I had one among my typical work-related nightmares final evening. Three years into retirement and I’m nonetheless anxious
about work. I feel it’s an fascinating train in how human consciousness
works and the way it led to the above graphic so right here goes.
As common it begins out in a medical heart, on this case
what seems to me a medical unit in a big hospital. I’ve by no means been on this particular setting earlier than,
nevertheless it has an analogous association to many items the place I’ve labored. There’s a walled off central sq. nurses’
station surrounded by a ten-foot-wide strolling space resulting in the affected person
rooms. Judging by the gear and ground
coverings it’s from about 1980 to 2000.
I’m seated within the nurses’ station and taking a look at a chart. I’ve been consulted to see somebody on that
ground and overview the chart. There aren’t any
computer systems, all the pieces is written on paper, and the chart clips all of it collectively at
the highest. Consequently, the notes should be
flipped on the brief edge to take care of the identical studying orientation. The setting
is drab however in colour. There’s quite a lot of exercise
however nothing overly hectic that may point out an emergency.
I take a look at a notice from the pervious marketing consultant. It’s in define kind with headings solely and
areas to be stuffed in later. The chart
notes are all lined in a typical pill format.
There’s a few web page and a half after which there may be a few ½ web page
narrative written like a paragraph by a special employees particular person. I stare on the house between the 2
notes. That house is about 1 ½ pages in
size. I begin occupied with how I can
squeeze my usually micrographic seek the advice of notice into 1 ½ pages.
I begin to get anxious.
I understand I’m simply staring on the chart and never doing something. I take a look at the doorway to the room containing
the affected person I’m imagined to see. I really feel
like I’m frozen and I’ll by no means get out of there if I don’t get in there and
work out the way to document my notice. I
begin to panic. I get up anxious with
an elevated coronary heart fee.
After laying in mattress for some time and occupied with the dream,
I affiliate to the Milwaukee VA and my first Inner Drugs rotation. The
charts within the dream appear to be outdated VA charts.
I bear in mind writing in these charts – very lengthy histories and physicals
and seek the advice of notes and progress notes that have been significantly shorter. I remembered a neurosurgery rotation the place a
handful of us lined a complete ground of very sick sufferers, a neurosurgery ICU,
and all of the emergency room and basic consults from two massive hospitals. The one doable approach we may try this was by
finishing all of the rounding and documentation in 2-3 hours as a result of we have been additionally
anticipated to be within the OR for a lot of hours per day. The standard rounding notice was lower than 20
phrases – “Afebrile; VSS; (temporary description of neuro standing and surgical wound).”
That led me to consider the shortest Inner Drugs
notice by a resident. Inner Drugs
residents have been among the smartest and most industrious individuals I’ve ever
met. However within the Eighties they (and me their
intern) have been severely abused. A typical
name schedule was on name each third evening.
On a name evening 10 admissions all evening lengthy of very sick sufferers whereas
cross overlaying the whole hospital was typical. That normally meant no sleep –
however you have been anticipated to do the standard work till 5PM in your sleep disadvantaged day
till you possibly can go residence and sleep. This resulted in some embarrassing moments
like falling asleep whereas writing notes or in a single case – not placing the notice
within the chart till my resident jogged my memory, I used to be nonetheless carrying it round on
my clipboard.
At some point in that VA hospital a pal of mine stated “I need
present you one thing”. He confirmed me a notice
written by his resident that was written in 48-point font. The one purpose I do know that’s due to the
experiment on the high of this web page (that’s my normal 12 level on the high and 48 level on the backside). It
was the most important cursive I had ever seen and there have been solely 3 or 4 phrases per
line. We each laughed about it. My pal informed me all his notes have been like that,
they usually have been signed off by attendings. He was principally writing down 12-15
phrases per web page to my 300-400. We didn’t
take the time to investigate the content material of the notes – we have been simply amazed by the
kind.
This morning, I thought of whether or not it was doable to
write all of your notes like that – even in 1982.
It actually wouldn’t go muster within the fashionable period of extreme and
typically ineffective documentation required by governments and insurance coverage firms. He
would get audited for “bullet factors” and would by no means get reimbursed. Within the fashionable world each notice must comprise
bullet factors of particular documentation whether or not it’s related to the medical
care or not. I used to be in a compulsory seminar
within the late Nineties when an FBI agent claimed that any doctor not finishing
the bullet factors could possibly be charged with mail fraud and sentenced to federal
jail on a RICO violation. That was earlier than 911 and the FBI found they
may most likely be doing higher issues than threatening physicians.
At instances, I get the psychological picture of exhausting drives spinning in
massive storage arrays containing all this nugatory medical documentation that
won’t ever be learn once more. I used to
suppose it was a excessive environmental burden till massive language mannequin AI got here on
the scene. Now these AI firms are
constructing their very own energy vegetation simply so the AI can scan huge quantities of worthwhile
and nugatory paperwork to synthesize a solution which will comprise some correct
knowledge or it might be an AI hallucination/confabulation – like a medical reference that doesn’t exist.
All these ideas sprang from a foul dream of an outdated,
retired man who at instances needs he was nonetheless working. However at different instances realizes that retirement is
a good suggestion.
George Dawson, MD, DFAPA
Supplementary:
Perhaps Hospital Desires could possibly be a sequel to Prepare
Desires. I attempted to work it in,
nevertheless it didn’t match.
References:
1. Arvikar SL,
Schaefer PW, Lemieux JE, Steere AC. Case 3-2026: A 58-Yr-Outdated Girl with
Diplopia and Fever. N Engl J Med. 2026 Jan 22;394(4):383-391. doi:
10.1056/NEJMcpc2412529. PMID: 41564400.
My take a look at sentence above is the primary line on this week’s Case
information of the MGH. One sentence is honest
use.