Your medical record

More fiction than fact

Only relatively recently did you have easy access to your medical record. The sick-care cartel guarded it like Fort Knox gold. If you filled out the appropriate forms, got a lawyer to write a nasty letter, paid for each page, and pleaded, there was a chance it would be released. Asking for it to be sent to another physician required effort. In retrospect, this was probably a good thing because you would not believe what is in your record. It is a treasure trove of misinformation. Computers have facilitated access but have not eliminated the inaccuracies. They merely amplified the mistakes.

As a pathologist, I spent hours reviewing medical charts prior to performing an autopsy. Many of these were on patients with chronic disorders and years of various therapeutic interventions. Some charts were so voluminous that they were delivered by a forklift on wooden palettes - three or four thick volumes, mostly filled with medically irrelevant information. No piece of paper is ever discarded. The primary consumers of this paper tsunami are malpractice attorneys. The sheer weight of paper in the medical records department may well be responsible for locally deforming the earth’s crust, causing a rise in quakes and other geological disturbances. (note to self — this could be a good topic for the Journal of Irreproducible Results)

During my review, some patients changed sex during the course of the illness, and others aged or became younger. Operative sites switched sides, medications were incorrect, and even key diagnoses changed. The only consistently reliable results were the laboratory and X-ray data. The first was due to good quality controls and computer-generated results, and the second was because of careful editorial oversight by the signing radiologist. That’s not to say that all were perfect, but they were admirable. Unfortunately, the daily scribbles in the chart by interns, residents, attending physicians, multiple hospitalists, consultants, nurses, and aides do not undergo editorial review.

To avoid wading through this quagmire, I focused on the discharge summary. Physicians are required to write one at the end of a visit or episode in the hospital. These are supposed to be accurate, succinct précis of all the critical facts of the patient’s condition. Many physicians hate this chore, procrastinating as long as possible. The longer the delay details get forgotten or misremembered. The idea behind this summary is that the nxt physician responsible for the care of the patient can rapidly become familiar with the essential issues. From the hospital's standpoint, an important reason is that reimbursement is based on all the diagnoses, procedures, and other details. Hospital administrators deplore losing money. Becaue this is so critical, hospitals have medical records committees monitoring the status of the charts, the summaries, and the operative notes, sanctioning physicians who fall behind in their charting obligations. Several studies that have audited medical records found mistakes in over 90%, with at last one crucial error.

In the old days, when I was a graduate, the discharge summary was considered sacred. During my surgical internship, discharge summary sign-out rounds with the chief of surgery were held every Saturday after Gthe rand Rounds. We had to cull the chart of all unnecessary paper, write the summary, and prepare a booklet for his review. The chief reviewed each summary. Before appending his signature, he rejected any incomplete, incorrect, or otherwise not living up to his medical, scientific, and literary the standards. He used group punishment to ensure our compliance. After staying until sundown the first few times before he was satisfied, we became adept at writing accurate summaries.

Along came computers and the bane of the physician’s world that — the electronic medical record. Things went from bad to worse. There is still no editorial oversight, and a single misplaced click can cause all sorts of potential problems. Even ignoring how the computer has perverted the physician-patient relationship, the error rate has not imp1roved. Once a mistake has occurred, it gets repeated for eternity.

The computer also provides a summary of your visit to the physician’s office.

The following are some brief observations from my recent forays with the medical establishment. Some of these are not due to record-keeping but poor data acquisition. They all become part of the record.

My weight changes dramatically depending on the time of the year, as it is always measured fully clothed. I know now how much my parka and overcoat weigh. My new cell phone is really heavy. On one visit, when the outside temperature was 25 degrees, and my hands were still blue, the medical assistant immediately placed an oximeter on my finger, recording an oxygen blood level generally associated with a corpse. It was automatically added to my record. The critical measurement of blood pressure is sometimes so poorly done that I have vacillated from being hypotensive to needing immediate treatment to avoid a stroke. These so-called Vital Signs don’t seem to be regarded as very important. The assumption is that if you walk into the office and are breathing, that’s vital enough.

I recently saw a new physician, although he did not see me. He spent the hour tapping away at his computer, staring at the screen. He never touched me. I sat in a chair fully clothed, occasionally grunting a yes or no. At the end of the visit, he handed me a summary. In addition to the standard medical vernacular of ‘denies’ or ‘negative’ ( eg. he denies pain, negative for falling), this is what I learned;

 - the patient is a fragile elderly man (perhaps the most accurate statement in the record)

 - bowel sounds normal, no edema, skin normal, abdomen soft, neurologically intact etc. All this was recorded without examination but demanded by the computer and required in order to be reimbursed for a “comprehensive’ visit. Physical diagnosis (i.e., examining the patient) is barely taught in medical school. It is time to get rid of this sham. The stethoscope is becoming a relic and could be discarded by most physicians like the old lancets used for blood-letting.

 - the medication list included at least a dozen I may have taken once or ceased taking years ago. The diagnosis list included every aspect of expected male aging - osteoarthritis, benign prostatic hypertrophy, arteriosclerosis, dyslipidemia (based on a questionable lab result 25 years ago), sagging jowls, etc. 

       Much worse is the inaccuracy of death certificates. Many studies have shown an error rate of almost 50%, and that during the days when autopsies were frequently performed. These are rarely done today, so inaccurate information is suspected to be even higher. This has important implications for health policy planning, public health, and numerous research studies that utilize death certificates. This highly flawed document’s primary value is to claim on life insurance by ensuring that you have indeed cashed in your chips. From the medical and scientific standpoint, it borders on farcical. Remember the adage; bad data in — bad data out. No statistical program can salvage poor data.

       Perhaps none of this is particularly important, merely the rumination of a mature curmudgeon. But once we accept these blemishes and glitches, we become inured to trumpery and malarky.