by Christopher Graham
People sometimes think it’s because the doctor doesn’t respect your time. Or that, they decided to come into the office late that day. Or any number of things that make it the doctor’s fault. The other thing that sucks about the doctor’s office is that, often, you feel like you get about 5 minutes of the doctor’s time before they have their hand on the doorknob and are clearly itching to get out of there. Just what are they doing, anyway? Why is that a near universal experience at the doctor’s office?
Honestly, it’s because the people who pay the doctors have the ability to simply decide how much they want to pay us. Each year, visits to the doctor keep getting reimbursed and lower and lower rates. But doctors don’t get a discount on things like “the electric bill” or “their office nurse’s salary” when that happens. So doctors schedule more patients. Medicine is one of those fields where you know you’re going to make less money every year, and so the only way to maintain or grow your income, is by working harder and seeing more patients. And so, slowly, the amount of time with any given patient is eroded away until you don’t have time to answer people’s questions. Here’s a print-out. Good luck. But what is the doctor doing in the back of the office between patients, anyway?
Sadly, the doctor is probably trying frantically to generate a document which is tasked with serving two masters, and in so doing fails at serving both: the progress note. This is the sacred duty of the medicine doctor. The true ritual. You see the patient. You do a subjective assessment (read: talk to the patient). You do an objective assessment (read: examine the patient and look at the labs). Then you write out what you think is going on, and what you’re doing to manage those problems and get the patient well again.
So, in essence, there’s a Subjective part, an Objective part, an Assessment, and a Plan in this note we’re tasked with creating. Look, we’ve been talking for a while now, haven’t we? I think you’ve learned exactly how creative we medical types can be with nicknames for things. And if you’ve read this far, you must be a very smart[ref]And inquisitive too, I see![/ref] person, so I will leave it to you, the intelligent and attractive reader, to deduce the entirely deliberate name for this note. I’m pretty sure you got it. As you have no doubt already guessed, this is creatively called a SOAP note.
In a bygone era, I understand these could be elegantly penned, succinct, pertinent, and well-stated documents. I saw a few of these nearly extinct, exotic creatures in the wild when I was an intern. We still had paper charts at one of the hospitals we rotated through. The older docs would write a paragraph, or maybe two, but you could read what they had to say[ref]Well, if you could read their chicken scratch – that stereotype is definitely true.[/ref] and instantly understand (1) all of the active medical issues (2) the as-yet unanswered questions, if any, and (3) the plan of treatment and why.
Alas, such days are gone. We live in an age when the system tasked with keeping and organizing our most private information is, first and foremost, a billing tool. The medical record part is a secondary consideration. Most doctors will tell you they don’t like electronic medical records (EMRs). The notes they generate tend to be rather worthless. In order to meet the increasingly byzantine legal requirements to bill or charge at a certain “rate,” you have to asses a certain number of things and write those assessments in the chart. You know that everything written on the chart definitely happened, and anything not documented in the chart didn’t happen, right? Well, that’s how payers[ref]You’ll hear this phrase in regards to medical reimbursement. A “payer” is something like an insurance company or the government that actually send a check to your doctor or hospital for services rendered.[/ref] think anyway.
And so, we have to “check off” the right amount of boxes – put enough information in the note, basically – to make sure we’re not committing billing fraud. It doesn’t matter if it’s somewhere else in the chart. They can audit you and say you up-billed above the level of care you provided if a certain number of things aren’t explicitly mentioned in the progress note. This is also a moving target, and the rules change a lot. A lot of it seems rather haphazard, too. Why do I have to review an arbitrary number of “systems” if I think it has no bearing on the case? I mean, ostensibly, isn’t that what we’re paying doctors for, in the first place? Sound medical judgement?
EMRs are designed to help you fill, essentially, the letter of the law and not the spirit. The notes are filled with auto-populated garbage text (including empty templates when there’s no entry in the database for a particular value) and enormous tables recapitulating pages and pages of information that (1) we already know and (2) isn’t particularly relevant to the patient’s active medical problems. But do you know what it is? Compliant. That’s the word we like these days. Everything should be compliant.
