Caring Relationship
M E D I C A L T R A D I T I O N S
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INTRODUCTION
“It is much more important to know what sort of patient has a disease
than what sort of disease a patient has.”
Sir William Osler (1849 – 1936)
“The good physician knows his patients through and through,
and his knowledge is bought dearly.
Time, sympathy, and understanding must be lavishly dispensed,
but the reward is to be found in that personal bond
which forms the greatest satisfaction of the practice of medicine.
One of the essential qualities of the clinician is an interest in humanity,
the secret of the care of the patient is in caring for the patient.”
Francis W. Peabody, M.D. (1903 – 2001)
PARADIGM SHIFT PARALYSIS
Overall, the widely used electronic medical record (EMR) by its structure and intent represents the accumulation of data necessary to justify a specific reimbursement level. Largely unchanged through 2019, the early versions of the electronic medical record are not useful as a basis for supporting a Primary Physician’s responsibility to promote healthcare that is justly efficient and dependably effective healthcare. The electronic medical record has a particularly negative influence on a commitment to achieve comprehensive integration of the health care for any resident person, especially if there are substantially Complex as well as Basic Healthcare Needs. As described by Doctors Osler and Peabody many years ago, the essential factor necessary for successful health care is a Primary Physician’s capability to establish a caring relationship as a basis for each resident person’s health care.
The current EMR formats and related data sets are poorly constructed as a basis for healthcare. The attention required to accommodate their operational requirements inhibits their use for promoting a caring relationship between each resident person and their healthcare team. By serving the documentation requirements for Medicare reimbursement, the Mission Statement for each EMR system has no connection with an obligation to engage the true customer/consumer, each individual person, viz., eye contact. In essence, the use of an electronic medical record fundamentally disengages the immediacy that is a necessary attribute of any caring relationship, especially to establish its Trustworthy character.
To start over, there are three attributes of any medical record that are absolutely required. It must: 1) reliably and succinctly maintain a real-time data set for characterizing a resident person’s overall HEALTH and their evolving comprehensive care plan; 2) represents intuitively accessible usability during the minute-to-minute events of any healthcare encounter; and 3) automatically compiles a continuing, real-time revision of a person’s comprehensive care plan as structured by a Process List ( aka Problem List) that is ultimately maintained by each resident person’s Primary Physician. So far, there is no electronic medical record available that will serve these three criteria.
TRADITIONS
HEALTH CARE
For 41 years, it was a very special privilege for me to offer health care for a resident person’s, Basic Healthcare Needs as their Primary Physician. About 3,000 times a year, each encounter for health care began with a unique story with special needs and a caring relationship to renew and refurbish. It was an event based on many rituals, customs, and examination methods. Integrating the process for every resident person’s encounter becomes a routine established by repetition but always, uniquely special. Over and over, the routine begins by knocking and opening the door of an exam room, making eye contact with a smile and offering a greeting commonly associated with a safe gesture, historically a hand-shake or a head nod. After the greeting, a mutually respectful ability to create spontaneity during the visit would give it a special character for the patient and for me. The micro-traditions of each visit continue until it concludes by mutual agreement. — 3 —
For each encounter, this scenario can be interrupted, unexpectedly, by the possibility of a rapidly evolving health condition. Initially, all decision processes are fixed on “early detection.” Immediately, the following question becomes the governing ritual: Is it possible that a rapidly changing health condition represents the need to initiate immediate health care to alter the possibility of preventable complications? My office was located across the street from one of my community’s 911 ambulance teams. By our request, they would arrive at our office about once every three years to transport someone with a rapidly evolving Emergent HEALTH CONDITION to a hospital’s Emergency Department. Even though very infrequent, the micro-traditions of each visit are interrupted by a variety of other events, but an emergency being ^the most worrisome, ^usually unexpected, and ^dangerous if its recognition is delayed.
