Haslam's view: Keeping the story behind the code
‘We regret that,' and then there was a momentary pause and a slight change of synthesised tone, ‘the 8.40… from Birmingham… has been delayed because of... engineering works... We sincerely apologise for any inconvenience caused.'
When railway companies fake sincerity they can't even get the voice to sound as if it's saying a complete sentence. Presumably, they believe it is more efficient for someone to type codes into a PC and for the phrases to come tumbling out. I'm sure it is cheaper, and it may be a reasonable way of providing facts, but it's certainly an appalling way to apologise.
But are GPs at risk of making a similar error? It may be wonderfully efficient, legible and searchable to enter Read codes 2315 and 2415 to say that the heart and lungs were normal, but it misses a whole layer of meaning if we only ever use codes when recording a history.
Free text may well capture the story more effectively. Our patients present to us in an infinite variety of ways but the finite number of codes we use to record the story inevitably means that much subtlety is lost.
There has always been a tendency to oversimplify history taking, to force the complex into a simple template.
I remember a partner of mine telling us of a patient who he had been called to see during morning surgery. The man was a farm worker, who had been working in the fields when he felt unsteady and odd.
No pain, just a bit dizzy and strange, with a real sense that something was badly wrong. This was a chap who rarely saw doctors.
My partner had a hunch – no more than a hunch – that the patient might have had a subarachnoid haemorrhage. To this day he can't explain where that thought came from, but I'm sure you will have had the same experience.
Anyway, he sent the man to hospital, came back to the practice, carried on with surgery and told us the tale at lunchtime.
A couple of weeks later the discharge letter arrived. It said, and I quote: ‘this 45-year-old farm worker complained of a sudden severe pain in the back of his neck, as if he had been hit by a baseball bat, and then complained of headache and dizziness.'
Oh no he didn't. Barely a word was true. And he almost certainly had never seen a baseball bat in his life. But you can imagine exactly what happened. A succession of junior doctors would have come to quiz him and, seeing the GP's letter with its suspicion of a subarachnoid bleed, will have asked ‘So, did you have a feeling of being hit in the back of the neck?'
And eventually, tiring of the repetition, he would have sighed and said ‘yes'.
And so the history suddenly became a ‘classic history' and the convergent thinkers will have felt much more comfortable. And indeed, this hunch of a diagnosis turned out to be right.
But how sad. The complexity of the presentation should have been fascinating; instead it was eradicated. Will the complex stories of our patients become similarly devalued when they are recorded solely in Read code recognisable words and phrases? Let us pray not. After all, the stories of our patients' lives demand the complexity of literature combined with the precision of science, not well intentioned oversimplification.
The moral of the story: carry on coding, but code with care.Author
Professor David Haslam CBE
GP, Ramsey, Cambridgeshire; President, Royal College of General Practitioners; national clinical adviser to the Healthcare Commission; and Visiting Professor at de Montfort University, Leicester