pleasant 86-year-old woman.” A frustrated doctor walking away from a confused encounter might write that the patient is a “poor historian.” Once a colleague combined these two with flair, saying that his patient was “pleasant, though not in the tradition of Herodotus,” referring to the Greek father of history. Some physicians quote their patients extensively: “It felt like there was a very large woman sitting on my chest.” Other doctors think this unprofessional and primly state that the patient complained of chest heaviness.

Few of us imagine the patient as a potential audience, but often times the note chronicles a pivotal life moment for him or her—the diagnosis of cancer or a miscarriage, or detailing a crippling car crash or a psychotic break that will define their coming decades. These brief histories encapsulate the absurdities, triumphs and anxieties of the patient population, as seen, interpreted and set down by their physicians, unintentional biographers.

Despite my best efforts, the note always feels inadequate. Billing will think the list of symptoms insufficient to itemize properly; legal would find inconsistencies and liabilities; my patient, reading his or her own story, would lament that the prose is too shallow and flat to tell of human suffering and joy.

Trying to produce a note that fulfills all its diverse and often conflicting tasks is laudable, but perfection in documentation stands between the patient and me and abbreviates our interaction. I prefer chatting to charting. Talking with my patient appeals to me more than catching up on unfinished notes. So, inevitably, at the end of the day I have a list of electronic documents to finish and sign. I make my way down the list, keying small additions and corrections before I sign each with an electronic signature, locking it forever in the hospital’s digital vault.

As I send a document out into the electronic ether, occasionally I have a small existential moment, reflecting on the story, imagining the potential audience. At the very least I hope the next physician will read my note and be able to pick up where I left off. At most I am the author of this small story, like a hidden diary. In that moment, I try to hold the story in my mind lest the cacophony of other demands drown it out. I go down the list one last time and punch in my electronic signature.

And so it goes. And so it goes.


By Noah K. Rosenberg

Noah K. Rosenberg (@NRosenbergMD) is an emergency physician working in Rhode Island and clinical Assistant Professor at the Alpert Medical School of Brown University. He is also an occasional essayist, politics junkie and outdoor enthusiast.

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