Thursday, October 13, 2016

Defensive Charting

Some recent conversations caused me to think about veracity issues with medical records. The world of workers' compensation is immersed in medical records. The foundational element central to every workers' compensation situation is an injury or illness. That is where it all starts, and unfortunately, this is sometimes forgotten. In a recent meeting, I once again heard the all-familiar refrain "medical drives the claim." I cannot count how many times I have heard that one. Medical in an integral part of the world in which we work.

But my most recent medical records conversation occurred with a non-workers' compensation patient. It was a casual conversation about a trip to a medical specialist. The preface to the story is that this specialist is so busy that patients wait for months for an appointment. The patient was told that this wait is justified because the expert is "that good." The patient's perceptions and conclusions did not confirm that justification. 

Unfortunately, this specialist did not make a great impression on the patient. There was the curt and condescending interaction with the front-desk staff. First impressions can be lasting impressions. An hours long wait in an examination room did not have the calming effect that perhaps the physician intended. From personal experience, I can commiserate with this patient's expressions of boredom from a long exam room respite. 

Some find it curious, in a business built on day-after-day processions of people, that time management seems all but impossible for medical offices. Has anyone, anywhere, ever been seen at 9:00 for a 9:00 appointment? The patient described to me that after a two hour exam room wait, the doctor was most reassuring that the long delay was uncommon, due to some particular urgencies of that particular day. In fairness, anyone can have a bad day. I have been late for hearings before; never two hours late though. 

But, the patient described being eventually seen by this specialist. Symptoms were reportedly discussed and notes were taken. Various data was input into a computer in the examination room. The physician then informed the patient that she/he would be changing the medications prescribed by the referring general practitioner physician. The physician assured that these drugs would make the patient "better," rather than "just alleviate symptoms." That is likely a welcome assurance from any doctor? Every patient wants to recover.

Curiously, the patient reported that this physician did not take even a few moments to discuss the purpose of the pills, or the potential side-effects. Apparently, this is seen by that physician as a task for others in the health care delivery system. It is common for pharmacists to document that they have afforded customers the opportunity to ask questions about medications, but apparently not so common for physicians. Or, perhaps this physician was an outlier in this regard? 

This patient in this instance followed the specialist's instructions and began taking the pills. Reportedly, there were immediately profound side-effects that were both uncomfortable and disturbing. Due to the doctor's schedule, the patient returned months later to the specialist for follow-up. As mentioned, getting in to see this physician was no easy task. The patient returned with hopes that the first appointment delay would not repeat, and the physician's prior assurances of anomalous urgency would be true. She/he related that the examination room delay on this second occasion was slightly less than an hour; a vast improvement over the first visit, but an hour in the exam room waiting?

The noted side effects were related, as were symptoms, etc. A fairly regular follow-up doctor visit. The doctor apparently assured and reassured. The medication prescription was renewed. The patient told to return in several months. And the side-effects continued. The persistent (and profound) side-effects led the patient to the Internet for information. There have been multiple interesting Internet articles about web-based medical advice. Most recently How do Online Symptom Checkers Compare to Doctors. The gist is that doctors are a better option. 

The patient discovered from the Internet that not only were side-effects being reported from various patients, searching for this medication led easily to advertisements for law firms. A cancer had been named after this medication, as in "XYZ medication-cancer." The patient "might be entitled to a significant cash award." If there is a risk of cancer or other detriment from a medication, the patient explained to me, it would be preferable to hear about it from the physician. 

The patient returned yet again to the specialist, having already stopped taking the medication. After yet another protracted exam room wait, the physician appears and inquires about status. The patient informs her that XYZ has been stopped, because of side-effects and the allegations that it is a substance allegedly causing serious cancer. The physician's response is that this cannot be so, she/he has read extensively about this medication and "it cannot cause cancer." I found that statement interesting. I have read a great deal about cancer over the years and I doubt anyone can say definitively what does or doesn't "cause cancer."

Alas, the relationship between this specialist and her/his patient ended that day. Perhaps this results from the interminable delays in appointments, or the long exam-room waits, or the condescending conversations, or the unexplained prescriptions, or the inability/unwillingness to discuss concerns about the medication. Perhaps it is the combination of them all. But, the relationship ends. Odd thing about patients, they tend to tell their troubles to others, just as this patient conveyed all this to me. And, word spreads.

