1. Morbidity and Mortality:Writing whats wrong
Rick Mansfield, MD MS
Feb 3, 2010
The Dying Narrative
The Case Example of Sylvia Plath and The Bell Jar

2. I request your feedback
3. A history of Mansfield M+Ms
P4P is Changing MeMansfield, R. Journal of Medical Economics.5/4/07. p.56-60.(Winner of Young Physcians Writers Award)
Patient flow in primary care (10/07 10/08): presented as a poster at the VA National Primary Care Conference in Arlington, VA July 7/29/08.
Medicine and the Arts: Ethics: [Excerpt] by Dietrich Bonhoeffer: Mansfield, R. AcademicMedicine.84(7):908-9, July 2009.
Virginia Woolf and PTSD:Mansfield, R. Accepted for publication in Journal of Academic Medicine: slated for 3/10.Proofs Finalized yesterday.
The Dying Narrative in the Bell Jar by Sylvia Plath: Mansfield, R. Presentation at Literature and Culture since 1900 Conference pending 2/18/10.
4. outline
Part one: Writing is the procedure of the pcp
Intro and terms
Typos and the cut and paste [the afib/coumadin case]
Timeliness and location of documentation its not all medical [the BMI case]
Treat writing like a procedure [the synthroid case]
What our writing says about us (a transition to the main case of the day)
Part two:
Narrative medicine with examples
the dying narrative of Sylvia Plath
5. Health care providers are writers
Patient care depends (in part) on what is written in the chart.
If you dont finish your notes you will be hounded until you do.
If it wasnt documented it didnt happeneven if it did.
Conversely, if it was documented it happenedeven if it didnt
Clinical follow up among numerous providers
Billing and coding
Medico-legal
Performance evaluations
Writing is the procedure of the pcp
6. The Pen is Mightier than the Sword
7. One letter!
tests indicate his liver has also been affected
8. One letter!
tests indicate his lover has also been affected
9. One letter!
tests indicate his lover has also been affected
we are waiting for the cultures
10. One letter!
tests indicate his lover has also been affected
we are waiting for the vultures
11. Case example: Mr. TIA-the cut and paste error. Please dont do this!
*med review/chart review:
A) the chart records this item in the history:
Atrial fibrillation Recently converted to normal sinus rhythm after a course of anticoagulation with Warfarin (off Warfarin for approximately 3 weeks now)."
THIS ITEM FIRST APPEARED IN A CARDIOLOGY NOTE DATED 1/7/02 - AND HAS BEEN COPIED VERBATIM AS RECENTLY AS 11/9/09. - MEANING THE CHART RECORDS HIM AS BEING "OFF WARFARIN FOR APPROXIMATELY THREE 3 WEEKS NOW" FOR THE PAST SEVEN YEARSTHis is relevant today as my approach to a TIA would have been different if a possible TIA occurred in the setting of just having stopped coumadin.
B) many notes record the patient as taking ASA qd - he states he does not. His wife confirms this. This is also relevant since he should not be considered an aspirin failure for possible TIA.
12. If youre going to cut and paste
Use hard dates
Do not say symptoms started three weeks ago. If you cut and paste this later it will be wrong.
Say symptoms started on 1/15/09. If you cut and paste this later it remains true.
Anotherexample:
Abx day 4 vs. 14 day course of abx started on 1/1/10 to end on 1/15/10 more words up front; but can be cut and pasted accurately for the duration of the course.
Make cut and paste work efficiently to your advantage but make it true.
13. Cut and paste (Be a writer)
Reference your source: e.g., PMH as per Dr. Js note of 1/21/10[then cut and paste the PMH]
Not medical knowledge
Its technology to which we have to adapt
Lets use it to our advantage.
Lets make sure the medical record is complete and accurate.
Do they teach this in med school or residency now?
14. Who else reads our writing?
Letter received from patient: Dear Doctor, Thank you for honoring my request for a copy of my medical records. I was quite pleased to see myself referred to as a pleasant elderly gentleman in your notes.
Most people refer to me as an irascible old bastard.
(thanks to Dr. Berman.thats not Dr. Berman)
15. the BMI example: timeliness and location of documentation
Evaluations and outcomes are not always based on what we actually do evaluations and outcomes can be based only what we document and when we document it.
16. the BMI example: timeliness and location of documentation
Some recent email communications:
Rick you missed 6 out of 11 patients this week for the BMI Reminder.Please call the below patients and satisfy the reminder- thanks
This is not true! These patients were all seen within the last 72 hours I just havent finished my notes yet. All my notes prior to this are completed. These notes will be finished promptly.
This is a research design flaw this data captured is confounded by its dependence on note status and therefore is not always an accurate measure of whether or not I addressed BMI with patients.
Glad to hear you are completing the BMI reminder. Please finish your notes on the same day as the visit.
17. 375
37.5
375
The Synthroid case: treat writing like a procedure
18. The Synthroid case: outcome
After one month of taking the wrong dose the pt felt his PTSD flare and the need to shoot back.