And so that’s probably the single biggest reason that you get to just sit around and wait. And frankly, as much as it sucks, you’re sometimes waiting even longer because the good doctors are spending the necessary amount of time with their patients, regardless of how long the visit is scheduled. With the good doctors, a visit takes as long as it takes, and so you wait. But that also means, when it’s your turn, you get all the time you and your doctor need. So it’s a blessing and a curse. But worry not, misery loves company and plenty of equally unhappy fellow travelers will be waiting right alongside you. You notice them, and, just like any situation with a group of strangers, you look around and size them all up. It’s people watching. But instead of being kinda fun and interesting, like at the airport, it’s just depressing.
Today, it was a lady with a bald head, wearing a baseball cap to hide it. Something about it just doesn’t look right to the pattern recognition machine that is our brain, though. Ladies are supposed to have hair. And when they don’t, our brain picks up on the fact that something’s just not quite right. It may take you a while to figure it out, but you can tell. Please don’t mistake that for a pejorative statement about this patient, merely a factual one. She and I, like many others in this room, are in the same slowly sinking boat together. We don’t know each other, but we’re all nonetheless companions on this particular journey, frantically trying to scoop water out of the canoe fast enough to stay afloat.
And not many people are talking, nor do they look particularly happy to be there. A lot of patients in the waiting room are like that. I’m sure I look like that: just kind of there, sitting and waiting. Often with someone else, a spouse or partner. It’s usually not a mystery which one is the patient. Sure, the white wrist band helps, but at this point, it’s mostly just a confirmation. I spend a lot of time around sick people. You can look at a lot of cancer patients and just tell that they’re sick. Some people are obviously in poor health. Seeing the hints of illness in otherwise healthy-appearing people, is a much more difficult skill to master. Doctors are perhaps slightly better at it than the general public, but even then, some people can really fly under the radar. People just like me, it would seem.
I’m one of the secret cancer patients. We exist. We’re the ones who, when we’re sitting in the waiting room, get the “heh, you’re not really sick” look from other patients. I really wonder what they think of me. They’re right, in a lot of ways, in thinking I’m not “really” sick. Well, at least, they’re not wrong. I’m young and yeah, I don’t look sick. Today, I don’t even feel sick. Later, I’m going to put on some workout shoes and go running in the park with my dog. I’m anemic, and it takes me 12+ minutes to run one mile, but I can. A lot of my comrades in cancer can’t pass through a single day without having multiple physical reminders of one kind or another that they’re sick. My biggest problem, right now, is that I run kinda slow. I tell myself, every day, that I’m (relatively speaking) one of the lucky ones and that I should be thankful for what I have. It could be worse. It can always be worse.
Finally, it was my turn at the bat, and my oncologist came in the room. He’s a very gregarious and empathetic man, and I really do feel like I’m in both competent and caring hands. He called me Dr. Graham the first time we met, so he was already starting out way ahead in my book. And, he’s just a really nice guy. He always makes a point to sit down and look at you at eye-level, not hover over you and lean in. At our initial visit, he saw that I was not in the greatest mood (hopefully for obvious reasons), and so he put his hand on my shoulder, told me that he was sorry I was going through this, especially at my age, and said that “this thing must be a real kick in the nuts.” So, I think it’s fair to say that I liked him from the beginning. In fact, I kinda want to go grab a beer with him some time.
He’s the kind of doctor who can quote literature from the top of his head, but also understands why things like getting a chemo holiday around my wedding were important. He’s an MD/PhD guy, and he definitely has the best parts of the skillsets from both of those degrees. He thinks about the high level, sciencey, technical aspects of cancer treatment, and he thinks about the everyday, how-are-we-going-to-make-it-through-the-week kinds of things that all cancer patients go through. He bridges that science-to-bedside gap just about as well as anyone I’ve never seen. He’s yet another physician worthy of emulation, and when I’m done with my training, I plan to be like him with my patients.
We had a nice chat. He always seems genuinely interested in how I’m doing in all aspects of my life, not just whether my blood counts and kidney function are stable – though he checks that too, of course. We had planned on doing 2 more cycles of doxorubicin and carboplatin, and there was no time to start like the present. So after our clinic visit, on a Monday, I went upstairs to the infusion center and got my intraperitoneal doxorubicin. I felt fine the first day or two. But later in the week, it really hit me like a ton of bricks.
Continue reading in the next installment by Christopher Graham here: Chapter 7 | Part 3: Struggling with Chemotherapy and a No-Win Scenario
Read the previous installment by Christopher Graham here: Chapter 7 | Part 1: Back to Reality and Chemo
