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The Value of a Patient's Story

2023; Lippincott Williams & Wilkins; Volume: 45; Issue: 11A Linguagem: Inglês

10.1097/01.eem.0000996360.26050.a3

1552-3624

Mark Mosley,

Artificial Intelligence in Law

FigureFigureBeing offered a story should never be automated. In fact, it would be foolish to collect data through an artificial intelligence kiosk or document data from an automated prefabricated electronic checklist, be that literal or metaphorical, and confuse it with a history of the patient. This fact will be put to the test on steroids as large language models like ChatGPT begin writing medical records. What we often erroneously call the patient's history is actually a compilation of multiple peoples' memories of their experiences. This is not the same as tallying bits of data for efficiency, billing, and legal defensive charting. This is why pre-fab fill-in-the-blank documentation is so dangerous. Legally, all the lawyer has to do is catch many of your pre-fab charts where you electronically pasted a paragraph that doesn't even fit the patient to prove to the jury (not of your peers) that you are just an automaton of the corporation and don't even know what you are putting in your chart. (There is a reason this is called “Dragon;” it can eat you alive if you do not harness it.) The purpose of this rather vain exercise cannot be documentation for documentation's sake. We must reframe what should actually be happening here. I have no problem documenting a chart electronically to get paid for my services, and it is wise to show your work in case someone later accuses you of medical care that does not meet a professional standard. This is a necessary and good thing. But the idea that you are going to maximize billing while maximizing legal protection in a five- to 10-minute bedside interaction while gathering data from other inputs (documented vital signs, old charts, EMS conversation, discussion with the APP, the patient's relative by phone, the physician consultant you paged) while being interrupted every 17 seconds is a fool's game with a fool's end. It is simply cutting meat so incredibly thin and lean and so unbelievably fast that you cannot help slicing your own finger. You and I know that we are lying, even though that is not our intent, when we electronically carve out maximal billing and maximal legal protection on every chart. Really, their lymphatics and reflexes were normal? (You probably haven't seen a reflex hammer in a decade.) You were at the bedside for 60 minutes doing critical care? ‘I Don't Care about the Contract’ We probably unknowingly do deceptive charting many times every shift (maybe every chart) because we have bought into the corporate lie that efficiency and good billing practices is the platform upon which we stand or fall as an emergency physician. It is stated as an obvious and implicit fact that you have to maximize billing while maximizing efficiency while maximizing defensive legal documentation. I do not believe you can do all three on the same chart consistently without lying. I know the arguments: “No one is perfect.” “Everyone does this!” “You are a pie-in-the-sky idealist; you can't survive in this profession if you don't play the game.” “The lawyers are going to eat you for lunch!” with no mention about why I have been paying a lot of money for medical malpractice coverage. Why not just settle and not destroy two years of your life depending on a jury that does not trust doctors much anymore? What about the reality that “You have to document this way or the hospital will not renew our contract!” Who is “our”? If the company I work for loses its contract with the hospital in my city, I am still working in the ED, just for a different company. I don't care about our contract. I just want to practice good medicine safely with scientific integrity and compassion. That is the only fact implicit in my professional practice of medicine. Truth without trust is just another byte of information I am competing against. Trust begins with the accuracy of how I record my interaction with the patient. Have you ever considered that playing the game is moral injury? The survival in this profession begins and ends with the preeminent meaning, time, energy, and accuracy of the electronic medical record. The Patient's Guest We are approaching the dawning of large language models into the electronic medical record. This will include automated input and timing of when you really first encountered the patient, and if you really told him to contact his primary the next day or come back to the ED if you get worse. And this will include videoed segments as part of the chart. Our inaccurate documentation will be captured, if not imprisoned, by AI. But there is a point to be made that is more important and more fundamental to being a physician than the bumbling with which we have tried to adapt to the horrible mishmash of medical electronic documentation practices during the era of the corporate takeover of the medical profession. You and I are receiving a story of the patient's perceived and sometimes rearranged experience of the events leading up to their ailments (always plural). There is almost always someone or something else you may not ever know about (a colleague's advice, WebMD, their Apple watch, their sister-in-law who is a nurse in a different state with whom they are texting), and this buffet of other background information includes their experiences added to this patient's story. The patient and others are offering to share a story with you. The patient has invited you into the home of his mind. You are a welcomed guest. They are serving you a homecooked meal prepared with their own language. Their medical history is a gift they are giving you. You must be a gracious guest. You must take bites of everything. You can try tidbits of all sorts of dishes, and you should say, “This is delicious!” or at least “It has an interesting flavor.” Curiosity is a form of trust building. Eating the patient's story is the reciprocity of hospitality: Thank you for sharing this with me; I am honored to be here with you. It is hearing the story as another human who prepares for healing to begin. It is the hungry receiving of language that builds relationships, not the yes/no provider/AI-driven efficiency of a checklist mentality. The automated or mechanically done checklist does not need a human being; it is an efficient commercial completion of information of limited meaning outside remuneration. Try not to use the vapid phrase, “take the patient's history” but rather “receive the story of the patient” offered to you potentially by multiple sources (and these other sources should be documented). The way we use our words affects the way we feel their meaning. You destroy the value of the patient's story when it is an automated electronic checkbox or AI. You do not take a history. And what you are calling a history, is not really a history; it is simply a program of data you are calling a history. The answer to the burnout of our profession is to politely and calmly ignore the fast-food chart. It has little nourishment for our profession. Regardless of what happens with AI, EHR, and corporate medicine, refuse to go into the drive-through and eat while you are driving. We will ultimately choke or wreck trying to do this faster and better. We must reclaim the nourishment of healing others. This begins with the right use of words. We must enter the room as the patient's home. Sit down graciously at the table of conversation. Chew very slowly and carefully on the conversation and the things not said. Be a guest of the patient and their others, and eat every word with appreciation. Thank everyone in the room for inviting you to such an amazing time and what they have offered you about the patient's story. Not only will this make you more comfortable about not ordering additional tests that will increase your efficiency and shape a human atmosphere that will likely decrease your chance of a lawsuit, but you will be healed in the healing of others. Regardless of whether this maximizes reimbursement, it will reimburse your soul. It will keep you in the game of the honored profession of being a physician in emergency medicine. DR. MOSLEY is an emergency physician in Wichita, KS. Share this article on X and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].