Notes on Notes

© Photo by Bertie

At the end of a visit, I’ll often ask the patient if they want to take notes. 

Sometimes they pull out a pen and paper, but usually they type into their phone. I’ll list the issues that we dealt with that day, and the plan for each one of them, including any new treatments, referrals, changes in medications, or lifestyle goals. 

Often, as they scribble or peck away, a question will come up that I get the sense came out of the act of writing the thing down - usually a good question that reveals a gap in understanding or a misconception that I suspect would have gone unnoticed otherwise. 

Sometimes, the patient will decline - “that’s ok, I’ll remember” - and though it’s true that I’m frequently surprised by sticky changes patient made in their lives based on something even I forgot I said months or even years earlier, if they don’t write it down, I have my doubts that it will translate into action.

And then there are my notes, the progress notes for every visit or patient encounter that I’m medically and legally obligated to document in the electronic medical record. 

Doctors love to complain about these notes, and they truly are a  pain in the butt. Each progress note has multiple sections that you have to click into, often those sections lead to separate databases in the EMR that require further clicks, prescriptions and orders lead to even more clicks, and that’s before you even get to the billing.

And of course, you can’t just blindly click - you have to click in the right place - which requires positioning the cursor just so - which requires peering intently at the screen as opposed to the patient, which is where a doctor should be, and wants to be, looking.

There is no scenario where this process can be satisfying for patients. At best, they must feel like travelers at the airport, standing at the ticket counter as the attendant works the keyboard like a concert pianist: “What could they possibly be typing so much about?” At worst, they must feel the frustration of parents trying to get a kid to put away their phone and look them in the eyes.

Doctors deal in different ways. Some soldier on and advise their children to go into a different profession: “Medicine is not what it used to be!” (I am not kidding about this - the rising tide of such administrative frustrations has driven more than one doctor I know away from the practice of medicine). 

Others write “skeleton notes,” sometimes with paper and pen on a good, old-fashioned clipboard, and defer the electronic transcribing for later, spending hours of “free” time in the evenings or weekends laboriously reconstructing the visit.

Still others are able to afford scribes - assistants who may be in-person, virtual, and soon will all be AI - to take the notes for them. Scribes: the Babylonian hack to our high tech world….

 For my part, when we founded WFM, eighteen years ago, I tried to pick the most user-friendly EMR. The one I settled on among dozens, Amazing Charts - well, it may not be all that amazing, but it has stood the test of time. It was designed by a Family Medicine doctor, requires a minimum of clicks, and works in an intuitive and relatively unobtrusive way.

Still, I’d prefer paper or a blank google doc if I could, and on the occasions when I have tried using a scribe, I’ve noticed something interesting: it feels like some important element somehow intrinsic to the process of thinking goes missing when I don’t write the note myself.

I try to follow my advice to always be learning, and through it all - high school, college, medical school, residency and beyond - I’ve taken notes. Every morning I study Talmud, or some other esoteric text, and every day I try to read up on something medical that I need to brush up on based on what I’ve seen that day, or some new development in the medical literature. In Family Medicine, the broadest field there is, I never have to worry about a shortage of topics that I should or want to know more about. 

I take notes in a yellow steno pad, which I love because I am a lefty: the binding is at the top and never gets in the way of my hand. And I write in pencil because like to make little changes and I hate to cross things out. 

I have a stack of filled up yellow steno pads on a shelf in my closet, which I almost never go back to. To my occasional regret, no one else will likely go to them either - out of a combination of bad handwriting, use of jargon and shorthand, arrows, brackets and other opaque symbols, and basic fact that secondary notes are close to impenetrable in the absence of familiarity with the primary text to which they refer.

The key point is that the reverse is also true: primary material can be indecipherable without notes.

That is to say, without taking notes, the process of learning something new is unchallenged and inchoate. Only by reformulating difficult idea - summarising and diagraming it - externalising it - can you ever be sure you really understand it. The same goes for teaching, by the way. If you want to make sure you understand something, teach it to someone who doesn’t.

And the process iterates. Taking notes highlights gaps in understanding that drives you back to the text that drives you to take more notes, until by the end, it’s like the idea has become a physical object that you can hold in your hand, turn around, and inspect from different angles as if from the outside. Or, put another way (see, this is what I do!), the act of taking notes is inextricable from the act of thinking, to the point where thoughts that I have not written down feel like they almost don’t exist.

As with ideas, so with patients. Taking notes is part and parcel of thinking critically and clinically about a case. Even for the most basic visit, unless I put it in writing there is a level at which it feels incomplete.

That’s why, when I finally get an AI scribe, I plan to keep taking my own notes - even if, like my steno pads, I may be the only one to read them. And why I’ll keep asking my patients, at the end of the visit, if they might not want to do the same.