Root Cause Analysis
Tort case against the VA
VHA NATIONAL DUAL CARE POLICY:(VHA DIRECTIVE 2009-038 - August 25, 2009)
I meet with VA regional counsel at 10:00 AM today
19. The Synthroid case: treat writing like a procedure
If we cant write it it wont be done. If we dont make the time to write how can we expect things to be done correctly?
What if a surgeon practiced surgery the way we write notes and orders?
What have I done? I treat my admin time with equal importance to my clinic time. I dont see two patients at once during my clinic why should I allow interruptions while writing my notesand orders?
20. Another Synthroid case: treat writing like a procedure
"To Dr. Mansfield,
I am increasing, after talking c Mr. X today,levoxylfrom .025 mg to .075 mg#90 daily. Disregard note from 1-22-10."
***************************************
date TSH VA dose of synthroid recommend dose by nonVApcp 8/26/09 3.00 0.025mg 0.025mg 10/23/090.025mg 0.05 mg (never received)1/22/10 0.025mg 0.10 mg (received after 1/26/10)1/26/10 0.025mg increase from 0.025 to 0.075 mg.
non VA rec's for change in levoxyl are inconsistent. I have no further labs since 8/26/09.
he needs to see me (with labs) before I change his dose
[this took>20 minutes to read/enter non-VA correspondence track VA data, construct a table, make a decision, order labs, and communicate this to scheduling20 minutes without an H+P evaluation]
21. Memorable quote from Med school:
Good surgeons
Great surgeons
Make good INcisions
Make good DEcisions
22. Patient satisfaction: the customer is always right?
Switzer walked back into the room, having been called by the nurses. Ms. Rydel recognized him, You again? she tried to sit up when she said this but it hurt she moaned and laidback down. I want a second opinion. No one is telling me anything I want Dr. Barr. She pointed a finger at Switzer, Havent you heard the customer is always right?!
He pulled a chair up beside the bed; sat down so that as he looked at her, he wasnt looking down, they were on the same level. He was calm when he spoke, Ms. Rydel, this is a hospital, youre not a customer, and Im not here to sell you anything. Im here to do everything in my power to help you as a doctor-
Then why dont you listen to me and do what I want? I have rights you know. Her voice was at least a little softer.
Yes you do. You have your rights, and I have my obligation as a physician to provide for you the best care possible. I wont deviate from that. I know youre in pain. And I cant cure you. Its not that I dont have the time to explain all this to you, its because you dont have the time for me to explain it to you.You need to have surgery soon, now.
Head Games:
by Rick Mansfield
p. 67
23. Now more about writing
What is writing?
Narrative medicine (and psychobiography) Rita Charon
Part Two: The case of Sylvia Plath and the Bell Jar
24. Strumpf and Douglas: The Grammar Bible. (p. xv)
Communication is the essence of the human condition.
The human condition is the subject matterof medical practice
The medical record is our medium of communication,
(dare I say, essence of our communication?)
even if his or her knowledge is unconscious.
25. Strunk and White: the Elements of Style (p. 67)
All writers, by the way they use the language, reveal something of their spirits, their habits, their capacities, and their biases. This is inevitable as well as enjoyable. All writing is communication: creative writing is communication through revelation it is the Self escaping into the open. No writer long remains incognito.
26. Ex/ who is this writer?
End stage metastatic pancreatic cancer
Hes an old friend
This is sad
Hes lived a good life
Request of the team: please give epo 14,000 U SC q wk
Might make him feel better.
J.O.
27. Ex/ who is this writer?
Cc: vague symptoms
HPI: nothing specific
PECTARRR.
a/p: symptoms treated in the EDok for d/c
will check TSHhe can f/u with me in endo clinic
A.B.
28. Zinsser: On Writing Well. (p. 5)
[writers]are driven by a compulsion to put some part of themselves on paperThe problem is to find the real man or woman behind all the tension. For ultimately the product that any writer has to sell is not his subject, but who he is.
29. Stephen King: On Writing. (p. 101)
It starts with this: put your desk in the corner, and every time you sit down there to write, remind yourself why it isnt in the middle of the room. Life isnt a support system for art. Its the other way around.
30. Narrative Medicine: Rita Charon
Definition: medicine practiced with the narrative competence to recognize, interpret, and be moved to action by the predicaments of others. (2 January 2001 Annals of Internal Medicine Volume 134 Number 1)
With narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and inaugurate consequential discourse with the public about health care. (JAMA 2001; 286: 1897-1902)
31. Rita Charon
Writing and humanities studies produce better physiciansbecause doctors learn to coax hidden information from patients' complaints
When Medicine Meets LiteratureByMarguerite Holloway Scientific American Magazine- April 25, 2005.
32. Sylvia Plath: The Bell Jar.
People were made of nothing so much as dust, and I couldnt see that doctoring all that dust was a bit better than writing poems people would remember and repeat to themselves when they were unhappy or sick and couldnt sleep. P. 57
So maybe doctors and writers could get along fine after all. P55
33. The Bell Jar: 1st Paragraph
It was a queer, sultry summer, the summer they electrocuted the Rosenbergs, and I didnt know what I was doing in New York. Im stupid about executions. The idea of being electrocuted makes me sick, and thats all there was to read about in the papers goggle-eyed headlines staring up at me on every street corner and at the fusty, peanut-smelling mouth of every subway. It had nothing to do with me, but I couldnt help wondering what it would be like, being burned alive all along your nerves.
