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Posted by Ishani Ganguli October 19, 2012 07:00 AM
The other night, a patient gave me a piece of his mind. Mr. Q was a middle-aged man debilitated by days of nausea, vomiting and intractable belly pain. That morning, his wife finally convinced him to get medical attention and drove him to our emergency department. On arrival, he sat in a cubicle in the waiting room and explained his story to a triage doctor: how he was doing well until he ate a particularly rich meal a few days ago. How he'd vomited five, maybe six times. How he hadn't noticed any fevers. How he'd tried Tums for his symptoms with little effect. After he was escorted to a bay in the emergency room, he repeated the unpleasant details for the resident who came in to evaluate him. This time, he added that he takes a statin for his high cholesterol, that penicillin gives him a rash, and that he doesn't smoke. Within the hour, he gave a repeat performance for the emergency room attending.
Just as he was settling into his slightly-more-permanent bed on the medicine floor, here I was, poised before a laptop on wheels and demanding yet another re-hashing of a narrative that had grown both trite and physically exhausting: “So, Mr. Q. What brought you to the hospital?”
"Doesn’t anyone write this stuff down?" He followed with a few other choice phrases.
Why do we make patients repeat their stories so many times? My standard answer is that when we assume care for a patient, we need to be sure that we understand his history so that we can take care of him properly. This is true, but it's worth unpacking further.
Each re-telling has a unique purpose, or at least a unique point of view: In the emergency room, the questions asked of Mr. Q were necessarily brief and to the point. There, the main goal was to rule out potentially fatal causes of his belly pain and to send him either home or to an inpatient hospital bed. When I admitted Mr. Q to the general medicine unit, I needed a more detailed story so that I could continue to diagnose and treat his symptoms, and I needed to cross-check his home medication list so that I could order those drugs for him during his hospitalization. Specialists consulting on a patient would have asked him for a re-telling of his story with a shifted frame: the infectious disease doctor would want to know about him eating uncooked hamburger; the cardiologist about whether he’d ever had chest pain while resting.
Even if I had found all of the seemingly relevant details in prior notes, I might have gotten unexpectedly valuable information from a re-telling: a diagnosis-clinching clarification of the exact quality and pattern of his abdominal pain, or a teased-out recollection of blood in his vomit. Asking those questions myself also helped me understand and remember my patient's story better than if I had read it from the chart.
So is the repeated story phenomenon a useful, error-reducing redundancy in our health care system? A necessary annoyance in an increasingly complex medical system involving multiple doctors and departments? A vestige of the Every-Man-For-Himself doctoring model in which you must re-check everything and trust no-one? Probably all of the above. But I wonder, in our slow but undeniable transition to team-based care, to what extent should we rely on the story as it has been collected? Where is the right balance between efficiency and patient comfort on the one hand, and Getting It Right on the other?
Later that night, Mr. Q stumbled out of his hospital bed to find me and apologize for his rudeness. Surprised by his gesture, I thanked him and told him it wasn’t necessary - he had every right to be frustrated and had given me something to think about.
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