During the encounter, even if interrupted, I usually connect with each person from their right side. Each of the exam rooms in our office has the same configuration. When I ask about their story, listen to their heart, or push on their abdominal muscles, I rarely think about whether or not the examination is really better by sitting or standing on the person’s right side. Should a left-handed physician stand/sit on the left side? Does my position give me more accurate information? As a physician, I do not always understand the meaning for each custom, ritual, and examination method that was taught to me and previously taught to my teachers by their teachers. The traditions for health care represent customs, rituals, and examination methods that were passed on to me as well as to all other physicians. Most professions have a similar ritual as they pursue their own professional style for each encounter, their own professional “litany.” Eventually, a health care encounter as a caring relationship is unusual for one specific reason. It involves “ a DIAGNOSIS. ”
a DIAGNOSIS
“What is it that you do?” Frequently, I imagine being asked this question. But, no one really asks it. They almost always know what I do. Just the same, I am ready to give an answer, especially if the person who is asking the question already knows what I do. My prepared answer is: “Basically, I manage uncertainty.” I collect a limited amount of information, formulate a temporary hypothesis, test the hypothesis with more but limited information, decide if a new hypothesis applies, reaffirm the temporary hypothesis with the person, propose a possible treatment plan based on this hypothesis, assess the treatment plan again by obtaining more information and, finally, negotiate the meaning of this process for approval by the patient. The process may jump from hypothesis to hypothesis and may be left unfinished during any encounter. When a patient finally accepts a proposed care plan, even if temporary, I am able to decide that a DIAGNOSIS exists.
To assist the decision process, a wide variety of supplementary data could include information from the person receiving health care, the person’s physical examination, laboratory tests or x-rays. a DIAGNOSIS may also require opinions from experts, trends of certain tests over time, or even serendipity. When my sense of uncertainty is mounting, I also try to remember that each person’s own understanding of their HEALTH can lead to the correct decision process. As a physician, you are trained “to be in charge” and that can interfere with an obligation to acknowledge the vast unknowns that determine any person’s HEALTH. To confess my own limits during a healthcare visit, I would express, “I am not sure what is really going on here, what do you think is going on?” I suspect that most physicians have their own, but similar, tactic. Very often, by asking the question, it triggered a discussion that leads to a conclusion for the encounter that was ultimately more accurate than I would have anticipated.
During 41 years ending in 2016, the sensitivity and specificity of health information as a Primary Physician had changed dramatically. Increasingly, there was a broad range of issues that determine the relevance, precision, and application of health information. The validity and precision of health information may also apply to the treatment process as well as to the iterative process for establishing a DIAGNOSIS. When there is a simple health problem such as a sore throat, a written record for the interaction would be concise and easily prepared. How a specific encounter and its medical record contribute to the overall health of a person with multiple levels of Unstable HEALTH is the larger question. This is where the quotations cited above are still crucial, even though they originated in the nineteenth and early twentieth centuries. — 5 —
The number of simultaneously unique decision processes can be overwhelming, especially for a resident person with Complex Healthcare Needs requiring 25 different medications each taken at least once during every 24-hour period of time. A mutually acknowledged awareness for and a regularly scheduled revision of a concise statement of each resident person’s overall HEALTH and its health care, known as a comprehensive care plan, should define the essence of enhanced Primary Healthcare. Now, more than ever, the physicians’ Sir William Osler and Francis Peabody had it right. To define the contemporary complexities of healthcare, healthcare needs a new structure for integrating the potentially endless interacting dimensions of each resident person’s healthcare needs. The precision of this time-dependent sequence ultimately occurs in association with nurturing caring relationships originating from within their Primary Healthcare Team. The Trustworthy strength of these relationships ultimately determines its success. More than fifty years ago, Carl Rogers Ph.D. established the operational characteristics of a caring relationship, viz., warmth, non-critical acceptance, honesty, and empathy. For me, these attributes have not, and should not, ever change. Given all of the alternate forms of caring relationships, I offer the following expanded definition.
Caring Relationship may be postulated for HEALTH as
^
a dyadic social interaction with a Human Dignity scnario that
begins by expressing beneficent respect for each other’s autonomy,
thrives when each person steadily renews their adaptive skills, and
flourishes from a timely intent to communicate ‘in harmony’ with
warmth, non-critical acceptance, congruence, and empathy.
MEDICAL RECORD
The traditional medical record for each resident person’s healthcare represents a “snapshot” summary of the important health information on a given date, a list of the most applicable, one or more, active diagnostic categories applicable on that date, and a treatment plan for each diagnosis applicable at that point in time. This record primarily represents a summation of the thinking involving the predominant diagnosis, at one point in time, that are applicable to a resident person’s HEALTH and its treatment plan. The use of a computer to document a visit-related medical record represents a special challenge. Since the variety and types of information for health care are almost endless, the electronic medical record may inhibit its own usefulness. By an attempt to accumulate all the available information, the assumption would be that the right decisions will be more likely to occur. Thru 2019, there is very little evidence that this actually occurs. To be useful, the information must be available in the iterative sequence used to formulate a DIAGNOSIS and its treatment plan. Scrolling through screen after screen often does not support the sequence of spontaneous data acquisition necessary to eventually arrive at the most precisely defined set of HEALTH Conditions, each with a DIAGNOSIS and a treatment plan.
