Notes on notes

    22 October 2015

    Information technology often gives us both too much and too little information: I have noticed this in my medico-legal work, which often involves reading through hundreds or even thousands of electronic pages of medical notes. One’s eyes glaze over in front of the screen almost immediately, and something akin to despair quickly supervenes. One has, alas, to read everything; a missed line may vitiate an opinion.

    I preferred it in the old days when notes were handwritten and doctors’ entries were separated, no doubt undemocratically but very usefully, from those of nurses, physiotherapists, occupational therapists, speech therapists, nutritionists, social workers etc, so that I could go straight to the heart of the matter.

    There were drawbacks to handwritten notes, of course. The doctor’s writing was sometimes undecipherable, though one could usually tell his rank from the type of pen he used, and sometimes the colour ink. Fountain pens and unusual colours were for seniors; others used biros, usually blue.

    Handwritten notes, however, favoured selection and confinement to the essential. It is in reducing, not in increasing, information that thought and intelligence are shown — just as it is more important for a writer to know what to exclude than include. But what I really miss about the replacement of handwritten notes by computerised ones is the occasional personal comment by the doctor that in lapidary fashion told you a great deal about the patient (or sometimes the doctor).

    The words ‘Here again!’ or the even more exasperated ‘Not again!’ told you either that the doctor failed to diagnose a troublesome or occult chronic condition, or (more likely) that the patient was a frequent attender whose visit to the doctor might have been the highlight of his or her week, and who cherished symptoms like a hobby or interest in life. Illness is sometimes a powerful defence against the disappointments of human existence and a putative explanation of them that enables a person to evade more distressing explanations. Better an illness, or at least a symptom, to explain one’s failure than a forced acknowledgement of personal weakness, lack of ability, determination and so forth.

    Computerised notes give me an impression of the impersonality of the system that employs them. They are appropriate to situations in which patients are more or less physiological specimens, such as in the intensive care unit, but not in those many situations in which character and personality are of determining importance in the medical outcome. Computerised notes are what you would expect of machines dealing with objects and though they seem perfectly objective they omit the brief comments that may alert a doctor to the real nature of a problem.

    Doctors are in any case much more cautious about committing an opinion of the character of their patients to any permanent record because everyone now has a right to possess and read his notes, and some people are upset even by compliments. But I know people nowadays are obsessively interested in anything that concerns or is about themselves. That is why honest and informative references are no longer possible.

    So gone from medical notes are those little acronyms, symbols and abbreviations that used to pepper notes, especially those written on the old Lloyd George-type general practitioner notes. For example, N4N used to mean Normal for Norfolk, which is not a reference to the charms of the countryside of that county but to the alleged mental slowness of its population, supposedly exacerbated or caused by… no, I had better not say. IG11 stood for the madness of a patient, not in the medical or literal sense but the metaphorical one, IG11 being the postcode for Barking, as in barking mad.

    Some acronyms referred to clinical states, perhaps the most common being TATT, for Tired All The Time. A person who is TATT is not thought by the doctor to be suffering from a discoverable physical illness, but rather with a form of taedium vitae, which he, the doctor, was ill-equipped to combat. No doubt he was sometimes wrong: an occult cancer, for example, would sometimes become evident. But where the diagnosis was right, it inhibited the ceaseless round of medical investigations that might otherwise be done in its absence.

    Recently I came across two acronyms in old notes that I had not previously encountered, the first was PTFO and the second LNWL. The meaning of the first I was able to inquire from the retired doctor who had used it: Politely Told to Fuck Off. Contrary to what people in an age of literal-mindedness might think, the doctor was a kindly, patient man universally beloved of his patients.

    The meaning of the second acronym I was able to work out from the context: Life Not Worth Living. The travails of a patient were reduced to, or summarised by, these four letters. I know the feeling well: whenever I start to read computerised medical notes, I feel a touch of the LNWLs.