We recently converted our electronic record system to EPIC, and although the first few weeks are a steep learning curve, the new perspective provides useful illumination. It also prompted a more sober reflection on adjectives, and a reaction against the unhelpful euphemism into which I’d slipped, addressing every single one of my patients in the chart as a “delightful lady.” Although I also do general oncology, my academic interest is gynecologic oncology, so I have a very asymmetric gender pool.
I was trained in the old school that required patients to be presented as title, name, age, marital status, occupation, and presenting complaint. So, Ms. Diana P. is a 45-year-old single farmer presenting with breathlessness and a productive cough. Over time, the pressure to avoid prejudicial framing has driven our culture to 45yo woman with history of NIDDM, HTN, spinal stenosis s/p L3-5 laminectomy on X/Y/1Z, presenting now with...
We have become boxed in with non-prejudicial problems.
Some categories can be helpful: helpful, helpless, anxious, preoccupied, fighting spirit, stoic denier,1 but there are implicit risks with such labels without extensive validation. They should be true to the situation and safely extrapolate to other situations. There is no adjective form of integrity. Many labels are far from “integrous”!
In contrast, a really helpful piece of advice from a resourceful psychiatrist was always to find something in your patient to admire, even the most difficult.2 It is really good advice. While I have taken this to heart, my positive reframing had slipped into the generic banality of redundant platitude.
My adjectives needed rethinking. Time for change. Furthermore, why should these adjectives be mine?
And so, displacing the challenges of learning the idiosyncrasies of EPIC, and somewhere between “Rooming” and “Wrap-Up,” I have been asking patients about what they’d chose for a personal adjective. Yes, I really have, and it’s been fascinating.
Only once has someone been totally perplexed, and completely unable to find an appropriate descriptor. Given the context of oncology in which I work, where the goals of care are such a challenge, many adjectives seem a little counter-phobic and overly life affirming: ebullient, thoughtful, energized, excited about life. Only one person to date has said, “Terrified!” Almost everyone wants to enrich and extend life.
Interestingly, the most productive conversations happen when my confession and the question about adjectives triggers a personal narrative of some significance. For example, the lady who described herself as “excited about life” immediately launched into a charming anecdote about chasing her granddaughter about a tennis court, which was also a helpful review of systems, evaluation of neuropathy, and stress test.
Truly patient-focused care requires that our practice and our records—verbal, written, or electronic—place the patient center stage. As you might have guessed, I have removed the adjectives from the electronic record altogether, but enjoy the confidential engagement with the patient that keeps the color, the depth, and what Ned Cassem, MD, (Chief of Psychiatry at MGH from 1989 to 2000) would have called the music that goes with the words.
The clinical encounter is a human connection that should reveal more of who the patient really is as a person. The challenge is always for wise judgment to navigate between note bloat and intrinsic bias as it adds, and not detracts, from the person. The patient should always be at the heart of that negotiation.
Julian Treasure (TED: “How to speak so that people want to listen”) helpfully says that fine language should HAIL: be honest and authentic, have integrity, and embody love.
I suspect that my PCP will have her own opinion about overly adjectivizing my care.