Monday, June 26, 2017

genre fiction vs the clinical note

Loborsoit, Tanzania, 2012

Did you know that, prior to 1916, clinicians recorded their patients’ notes in a single common log that was kept on each hospital ward? There was no such thing as an individual patient chart until the idea took hold at Presbyterian Hospital in NYC, one hundred years ago.

“Fold the worst events of your life
into a narrative triumph.”
~Andrew Solomon~
Still, back then, there were no guidelines as to what went into the chart, how information should be recorded, or where it belonged. Not until the 1970’s, when Dr. Lawrence Weed created the problem-oriented medical record (POMR), was there any organization or consistency to the clinical note. In other words, it was hard for all the people involved in the patient’s care to follow his clinical course or to extract information from his haphazard record. It was time-consuming and error-ridden.
This kind of thing is not acceptable when it comes to practicing medicine. Nor is it tolerated in literature.
Imagine reading a mystery that reveals clues to the crime in no logical order. Imagine a romance that fails to capture the growing passion between two lovers. Readers have certain expectations that attract them to certain genres, and each genre follows its own set of conventions in order to satisfy the reader. Without this predictability and order, readers are likely to abandon the story out of confusion or disappointment.
For example, in writing mystery, plot is everything. The main character must be the detective or sleuth. The crime should be sufficiently violent (ie. murder) or cruel so as to engage the reader’s interest and curiosity. The details of the crime must be accurate and plausible (when, where, why, and how it was committed). The detective must solve the mystery using rational/scientific methods…rather than depending upon divine intervention, pure coincidence, or gratuitous drama. Justice must be served. This is what the mystery reader wants.
“Plot is a literary convention.
Story is a force of nature.”
~Teresa Nielsen Hayden~
In romance, on the other hand, a love story must be at the center of the plot. The lovers must encounter and overcome obstacles to their relationship. The ending has to be emotionally satisfying and optimistic, with a happy outcome. Romance readers expect this. They don’t want the relationship to fail.
Simply put, if you enjoy reading romance, you may not be entertained by blood thirsty creatures from the netherworld. Likewise, if you love horror, fairies and elves may not be your thing.
This is why authors in different genres observe certain “conventions” when they write…widely used and accepted techniques in literature that embody the readers’ expectations and promote satisfaction with the course and outcome of the story. Within this general framework, the details can vary with regard to time period, setting, characters, and plot.
Likewise, every patient’s story is different. No two heart attacks, no two cancers, no two injuries are ever the same…so it’s good we have a framework for recording our patients’ stories. Most of us have been trained to write our notes according to the SOAP format—Subjective, Objective, Assessment, and Plan. What patients tell us about their illness is considered “subjective” information, recorded as the HPI—the history of the present illness. We learn more about the main character in the PMH (past medical history), FH (family history), and SH (social history). Clues to the diagnosis are found in the objective realm of the physical examination and tests we order. All the elements of the story come together in our assessment. In our plan, we consider all the ways the story might end.
Because the practice of medicine embodies narrative elements, it makes sense to train health professionals in narrative skills: how to listen to the patient, how to interpret what we hear, what the patient means by it, and how to record his story. Ultimately, the goal of training in narrative medicine is to allow ourselves to be personally moved to action on behalf of the patient.
“I use the term narrative medicine to mean
medicine practiced with these narrative skills of
recognizing, absorbing, interpreting,
and being moved
by the stories of illness.”
~Rita Charon~


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