Dedicated to the Game

When I was a kid, our family doctor kept my medical record in a card file. He kept everyone’s medical records in a card file, each visit documented on one side of a 3×5 index card. The format gave him about two dozen words to put down the reason for the visit, a few salient physical findings, his conclusions and prescribed treatments. For easy, clear-cut problems, it was plenty of information. For the tough stuff, it was woefully inadequate, and he had to recapitulate the entire history and decision making process with every return visit for those complicated problems.

So, the next generation of doctors moved to dictated medical records. This new tool captured better the details of a patient’s past history and the doctor’s thought process . No return visits needed to be from scratch, the doc. just jumped back into the stream of consciousness where he, or the last treating physician, left off. The problem with the thought-to-paper system only became apparent when our society started to spend ridiculous sums for medical care.

The current pricing and payment system is a modified command system. It’s not optimal for a few elective procedures, like LASIK surgery. But given the practical impossibility of  determining individual value for medical care in all other cases, it is about the best we can do. Payments go with terms, defined processes (whether the type of stitch used or the number of steps in a decision), and sometimes even specific words. To get paid, doctors have to extract the valued information from the stream of consciousness. Or rather, the doctors  need teams of technicians to do the extracting. To compensate, doctors are switching from thought-to-paper to paper-to-thought records, otherwise known as templates.

Templates are forms tailored to individual diagnoses or complaints. Each form has billable terms to check off and short narrative sections for processes that produce a charge. As account sheets, they are wonderful. As a means of communication, they are abysmal. At worst, they are checklists gone bad, outlines for linear thinking. Some doctors even propose using data extracted from digital templates for research and quality control in their practices. Except in very limited circumstances, such endeavours will yield more information about the cognitive/behavioral effects of template usage than anything else.

Still, if doctors can learn to adapt their methods to the use of templates, the forms may help after all. The dictated record has dangers of it own. Because it looks so comprehensive, it encourages passivity. It also codifies miscommunication; it is the doctor’s interpretation of the patient’s words, often set down as from an omniscient narrator(“the patient recalls some chest pain, but was experiencing a number of severe stressors at the time”). A template can convey the reason for a visit, a few physical findings, conclusions and treatments – about two dozen useful words. Templates need intermittent narrative summaries as background, but if doctors can remember to use them like 3×5 cards and are granted the time to do so, we may just be off to a good, fresh start.