Ben Hoban is a GP in Exeter.
How do you write up your consultations? Are you a template jockey, a fan of mysterious abbreviations and pithy one-liners, or does your typing speed allow you to expatiate in prose? Little Jimmy entered the consulting room reluctantly, clutching his teddy while wiping away a dirty tear… I’m regularly surprised on reading other doctors’ entries in the notes how distinctive an individual’s style can be, even when the subject matter is humdrum. For those who aspire to greater standardization, this is of course anathema: the same problem should be described in the same way by any number of doctors, surely! The use of clinical codes encourages uniformity, and my software system even corrects my use of them – sorry, offers ‘preferred alternatives’ – on a regular basis. When my medical imagination abandons me and all I can think to write after seeing a febrile child is ‘Viral illness,’ the computer winks at me and logs instead ‘Viral disease.’ I can hear Cecil Helman turn in his grave1 and have to resist the urge to kick the PC, which is just as well, as it morphed from a large noisy box under my desk into a small quiet one on top of it a while ago: is this progress, or just a sign that machines are getting sneakier?
It is as if someone had drunk too much coffee and tried to build a hyper-dimensional spreadsheet combining every possible medical and situational variable, and then fallen asleep halfway through.
Clinical codes are of course created by the machines’ human lackeys, but sometimes betray a way of thinking that is hard to relate to. Nontraffic accident involving collision of motor-driven snow vehicle, not on public highway, rider of animal or occupant of animal-drawn vehicle injured (SNOMED-CT ID: 214704000), for example, is spot-on if you ever need to describe that event, but tells us little about the patient: are we talking about Lester Piggott or Father Christmas? It is as if someone had drunk too much coffee and tried to build a hyper-dimensional spreadsheet combining every possible medical and situational variable, and then fallen asleep halfway through.
Codes include diagnoses, disease constructs which are clearly defined and come with a standard package of symptoms, signs, investigations, differential diagnosis and treatment. From the perspective of general practice, there is something almost quaint about this: we spend so much of our time risk-managing non-specific presentations and wrestling with complexity that anything more straightforward feels like a throw-back to simpler times, an oddity or just an opportunity to claw back a few minutes in a late-running surgery. Medicine certainly seems more complicated now, a web of interconnected problems, and when we have to apply a label to something, it can be hard to know where to begin. I find myself using codes like Frailty and Multiple symptoms more often these days, a strategy that accommodates more under one roof and saves having to open a handful of tabs for each consultation.
Sometimes precision comes at the expense of understanding, and it may be more useful to see a bigger picture at low resolution than a small one with crystal clarity.
There is perhaps in all of us a reasonable desire for accuracy and precision, but I think also an awareness that this approach has its limits. Sometimes precision comes at the expense of understanding, and it may be more useful to see a bigger picture at low resolution than a small one with crystal clarity. It’s common for patients’ notes to be littered with codes that reflect this: Depression, Post-Traumatic Stress Disorder, Bereavement, Chronic alcoholism, Homelessness, Lost prescription. Even these individual labels are just shorthand for a unique experience, but they huddle together on the summary screen, data points with a particular centre of gravity.
Ultimately, codes are names, and just as any individual can have a first name, surname, nicknames or titles, so they are a reminder that in deciding how to record a consultation, we are choosing one perspective over others. A diagnostic term (Disorder of rotator cuff) is conclusive but impersonal, while a descriptive one (Shoulder pain) is more tentative but focuses on what is most important to the patient. Headings referring to the cause of a presentation(Motor vehicle traffic accident) or its consequence (Disability) give a different point of view again. Of course, knowing who someone is and knowing them well are different things, but to a doctor who is familiar with their patient’s story, the one code that takes into account all these different perspectives may actually just be their name.
Reference
- Helman C, Disease versus illness in general practice, Journal of the Royal College of General Practitioners, 1981, 31, 548-552.
Featured photo by freestocks on Unsplash.
