The 12 Word Note...

 

I had one of my typical work-related nightmares last night.  Three years into retirement and I am still anxious about work. I think it is an interesting exercise in how human consciousness works and how it led to the above graphic so here goes.

As usual it starts out in a medical center, in this case what appears to me a medical unit in a large hospital.  I have never been in this specific setting before, but it has a similar arrangement to many units where I have worked.  There is a walled off central square nurses’ station surrounded by a ten-foot-wide walking area leading to the patient rooms.  Judging by the equipment and floor coverings it is from about 1980 to 2000.  I am seated in the nurses’ station and looking at a chart.  I have been consulted to see someone on that floor and review the chart.  There are no computers, everything is written on paper, and the chart clips it all together at the top.  As a result, the notes must be flipped on the short edge to maintain the same reading orientation. The setting is drab but in color.  There is a lot of activity but nothing overly hectic that would indicate an emergency.

I look at a note from the pervious consultant.  It is in outline form with headings only and spaces to be filled in later.  The chart notes are all lined in a typical tablet format.  There is about a page and a half and then there is about a ½ page narrative written like a paragraph by a different staff person.  I stare at the space between the two notes.  That space is about 1 ½ pages in length.  I start thinking about how I can squeeze my typically micrographic consult note into 1 ½ pages. 

I start to get anxious.  I realize I am just staring at the chart and not doing anything.  I look at the doorway to the room containing the patient I am supposed to see.  I feel like I am frozen and I will never get out of there if I don’t get in there and figure out how to record my note.  I start to panic.  I wake up anxious with an elevated heart rate.

After laying in bed for a while and thinking about the dream, I associate to the Milwaukee VA and my first Internal Medicine rotation. The charts in the dream seem like old VA charts.  I remember writing in those charts – very long histories and physicals and consult notes and progress notes that were considerably shorter.  I remembered a neurosurgery rotation where a handful of us covered an entire floor of very ill patients, a neurosurgery ICU, and all the emergency room and general consults from two large hospitals.  The only possible way we could do that was by completing all the rounding and documentation in 2-3 hours because we were also expected to be in the OR for many hours per day.  The typical rounding note was less than 20 words – “Afebrile; VSS; (brief description of neuro status and surgical wound).” 

That led me to think about the shortest Internal Medicine note by a resident.  Internal Medicine residents were some of the smartest and most industrious people I have ever met.  But in the 1980s they (and me their intern) were seriously abused.  A typical call schedule was on call every third night.  On a call night 10 admissions all night long of very ill patients while cross covering the entire hospital was typical. That usually meant no sleep – but you were expected to do the usual work until 5PM on your sleep deprived day until you could go home and sleep. This resulted in some embarrassing moments like falling asleep while writing notes or in one case – not putting the note in the chart until my resident reminded me, I was still carrying it around on my clipboard.     

One day in that VA hospital a friend of mine said “I want show you something”.  He showed me a note written by his resident that was written in 48-point font.  The only reason I know that is because of the experiment at the top of this page (that is my standard 12 point at the top and 48 point at the bottom).  It was the largest cursive I had ever seen and there were only 3 or 4 words per line.  We both laughed about it.  My friend told me all his notes were like that, and they were signed off by attendings. He was basically writing down 12-15 words per page to my 300-400.  We did not take the time to analyze the content of the notes – we were just amazed by the form. 

This morning, I thought about whether it was possible to write all your notes like that – even in 1982.  It certainly would not pass muster in the modern era of excessive and often useless documentation required by governments and insurance companies. He would get audited for “bullet points” and would never get reimbursed.  In the modern world every note needs to contain bullet points of specific documentation whether it is relevant to the medical care or not.   I was in a mandatory seminar in the late 1990s when an FBI agent claimed that any physician not completing the bullet points could be charged with mail fraud and sentenced to federal prison on a RICO violation. That was before 911 and the FBI discovered they could probably be doing better things than threatening physicians.

At times, I get the mental image of hard drives spinning in large storage arrays containing all this worthless medical documentation that will never be read again.  I used to think it was a high environmental burden until large language model AI came on the scene.  Now these AI companies are building their own power plants just so the AI can scan vast amounts of worthwhile and worthless documents to synthesize an answer that may contain some accurate data or it may be an AI hallucination/confabulation - like a medical reference that does not exist.

All those thoughts sprang from a bad dream of an old, retired guy who at times wishes he was still working.  But at other times realizes that retirement is a good idea.

 

George Dawson, MD, DFAPA

 

Supplementary:

Maybe Hospital Dreams could be a sequel to Train Dreams.  I tried to work it in, but it did not fit. 

 

References:

1.  Arvikar SL, Schaefer PW, Lemieux JE, Steere AC. Case 3-2026: A 58-Year-Old Woman with Diplopia and Fever. N Engl J Med. 2026 Jan 22;394(4):383-391. doi: 10.1056/NEJMcpc2412529. PMID: 41564400.

My test sentence above is the first line in this week’s Case records of the MGH.  One sentence is fair use.