Reading Beyond the Medical Chart

Abstract

How can one understand a human life by reading a medical chart? Only so much can be conveyed through written words and the rest in conversation. While a patient’s social history is often overlooked, these details are the most revealing. It is late afternoon, and I am a physical medicine and rehabilitation resident working at a rehabilitation hospital. My pager buzzes, telling me that a new admission will arrive in one hour. The admissions liaison—the nurse in charge of identifying patients suitable for our hospital—brings me a large stack of documents made up of daily progress notes, routine lab reports, repeat imaging, and detailed medication changes. Thus, I begin a 90-day journey through my patient’s hospital course, one that I have only an hour to traverse. I sift through weeks of data, highlighting what I must know: how to dose his daily medications, how long to continue his antibiotics, and which physicians he needs to follow in the outpatient setting. The details of his complicated hospital course—the emergency surgery, complicated coagulopathy, and unexpected bacteremia—infuse my brain. When he arrives, I run upstairs to meet him. He is lying in bed talking on the phone, and when I enter, he pauses to tell the person on the line that he has to go. For the most part, patients look to be in better health than their doctors’ notes suggest, and I am impressed by the jolly voice that greets me after reading that he had been intubated for weeks. As our conversation begins, it becomes apparent that he has no interest in quizzing me on his medical complexities. He brushes over the details of his hospitalization and rushes to tell me that he wants to go home soon. He lives in a mobile home, and it scares him to think that this hospital is in the city because he has lived his entire life in the country. He cares for his 95-year-old father whose memory fades by the day—much like his once bright peonies, which have since withered in the summer heat. He is very busy managing his shop, but every week, he takes his father to Sunday brunch. Brunch helps his father remember that the day is Sunday. But for the past 90 days, there have been no more Sundays. His father calls daily, wondering what day it is and wondering when he will come home. His voice trails off, and I notice him blinking. His snowy white hair is overgrown, but it cannot hide the sadness in his heart. He hastily pushes his spectacles up his nose and reaches into the stash of peppermints hiding in his lap. He offers me a piece of candy as he nibbles on his own. “Remember, that life can be sweet,” he says. I accept the peppermint, and I tell him that we will work to get him home. Back in the workroom, I pause for a moment. It is an immense task to transcribe a patient’s story into a standard note. So often, we get caught up in studying and updating the medical chart. When we get to know our patients as human beings, however, we realize that providing care goes beyond triple-checking medication dosages. Providing care involves understanding the social context in which our patients live and appreciating their routines outside of the hospital setting. Human beings are gregarious creatures by nature, and a human being is the product of every person, every success, and every misfortune he or she has encountered. Thus, to truly care for a human being, we need to appreciate the social context in which they live. This is especially important in situations where patients are not afforded visitations. This patient taught me that having a plan to care for the loved ones who depend on the patient is equally important as caring for the patient. The lightness that he felt after our conversation eased my fingers as they clattered across the keyboard. I tap my fingers and shuffle again through his discharge documents, making sure his note is up to date. As I finish my note, I add one directive to his disposition plans: Please call to update his father every Sunday.