A doctor's dilemma: what to chart

November 18, 2007|By Claire Panosian Dunavan

The young man in the hospital bed first cajoled, then narrowed his eyes to angry slits. No-way, no-how did he want certain details in his medical record. Finally, he threatened. He was a lawyer, he said, and the situation could get ugly.

"You're a lawyer?" I thought in amazement as my eyes moved from his meaty, chiseled shoulder to the IV drip-drip-dripping antibiotics into his forearm. "You're a lawyer - and you use illegal steroids? Then browbeat doctors into deleting the fact from their notes?"

Forty-eight hours earlier, when Mr. Body Beautiful arrived in our emergency room, he had been too sick to question his doctors' notes. An angry infection covering half his leg, plus a rocketing fever and white cell count, pointed to a feisty match of microbe versus man. It wasn't a rout, but the microbes were definitely in the game.

Now, the man was winning - which was great. But wasn't it my luck, I mused, to meet him when his vim and vigor (and steroid-fueled emotions) were ratcheting up. Then, after examining his abscessed leg, my thoughts took a U-turn. Why should I get involved in the patient's chart worries? I was just an infectious diseases consultant asked to recommend what antibiotic he should remain on, and for how long.

On the other hand, I couldn't ignore his dilemma. "You must have told someone in the ER that your infection started after injecting your calf with steroids," I said icily. Then I played my trump card. "Your chart already has three entries stating the same facts."

Ah, youth. When I think back on this decade-old incident, I have several regrets, starting with my lack of kindness. Yes, I was under attack, but the doctor-patient relationship is asymmetric in the best of times, and this patient was lying in bed, connected to tubes. He was a toothless lion. I wish I had fumed less and empathized more.

My second regret? That I didn't spend more time counseling the young man about the deadly duo of steroids and Staph. Now that drug-resistant Staph is making headlines, the public is more savvy. But years ago, few lay people - especially athletes and muscle men bursting with health - understood that tiny, grape-like clusters of bacteria could be their downfall. Or that steroids exert paralyzing effects on the body's defenses against infection.

Past experience with substance abusers was another reason not to shortchange this patient's education. What if he continued to tempt fate with syringes of gym candy? His next Staph infection could wind up on a heart valve - or in his brain.

Last, but not least, I feel remorse over my fuzzy thinking. The crux of the conflict was not the patient's unlawful behavior, or his threats, but the content of his medical history.

A medical history is a tool to facilitate the best possible health care. The process of documenting a medical history is, in turn, guided by certain principles. Doctors need not include every nugget of information or confidence they receive from patients, nor can patients dictate what is written about them. And does that leave a gaping gray zone? You bet.

To complicate matters, the gray zone looks different to doctors and patients. Injection of illegal substances, for example, is a major risk factor for several diseases. To omit this risk factor from a patient's chart - like it or not - is a medical breach.

Some patients, on the other hand, see the medical record as a source of potential backlash and harm. Will the long arm of the law subpoena their chart and haul them off to jail? Or, in these days of insurance angst, will their carrier read it and revoke coverage?

Not long ago, a colleague shared a cautionary tale. He told me about elderly patients denied long-term care policies. The reason? Their geriatricians sought subtle signs of cognitive decline, then recorded their findings. Ironically, he added, patients whose less-zealous docs didn't log "mini mental status" exams were more likely to receive policies. Voila. Medical record backlash, alive and well.

So perhaps some highly motivated docs among us need one last charting reminder: Do no harm.

Come to think of it, some of those rejected long-term care applicants could have a case. Steroid lawyer guy, are you out there?

Claire Panosian Dunavan is a professor of medicine and infectious diseases at the University of California, Los Angeles. Her e-mail is cpanosian@mednet.ucla.edu.

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