I thought it must be the worst thing in the world. (p.1)
1st person/past tense
34. The Bell Jar: 1st person/present!
It was a queer, sultry summer, the summer they electrocuted the Rosenbergs, and I didnt know what I was doing in New York. Im stupid about executions. The idea of being electrocuted makesme sick, and thats all there was to read about in the papers goggle-eyed headlines staring up at me on every street corner and at the fusty, peanut-smelling mouth of every subway. It had nothing to do with me, but I couldnt help wondering what it would be like, being burned alive all along your nerves.
I thought it must be the worst thing in the world. (p.1)
35. Electrocution vs. Electroconvulsive therapy.
Context
text
The Rosenbergs. 1950s McCarthyism. 1st U.S. citizens to be condemned to death for espionage.
Executed by electrocution.
down the hall between two nurses, with dignity, like a person coolly resigned to execution. P.211
ECT Tx is the climax of the book.
36. Present tense
37. Present tense
38. Next present tense example:
For a long time afterward I hid them away, but later, when I was all right again, I brought them out, and I still have them around the house. I use the lipsticks now and then, and last week I cut plastic starfish off the sunglasses case for the baby to play with. (p. 3)
39. Change in verb tense?
For a long time afterward I hid them away, but later, when I was all right again, I brought them out, and I still have them around the house. I use the lipsticks now and then, and last week I cut plastic starfish off the sunglasses case for the baby to play with. (p. 3)
40. Does she give away the ending?
For a long time afterward I hid them away, but later, when I was all right again, I brought them out, and I still have them around the house. I use the lipsticks now and then, and last week I cut plastic starfish off the sunglasses case for the baby to play with. (p. 3)
41. The baby?
For a long time afterward I hid them away, but later, when I was all right again, I brought them out, and I still have them around the house. I use the lipsticks now and then, and last week I cut plastic starfish off the sunglasses case for the baby to play with. (p. 3)
How easy having babies seemed to the women around me! Why was I so unmaternal and apart?...If I had to wait on a baby all day, I would go mad. (p.222)
42. that after I had children I would feel differently, I wouldnt want to write poems anymorewhen you were married and had children it was like being brainwashed, and afterward you went about numb as a slave in some private, totalitarian state. P.85
Im never going to get married. p.93..p.26;83
Children made me sick. P.117
I didnt want to give my children a hypocrite for a father. P. 119
More on Babies
43. Next example: the Bath and Baptism
Whenever Im sad Im going to die, or so nervous I cant sleep, or in love with somebody I wont be seeing for a week, I slump down just so far and then I say: Ill go take a hot bath.
I meditate in the bathIm never so much myself as when Im in the hot bathI dont believe in baptismbut I guess I feel about a hot bath the way those religious people feel about holy water. (p. 19-20)
The longer I lay there in the clear hot water the purer I feltI felt pure and sweet as a new baby. (p.20)
44. Baptism the very last page!
There ought, I thought, to be a ritual for being born twice patched, retreaded and approved for the road. (p.244)
45. Plaths Only Novel
Secretly, in studies and attics and schoolrooms all over America, people must be writing. P. 102.
Then I decided that I would spend the summer writing a novel. That would fix a lot of people. P.121
A feeling of tenderness filled my heart. My heroine would be myself, only in disguise.
She would be called Elaine. Elaine. I counted the letters on my fingers. There were six letters in Esther, too. It seemed a lucky thing. (p. 120)
There are six letters in Sylvia, too. (It seems a lucky thing.)
46. The Bell Jar
I saw[these girls] on the sunroof, yawning and painting their nails and trying to keep their Bermuda tans, and they seemed bored as hellbored with skiing in Switzerland at Christmas and bored with the men in Brazil.Girls like that make me sick. Im so jealous I cant speak.(p.4)
Those girls, too, sat under bell jars of a sort. (P. 238)
47. The Bell Jar
To the person in the bell jar, blank and stopped as a dead baby, the world itself is the bad dream p. 237.
I would be sitting under the same glass bell jar, stewing in my own sour air. p. 185.
I felt surprisingly at peace. The bell jar hung, suspended, a few feet above my head. I was open to the circulating air. P. 213.
How did I know that somedaythe bell jar with its stifling distortions wouldnt descend again? P. 241.
48. She uses the present tense to:
Compare ECT to electrocution
Discuss babies/children
Desire for new life/baptism
Writing
Understand other people
Depression: The Bell Jar.
49. Conclusions:
Writing matters
It is the procedure of the pcp
What we write says something about who we are
Write what you know the age-old writers adage is just as true for the health care provider writing in the chart.
Narrative Medicine: Understanding the patients story IS caring for the patient. (present tense)
50. Upcoming installments
Heisenberg : The Uncertainty Principle (as it applies to health services research)
Ben Franklin: Autobiography (cognitive behavioral therapy)
Edgar Allen Poe: The Raven (psychosis)
Robert Louis Stevenson: Jekyll and Hyde(alcoholism)
51. The END