No doctor ever wants to go to record-keeping school.
But it was "highly recommended" that I go after a peer reviewer from the College of Physicians and Surgeons of Ontario examined some of my patient charts. He pointed out a number of lapses in my record-keeping. According to him, I clearly misunderstood some of the necessary and essential elements of legal and professional responsibility.
As the doctors' regulatory body in Ontario, charged with how the 24,000-member medical profession conducts its business, the College reviews over 800 practices per year. Stack that against the 20,000 complaints made by patients each year and the vastness of the College's job -- and some say, the impossibility -- becomes clear. What is certain is that the College believes that the patient's record is the best indicator of quality, continuity and completeness of his or her medical care.
I wasn't surprised to see that my fellow participants averaged over a quarter of a century in practice. Nor was I surprised that the format was a first-name only roundtable discussion so we could share where we worked, the nature of our practices and other vital issues. I privately viewed them as reprobates and geezers. They were (who am I kidding? We were . . .) experts at holding our cards very close to our chest -- no sense of duress, threat or unfair scrutiny emanated from any of these men. (Yes, there were 8 men and myself). We were an impassive group of old medical hands who shared our problems and never griped at our exposure.
The course director, Dr Henry Wu was deceptively congenial in his enthusiasm. Deceptive because we all knew he is both a peer reviewer (which is considered benign) and an inspector who, by definition, has an iron fist.
But on this day he spent over two hours in a modest but nonetheless messianic attempt to get us to agree that the patient record is a wonderful thing. "If we can't agree on this," he said, "that the chart should tell the story of the patient, that it should be able to stand alone as a testament long after we're gone, then anything else I say won't matter."
So, much like drunk-driving or anger-management programs, the thrust of this course is to change attitude in order to change behaviour. Because then, armed with a renewed sense of purpose, our efforts to change a life-long habit of making mental notes rather than scribbling physical ones, will work.
These doctors are oral historians. They can keep an entire family's medical history in their heads, going back many generations. Indeed, all doctors edit by omission, and I'll bet lots more do so under the unprecedented stress to keep good notes while they're deluged by a health-care system that gives Ontario's family physicians 15 minutes to see each patient. This is not an excuse, but "no time" is the number one reason offered for poor records. Generally, my fellow reprobates serve large aging populations that younger doctors don't want to take on as solo practitioners. They're a dying breed for sure. But as Dr. Wu put it, one that still needs to protect themselves and their patients with good records.
One of my classmates is a true outpost doctor, servicing a fluid northern population of 6,000 including miners, the lumber company and tourists. He is an integral part of the bush and shield landscape and he's been practising for 28 years. He grew up there, raised his kids there and has been on call one in two nights and every other weekend all those years. This simple disclosure brings a nod of respect from we who haven't done that since our internships. He has outlasted the drop-ins, those transient doctors who come, do a few years of obligatory service and are gone. Yet now his 68-year-old secretary is set to retire, leaving him to fend for himself.
What's ahead for him?
With great pride, he reveals that two of his grown children went to school out of town, but are returning to work in this remote area have applied for and are at the first level interviews for the first truly northern Ontario medical school. Its mission is to train medical people from the north, in the north and for the north. For this doctor, help may be on the way.
Even so, many of the doctors in the room are regularly in the office until nine at night: It is their life. Otherwise why put yourself through this course in attitude readjustment?
The ice broken, we get down to business and the day flies. We never get to the records we sent ahead for review. We barely cover the prospectus. But by the end of the day, as one doctor predicts, none of us will leave without changing something about how we acknowledge and record our work with our patients.
As for me, I know I have done this course for my colleagues who have put up with my lean records for years. I have done it for my patients who surely know that a doctor's memory lapses leave everyone scrambling. I have done it because in reviewing the volumes of records to send ahead as examples for this course, I rediscovered some amazing facts about my patients buried in the records.