In your words

Requiem for the written note

There is something mystical about the thinking/writing nexus—the direct connection, the crackling intellectual current that flows unimpeded from brain to paper.

Editor’s note: This story was originally published on Doximity’s Op-Med and is republished here with permission. It has been edited for The DO. The views expressed in this piece are the author’s own and do not necessarily represent the views of the AOA.

When I was a medical student, sometime in the late Cretaceous Period, one of the first things of note I was allowed to do was just that: I got to write a note in a patient’s chart. I didn’t dictate it and it was eons before the term “copy and paste” entered the medical lexicon.

The days of written notes

It was an unusual time. Clinicians carried many strange implements in the pockets of their short or long white coats back then. Some you might still glimpse—a tuning fork or a reflex hammer—but only if you’re a neurologist or are on a neurology service. Even the beloved stethoscope has given way to Android phones, smart watches, and VR headsets.

But one of the even rarer artifacts spied these days is a writing instrument. It used to be called a pen before it came full circle and morphed back into being a stylus, all the better to write on touch screens or tap tap on miniscule keyboards.

Those of us lower on the chain of trainees used the ubiquitous (and free!) industry ball-points while attendings chose pens the way they chose cars. A Montblanc was a Mercedes. A Cross was a Cadillac. Everything else was a Volkswagen or a Chevy Vega. But at some point, much like the way rubber eventually meets the road, the ink met the paper and we tattooed our mark into someone’s personal history.

The transition to digital

Such written notes are hard to find today. As EMRs have faithfully followed the plot of “Rise of the Machines,” the vestiges of uniquely human-to-human care are disappearing one by one—like messages written with invisible ink.

This is a loss. Perhaps one of greater importance than we realize.

Handwritten letters have been replaced by emails, texts, and tweets—but these are merely substitutes for casual social conversations. Progress and clinic notes are something different. They’re not a conversation; they’re a story—a story of one person’s journey through illness to which we are witnesses as well as guides. Such a story deserves to be told carefully and thoughtfully.

Electronic notes accomplish neither.

Pull one up and take a close look. Most are about as readable and informative as the encyclopedic user’s manual that comes with your new cell phone. They certainly don’t lack for length—I’m sure the health care accountants who run hospitals these days would love to find a way to bill by the character.

A lack of nuance

But they’re hollow—parroting scripted phrases and forcibly including verbiage designed solely to maximize billing and satisfy coding audits. And, like the DNA in a rogue cancer cell, once an error is introduced in one, it tends to replicate exponentially, resulting in erroneous diagnoses and errant conclusions. And they lack another vital element: Nuance.

Human beings are the only species who can create a story, tell a story, repeat a story and—most importantly—write it down for other human beings to read. We’re also the only species who can analyze a story. I won’t belabor the point that modern notes are almost useless—what’s the greater loss is that crafting a cogent note is an exercise in critical thinking.

The newly minted clinical clerk struggles to fit their bit of knowledge and their understandably vast ignorance into the SOAP format—subjective, objective, assessment, and plan—for a reason. They’re learning a skill—learning how the four elements interrelate. They’re learning how to place that vital information in a readable format and how to do it accurately and succinctly. In other words, they’re learning to cogitate like a doctor.

‘Something mystical’

And there is something mystical about the thinking/writing nexus—the direct connection, the crackling intellectual current that flows unimpeded from brain to paper.

Interpose a complex manual task such as keyboard entry or manipulating a peripheral device and, I believe, much is lost in the transfer. A significant cerebral step-down occurs, reducing the information to something between barely passable prose and pure digital drivel.

I was a hospital director of medical education for 20 years and so had a close look at how medical education is at once so much better now and, in small but important ways, so much worse. I once proposed a middle ground, suggesting that pink paper progress notes be placed in charts for medical students to write actual notes on.

These notes could be reviewed and critiqued by senior house staff or a teaching attending. Their vivid color would allow them to be easily ID’d and removed when the chart was broken down or retired.

I am going to make the bold statement that rarely is a med student’s digital note even glanced at. The hospital’s CMO, who lacked any real bona fides in medical education, summarily dismissed the idea as counter to the hospital corporation’s mandate to completely eliminate the physical chart in favor of the virtual.

And we call ourselves teachers.

My experience

True to my disruptive nature, I continued to write notes until the day I retired from practice. I found them to be not profound, but profoundly helpful. I could see what I was thinking and follow my train of thought by scanning my previous notes.

It took less than a minute in most cases. More than once it was of high importance and great value. When I tried to see what my colleagues on the case were thinking, I often ran into a blizzard of bytes bordering on the incomprehensible. I could find no virtue in the virtual.

As doctors, we’re moving from being a profession of thinkers to being one of sentient looker-uppers and left-clickers, beholden to predetermined phrases and drop-down menus. The written note was a personal investment in the care of our patient—a uniquely human touch and sometimes the only one identifiable as such.

This isn’t a call to action. The ship has sailed.

I just wanted to make note of it.

Do you prefer written or digital notes? Why? Share in the comments.

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9 comments

  1. When I retired 3 years ago, the health department STD clinic where I worked had no EMR system so all our notes were hand-written. I agree with Dr. Waters that electronic notes would have lacked nuance and would have been particularly sterile in these cases. When I worked ER at the beginning of my career, I was often told my written notes were too long. But the readers got a more complete picture of what occurred.

  2. I could not have stated it better myself, and will not press on as brevity is the soul of wit. Congratulations on an accurate and well written comprehensible note.

  3. Great article! I still do paper charts at my office and plan to always. You can’t replace prose with something that reads like ”stereo instructions”. EMR’s limit your ability to “paint a picture”.

  4. The pen is mightier than the keyboard. Down with the EMR as it currently exists. We have been relegated to data entry dorks who now suffer death by a thousand key strokes as well as death by a thousand paper cuts. Since we lack the leadership to decide how medicine will be practiced we are condemned to be relegated to
    professional laborers under the thumb of politicians, insurance companies, and bureaucrats. What we forget is that we all will be patients at sometime. We need to make the system better for those who come after us. The question is what kind of health care system do you want to be cared in when you need help?

  5. In the 1980’s I wrote my notes mostly when with the patient. In 1990 I learned how to dictate the entire note while with the patient (this allowed patients to correct any errors). I fortunately learned to type in high school in 1965 as an after hours course. I transitioned to Electronic notes in 2000. The critical skill that I learned was to type as I was talking to the patient and while listening to the patient. That way, 90 % of my note was completed with the encounter. During breaks, I re-read my note, corrected punctuation and spelling and sentences that were not complete or did not convey my thoughts and “fluffed” the notes. This way I had the best of both worlds – free form notes with my thoughts and actions. I used the Assessment/Plan to note each problem and current and future interventions and then cut and pasted this section as the beginning of the Subjective portion to review with the patient at the next encounter. The copy forward does a good job with the basic data that does not change but we can learn to have our notes reflect the evolution of our thinking and care we render.

  6. Succinct sentences and trains of thought for communication are gone as billing and CYA have become the standard of emr.

    I am amazed at the many 39-page DC-summaries I see. Most of these have poor if any temporal or sequential information.

  7. There was a huge problem with hand written notes that I do not miss, illegibility on the part of many. I think there is a middle ground that needs to be explored. Dragon dictation was an imperfect but very good system, when I first used it more than 15 years ago. Voice recognition has improved greatly, and AI could certainly take a dictated SOAP note and extract the necessary billing information. Current EMR notes do a poor job of aiding communication among providers, to the detriment of patient care.

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