Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20

Controversy: Pomr-The Case in Favour Max Rendall To cite this article: Max Rendall (1979) Controversy: Pomr-The Case in Favour, Medical Teacher, 1:3, 147-150 To link to this article: http://dx.doi.org/10.3109/01421597909023830

Published online: 03 Jul 2009.

Submit your article to this journal

Article views: 13

View related articles

Citing articles: 1 View citing articles

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imte20 Download by: [Deakin University Library]

Date: 08 November 2015, At: 00:36

CONTROVERSY

POMR-The Case in Favour MAX RENDALL

Downloaded by [Deakin University Library] at 00:36 08 November 2015

Max Rendall, M B , B . C H I R , FRCS, is Senior Lecturer and Consultant Surgeon, Guy’s Hospital and Medical School, St Thomas Street, London SEl 9 R T , U K . The subject of medical records is not popular with clinicians these days. Having to see patients in the clinic without their notes is too common an experience, and one which raises the blood pressure of both doctor and patient. Paradoxically though, it does force us reluctantly to concede that these maligned documents do have a purpose. It might even persuade us that it is illogical to attach so much importance to them when they are missing, and to treat them with such indifference when they are not.

servations collected by nurses and others, and of correspondence. This store conveys thoughts and feelings to which values are attached, as well as physical findings and details of treatment. Such, therefore, is the raw material from which clinical decisions are mined, and mining is all too often necessary because the facts that we need are so inaccessible. Information is only valuable if it can be used, and it will only be used if i t can be found easily and quickly.

Efficient Means of Communication What Should a Medical Record Be? The new clinical student, fresh on the wards and at last getting down to the real business of medicine as he perceives it seeing patients will quickly recognize the fundamental importance of collecting information on which to base decisions. He will spend many hours with his patients taking their histories and examining them, and he comes to appreciate that these basic skills are not easy to learn. He is content to practise until he achieves an acceptable standard. However, the ability to record data with the same application and thoroughness is seen in a somewhat different light. Certainly, it has to be done, but the process of translating what is in the mind onto paper is time consuming, and the immediacy of the situation might seem to be as well served by memory. For this and other reasons, the paper transcript of what is in the memory is both imperfect and incomplete. In due course experience enables us to take some short cuts both in history-taking and in the recording of information about patients, but it also teaches us that we do need to commit things to paper because we cannot trust our memories. This is an important realization, and one which scientists grasp much more quickly than doctors. ~

~

Source of Information A medical record must be a repository of information about a patient. I t will be as unique as the individual to whom it refers, and if it is lost, it is irreplaceable, as the frustrated doctor in the clinic has found. But a record is not merely a collection of histories; i t is a store of investigation results, of huge numbers of individual obMedical Teacher Vol 1 No 3 1979

The organization and complexity of medical care today is such that many people are involved in the care of almost every patient. Communication between all those concerned should be achieved largely by means of the individual’s medical record. It is the obvious solution to the problem, but success or failure in this regard will depend upon how easy it is to get the record when you want i t , and to find things in it once you have it the accessibility of its contents. ~

Legible and Available Legibility and availability are clearly two vital qualities of a good medical record, and are but two further aspects of the problem of accessibility. It is perhaps strange, in view of the reputation for bad handwriting that the profession has earned, that illegibility is not more of a problem in hospital records than it might be. As there is no realistic likelihood that all hospital records in the U K will be typed, we have to accept for the immediate future that some information will be buried deep in a caligraphic tomb, from which exhumation is too time-consuming to attempt. We must also admit that, for conventional paper notes, the ideal of availability when and where a medical record is needed is a mere mirage. There are now too many users for this ever to be possible, and the situation can only get worse.

Aid to Teaching and Research Few students or teachers today would rate a medical record very highly as an educational tool and few in-

147

vestigators would regard clinical notes as sources of data for research, yet they could aid teaching and research. Given, therefore, that the underlying purpose of a medical record is to store unique information about a unique individual, its usefulness is determined not by the completeness of the data, but by its accessibility and availability. A medical record is a tool to be used by those who can help the patient, and they are likely to do a better job with a good tool than with a bad one.