The patient explained that she/he then made arrangements for a new specialist. In preparation, the patient's medical records are obtained from the first specialist, and provided to the next. This is where the patient is surprised. Despite that last visit being a conversation primarily about the cancer risks of this medication, there is no mention of cancer in the specialist's notes. In fact, the specialist's notes instead make a cursory mention of the side-effect complaints, and the patient's unilateral decision to stop taking the pills. 

I related this conversation to a friend who is a physician. We ran into one another at a recent conference. I was curious whether such behavior, inaction, action, record keeping is common among physicians. I expected to hear that time is limited and that errors of omission happen. I expected to hear that the patient was perhaps embellishing or maybe misperception. I was surprised that my physician friend's instant reaction to the story was "defensive charting." What, I asked, is that?

This physician explained to me that the last thing this specialist will do is document that a patient has concerns or issues with the specialist's care and treatment. He explained that it is not in the doctor's interest to mention the cancer concerns in his chart. This is particularly true since the earlier office-visit notes do not contain any memorializing of the specialist warning the patient of the potential down-side to taking this medication. The specialist likely cavalierly prescribed the medication without discussion of its potentials for benefit or harm. According to this physician, defensive charting is both common and expected in such an instance, a shield against potential liability or complaint. 

I cannot vouch for the content of the patient/specialist conversations, nor for the content of the medical records in this scenario. I can only take that as represented to me. I likewise cannot vouch for the opinions expressed regarding the practice of "defensive charting" or its pervasiveness. This also I can only take as represented to me. 

But, I can vouch for the fact that the workers' compensation system is dependent, in no small degree, upon medical professionals and the records they keep. In workers' compensation, there are injuries and illnesses, symptoms and signs, complaints and representations of improvement and/or persistence. Doctors are depended upon to take in vast quantities of information, to process it, and to render sound opinions from it. In the process, they create records and reports. And those reports become evidence in the disputes that arise. 

I have heard many arguments about medical records. Sometimes it is argued that certain complaints were not voiced by a patient. I have heard it argued that a patient did not report all of her/his medication sources. Often I have heard "or that would be in the records." There is a tendency to either argue that the doctor's records are the best evidence we have, or to argue that doctors are busy and cannot possibly document everything. The difference being which of these best supports a particular attorney's position. 

But, this is the first I have heard of "defensive charting." Is there really a systematic and purposeful process of preparing medical records focused on the best interest of the physician? If this does exist, is it widespread through the medical profession or is it isolated to a few bad apples? 

I wondered whether any patient can find a way to document what is said to the physician, what symptoms, thoughts, or complaints? Is the patient at the whim and caprice of the physician in this regard? Does the potential of such a charting practice instill faith in either our medical system or those who work within it? With medical opinion so critical to the decisions of workers' compensation, should we somehow answer these questions?

After I wrote the foregoing, as it awaited publication, I attended a seminar. A panelist noted a perception that injured workers have increasingly begun requesting to bring videographers to medical appointments. That request has been made for years regarding independent medical examinations. Lawyers say they believe it documents how long the examination lasts, what testing or procedures are performed, and the outcomes or signs elicited. But, I had never heard of such a request for a treating doctor visit. This speaker assured me that such requests have occurred, and a perception they are increasing. The point being a distrust of medical providers, a perception that documentation is advisable, a feeling that independent verification is desirable. 

And all of this causes me to wonder and think. There is a value in human interaction. Prompt service at the doctor's office, as scheduled, likely enhances the relationship. Explaining the why and "what if" of prescriptions or procedures likely has value to the patient, and instills faith and trust. Sure, the doctor sees this all day, every day, but for this patient such interactions are much more limited. Today is this patient's only such appointment, it is special, it is important, to this patient. Accurate record keeping by physicians is critical; critical to delivering care, critical to patient trust, critical to documenting risks and benefits.

I expect that I will hear from a doctor or two about this post. Some will doubt the story, express belief of exaggeration or assure me I have misunderstood. And, I hope they are right. But, nevertheless, reputations of practitioners and professions are sometimes built on the perceptions of others as much as they are upon the performance of the professionals themselves. Where do you think all those lawyer jokes came from? Will physicians find themselves the next punch line?

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