What is the problem with the traditional medical record? Health care represents a process that is very difficult to define. It may be that the decision points, especially for a person with more than one active diagnosis, represent a combination of deductive and inductive reasoning that follows a decision process unique to each diagnosis. To further complicate the process, the shifts between deductive reasoning and inductive reasoning can occur in unpredictable sequences and uniquely between any specific diagnosis and its own treatment plan. The precision related to a Diagnosis for a genetically inherited disease is totally different as compared to the diagnostic process for a respiratory infection for a resident person with chronic lung disease. Ironically, the currently most useful testing process for chronic lung disease, as in asthma, uses a technology first described in 1819, a stethoscope (shown above). The level of precision among the separate arenas of possible alternative diagnosis is huge. It is no wonder that the level of “burn-out” is so profound for physicians.
As an example, John came to see me one month after visiting an Emergency Department (ED) for a “sore throat” and a cough. Before the Emergency Room visit, he had been started on another medication for his heart function by a specialist. During his follow-up visit for the ED visit, I reviewed my flow-sheets and noted that he had previously been started on this new medication briefly 10 years earlier for his high blood pressure. I had stopped this medication at that time because of a cough. This was simple to discover because of the hand-written flow-sheets on his chart that spanned 15 years. The same information had not been captured by or was not accessible to the specialist. Over the last 40 years, these relevant details over time have become increasingly difficult to manage. Currently, there is no widely recognized format for a concise medical record that is continuously updated and formatted to reflect all of the important trends and processes applicable to a person’s health, especially its social and genetic dimensions. A Commentary in the New England Journal of Medicine regarding the failure of an electronic medical record to track the pneumonia immunization process for a person who had no spleen represents an unfortunate example of an inadequately formatted and maintained electronic medical record.
The currently formatted “EMR” for defining a resident person’s Primary Healthcare is now an important contributor to the inefficiency of our nation’s industry. The perspective necessary for the long-term character of a resident person’s HEALTH and its healthcare is lost. Furthermore, the focus on discrete units of information inadvertently discourages the use of emotional and social information as contributing factors for individualized health care. I am aware that the Veteran’s Administration has evidence that its original computer system initially decreased the efficiency of its surgical services by 25%. In 2016, the VA announced that it would seek to eventually evolve to a new EMR using the CERNER System, and so it began in 2019. That transition has its own saga as of 2023. — 7 —
PARADIGM SHIFT REVERSAL
In 1968, Lawrence M. Weed, M.D. described a new concept for the medical record as a means to improve the precision of health care. This concept apparently had evolved over several years before his two essays appeared in the New England Journal of Medicine (Weed 1968). The concept applies to all forms of health care but would be especially important for Primary Healthcare. The range of inadvertently competing, active health problems can be quite long for a person with highly Complex Healthcare Needs. Unless the Problem Oriented Medical Record (POMR) is in place for all resident persons receiving health care for their Basic Healthcare Needs, an EMR is less likely to be useful for managing the unexpected occurrence of rapidly evolving Unstable HEALTH.
In spite of the inherent validity of the concept developed by Dr. Weed, the Problem Oriented Medical Record (POMR) including flowsheets is currently in use for only a very small number of resident persons. In spite of the profound changes in healthcare since Dr. Weed’s paper appeared in 1968, there has been little recognition of its potential value for every resident person’s health care. Truly, the POMR has suffered from the paradigm paralysis within the healthcare industry during the last 50 years. If a person has Complex Healthcare Needs, the medical record needs the ability to define multiple diagnoses and identify their respective treatment plans separately but also simultaneously. When honored at the time of any health care encounter, the use of a POMR and a real-time flow-sheet represents a significant attribute for the enhanced level of Primary Healthcare that will be necessary to improve the cost and quality problems of our nation’s healthcare industry.
In the fall of 1926, Dr. Peabody presented his ideas about health care to the medical students at the Harvard Medical School. (Peabody 1926) The last four words of his lecture best summarize the priorities also emphasized earlier by Dr. Osler. I propose that the use of the POMR should eventually become the essential means to augment each Primary Physician’s “… caring for the patient.” Based on my own experience with a small group-practice and a gate-keeper, risk-sharing HMO for @2000 members lasting nearly 15 years, I also propose that this style of healthcare would promote meaningful improvement in the efficiency of our nation’s healthcare. Fully implemented, this model for offering equitably available enhanced Primary Healthcare to every resident person could reduce, by itself, health spending for our nation’s healthcare from 18% to 15% of the gross domestic product. We have everything, but the will, to make it happen!