Monday 11 February 2008

Subjective Comment

There used to be a habit of documenting personal comments in medical notes.

Pick up any letter from 20 years ago and it will invariably start with :

"Thank you for asking me to see this delightful 57 year old retired lady who presents with . . . "

"Thank you for referring this disgruntled 84 year old married lady who presents with . . . "

"Thank you for asking me to see this difficult 36 year old divorced teacher who presents with . . . "

"I reviewed this charming 71 year old widowed gentleman who presents with . . . "

And so forth.

In General Practice, such details were commonplace in correspondence. When training in psychiatry, the vogue was to purge such details from all letters, censorship that still intrudes in to my consciousness today.

This struck me when, this morning, I reviewed a lady's care with nursing, social work and occupational therapy staff. We'd found her to be perfectly normal, her care home found her problematic so had asked her GP to refer her on to me.

The GP's referral letter asked us to see, " . . . this stubborn lady."

Through my background indoctrination of objective, factual correspondence this piqued me, initially. My, that's a rather judgemental comment, no? She's not firm, she's not assertive, no, she's stubborn. That rather colours perceptions of her, doesn't it?

On meeting her, her daughter and the home carers (in a regular nursing home, not an EMI unit) things became clearer. She's in her room a lot of the time because she favours her own company. She happily attends for meals and medication and the like, she just prefers not to socialise all the time with the other residents. Physically she's reasonably well, mobility's poor after a fractured hip (and surgery that's been undertaken a couple times to sort this, unsuccessfully) but otherwise is pretty well. She's a very warm lady, you can't help but smile and be charmed by her ways. Despite what the staff say about her, she's very likeable.

She does indeed like things her way. She wants to be on her own but then buzzes for nurses to attend to her needs. Nurses want her sitting in the day room so they can sort her needs more conveniently for them, rather than going to her room. Too, they're worried she's not showing compliance with the "social stimulation" they need to document they do. She wants none of that, thank you very much. Her daughter says she's always been like this, they had a major falling out 'cause she's been so opinionated and assertive in determining what she wanted and how she wanted it.

She wasn't depressed. She wasn't anxious. She wasn't demented. She was perfectly well.

Her GP had the truth of it. She is, indeed, simply a stubborn lady. It was the right information to share, it was succinct, it was meaningful and useful in the assessment (knowing she's always been like this, rather than labelling her with some random psychiatric diagnosis to explain her current behaviour).

In future I'll just reframe subjective comment as "premorbid personality" and welcome it. It's got meaning and it helps patient care.


Disillusioned said...

Ah, but what if the comments are subjective and say more about the writer than the subject? Is it possible to distinguish?
For example, my reading of the lady you describe here is that she had a perfect right to want to spend time in her room. Stubborn is, in essence, perjorative is it not? It's a judgement. OK, it's a shorthand and you could see past it to the real person, who as you say was charming, warm and likeable. But waht about others who would read the "stubborn" and base all their interactions with this lady on that supposition, taht summary?
I guess I am just uncomfortable with judgemental labels, however well meant.

Cockroach Catcher said...

In the book ”The Cockroach Catcher”, Dr Zhang had to deal with a stubborn patient and he thought:
“……Stubborn patients deserve stubborn doctors……” .

It takes some doing for the lady’s doctor to put what he put down on paper for you.

The Cockroach Catcher

Elaine said...

I reckon by these standards that I am a stubborn lady, and would/will fight for my right to remain so. Makes life that bit more fun, doesn't it?

Fiona Marcella said...

I'm becoming aware that I work within a time warp - the old "chatty" kind of letter is alive and well, and not just on the side of the GP. The psychiatric reports I've had to scan in to notes have on occasion been somewhat "colourful" too. There IS a drive on the part of the more "modernising" GPs to stick to the "facts" - to send a referral letter which consists of a medical summary and "please see and treat" - but that depends on the quality of the summary, the notes, the dreaded Read Codes. And Read Codes after all are just labels themselves.

Unknown said...

What if someone read their comments and then formed their behavior so as to disguise certain aspects that were considered as negative from the former doctor? Wouldn't they present a false picture of themselves? Or are such letters disguised?

Midwife with a Knife said...

I have to say, good for her. We all have rights to remain "stubborn" ladies and gentlemen. I certainly plan on it.

Dr Andrew Brown said...

Fascinating! I always used to start my referral letters "Thank you for seeing this 99-year-old lumberjack who..." Sometimes I would use an adjective, but "pleasant" simply means "middle-class". Those were the days when doctors were communicating between themselves.
Nowadays things are more patient-centric, and my letters might begin "Mr Bloggs is a 99-year-old lumberjack who..." except that this is ageist and jobbist. All such details should be saved for the social history paragraph: "he is 99, lives in a terraced house with both parents, and still ekes out a meagre living cutting down trees".
But the opening "Mr Bloggs is 99, and..." sounds a bit feeble.
What the old-fashioned opening sentence was trying to do was provide a thumbnail sketch of the patient in a single sentence, in the way a novelist or poet might try to do.
I'm afraid that my referrals nowadays tend to the bland and mundane. I don't know who I'm writing to, for one thing, and typing into a small field doesn't encourage literary effort.

The Shrink said...

It's a tricky one. With subjective comments there's the possibility to either prejudice things unfairly (as Disillusioned suggests) or to rapidly convey a summary and meaning (as Dr Brown suggests).

Too, as Elaine and MwaN suggests, is it that bad . . . I want to be stubborn when I'm a venerable age!

I have always favoured Disillusioned's view that they're best avoided, whilst being aware of Panagiotis' point that patients could at some point read any letter I send.

But political correctness, censorship and the like irk me. Shouldn't we be able to say what we want, as professionals, and assume that colleagues will be both adult and professional in their interpretation and use of this? Heck, it is after all sent as clinical information, not gossip!

Letters conveying evocative imagery, akin to poetry . . . I like that analogy a lot.

Dr Brown, letters are typed or hand written to me, still, by my GP colleagues. Many are sent to me personally, with some GPs and Consultants writing on first name terms. I think it would be sad, if this professional relationship were to be lost.

Anonymous said...

I've never been fond of them for same reasons as dissillusioned. However, they can be regarded not as a statement of fact, but as an indication of the immediate or projected relationship between the pt and the health care provider(as per the nice old "stubborn" lady).
In this essence, it has been useful in understanding where some of the 'problem issues' might be coming from when those charged with their unconditional and professional care begin correspondence with something akin to "Thank you for seeing this obnoxious little bastard.... "

Katie! said...

As a person just learning how to write reports and letters like these, I'm glad to know that I am not the only one who finds those added comments unnecessary, annoying, and judgmental. It drives me crazy to read charts and find it full of editorials about the patient. I will make up my own mind, thank you very much!

(I'm in line to be a "stubborn" old lady too.)

PhD scientist said...

Michael O'Donnell wrote very entertainingly about the changing style of letters and notes in "Medicine's Strangest Cases"

Re the meaning of stubborn, if "stubborn" has a pejorative sense, what about "strong-willed" (which I take to mean "stubborn, but not in a bad way")?

PS The only time I ever saw a referral letter the GP had written for me (to a general surgeon for a minor procedure) he told the surgeon in the letter that I was taking an antidepressant I had taken for a few months more than a year previously...! I always wondered whether that was why the surgeon was so solicitous, although it could have been the private insurance.