• Resisting callousness in healthcare

December 5, 2014 First posting

Providing health care is too often personally and professionally unsatisfying for practitioners, as well as being too expensive, and providing only inadequate compassion in the treatment of patents suffering with illnesses. For there to be an environment conducive to compassionate care (health care beyond commodity), there has to be self-examination and dialogue – within ourselves, with our clinical colleagues, and with health care administrators.

Health care is about providing healing and support for patients suffering with illness. Health care administration is about making health care affordable to populations with illnesses. A tension has grown recently between providers and administrators of health care, because events in recent years threaten to disrupt the balance between care and administration. Restoring balance will require much respectful and mutually curious dialogue.

There is no “fault” in this imbalance, except in the general inability to spend time and energy on reflection and thought. As wise minds have stated, few are guilty but all are responsible. All are responsible, and in health care providers have forgotten or lost their voices in defense of their calling.

Health care is not just another commodity. Health care is about relationships of trust and healing: before there were administrators and insurance, before there were drugs and devices, and even now when there are not adequate resources to rescue patients from preventable diseases – there has always been and there will always be a role for healers and providers of comfort. That is the tradition that providers are connected to.

But health care has become a commodity, or so the modern culture would have us believe. A commodity is something that is bought or sold, including “a good or service whose wide availability typically … diminishes the importance of factors other than price.” There is no denial of the trends in health care, but if there is not to be acquiescence, where can changes begin to occur?

Change begins within oneself, and with modeling of behaviors one hopes to see in others. As self-sacrificing and deserving as we might imagine ourselves to be, there is room for improvement in how we deal with the demands of “the system.” One place to start would be with our own medical record-keeping.

As we all know, the electronic medical record has become a record of largely meaningless use medically because it has become a record of billing justification. A huge fallacy foisted on clinicians was that using electronic records would save time. That might have been true if the only purpose of record-keeping was the efficient justification of billing. But the original purpose of keeping records was to narrate a patient’s medical problems for current and future clinicians, with a secondary purpose to provide documentation of decision-making for medico-legal purposes. The billing purposes and the medical and legal purposes can co-exist successfully, but it will take re-organization of templates and re-invigoration of narrative.

The most clinically relevant information should be given positions of prominence, for instance at the beginning of a long note, not the end. (The billing roles can be relegated to lesser priority. The billable elements can all be present still, always with care to scrutinize notes so as not to copy and paste erroneous data that could be construed as fraudulent documentation.) It could be a badge of professional distinction to provide clinically meaningful discussion – much more important than any award for documenting all the right bullets. Is it too much to hope for, to see a thoughtful and accessible note from a respected colleague, instead of boiler-plate formatting with only perfunctory medical discussion?

Re-invigorating medical notes is both a major and a minor change to make in the larger scheme of modern American health care. The net effect of many small changes in record-keeping will be difficult to predict. Watching for good examples and being aware of bad ones, giving attention and making corresponding changes in oneself, can help re-vitalize the sense that health care is a calling, and more than just a job.

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