Downloaded by [Deakin University Library] at 00:36 08 November 2015

T h e Reality of the Situation It would surely be reasonable for a patient who has been admitted to a particular hospital several times to expect that any clinician seeing him for the first time would know quite a lot about him. Sadly, we have to admit that this is not the case. The paradox is that as a source of the kind of information needed in a clinic the standard record is useless. The bigger it is, and hence the more data it contains, the more useless it becomes, whereas the smaller it is, the easier it is to grasp what little it does contain. This is not because the quality of two such records is different; it is simply that in the time available we cannot read the former and we can read the latter. This is a grave condemnation of our existing records.

Lack of Structure of Most Hospital Records The problem is inaccessibility, for which there are several reasons. The most important is the almost total lack of structure of the majority of hospital records. If the record is a collection of randomly shuffled bits of paper, there is no way of predicting where you might find the information you seek: you have to plough through the whole bundle. Things get a little better when the notes of an admission, or the correspondence, or the outpatient notes from one department, are all stapled together, but this does not go nearly far enough. There is no clinical index or summary to which rapid reference can be made. Experienced users of most hospital records will usually read the correspondence and the discharge summaries, if there are any, because, being typewritten, they are legible. Discharge summaries are so useful in this respect that they are usually written with this role in mind, and consequently are little suited to the general practitioner’s needs, particularly as they are so often superseded by events before they reach his surgery. What an admission of failure this is. The slavish preservation of reams of paper further compounds the chaos. The more valueless information is preserved, the harder it is to find what we need. The presentation and storage of invesigation results is bulky and inconvenient, and presupposes that the results actually reach the record.

Notes Not in File In a recent survey done under the auspices of the Association of Health Care Information and Medical Records Officers in 44 representative teaching and nonteaching hospitals, over 20 per cent of notes were not in file when required for a clinic (unpublished data 1976). It 148

is a matter of common experience that the records of a patient who pays an annual follow u p visit to a clinic are always available, while the patient recently discharged or attending other clinics stands a high chance of having to be seen without his notes. This is an ironic situation since the former patient probably could be seen without notes, while the latter should not, if potentially serious hazard is to be avoided. The more people who need to see or contribute to a record, the less likely it is to be available precisely the opposite of the situation that should obtain. The great proliferation of independent clinical roles that we now see can only make this worse. Many new paramedical professions are contributing to the care of patients, and they must use the clinical records. However, this will make them both bulky and less available. In short therefore, current pressures in medical practice, particularly in hospitals, are conspiring to render medical records increasingly inadequate at a time when treatment is becoming ever more powerful, and hence hazardous. Iatrogenic ill-health is increasingly common. If it is to be reduced we must have up-to-date information readily available about patients, in other words a good medical record. The profession recognizes the inadequacy of the present situation, and shows it by its inarticulate frustration when the subject of medical records is discussed. When it will rise up and do something about it is hard to say. Most clinicians, perhaps, do not realise that there is a solution to this problem, or if they do, they are not yet prepared to invest the necessary energy. This is an understandable position. There are many other demands on time and energy which are arguably more threatening or pressing. In today’s climate a major change of habit or thought is unlikely to commend itself to the profession, which perceives itself to be under siege by politics and by certain sections of society, and to have been assailed by too much change too fast. I would not argue that these problems can be solved overnight, or even quickly, but I am convinced that the Problem Orientated System-for it is more than a set of rules for record keeping-offers us a clear road ahead. The use of Problem Orientated Medical Records (POMR) should not be advocated as a fashionable doctrine. It must be seen to be what it is - the only tried and tested alternative to a failed and bankrupt system.

POMR-A Tried Solution The pressures that have brought the conventional medical record to its present sorry state are not parochial; they are born of the nature of medical practice today. The solution demanded a new approach which was not simply more or better of the same. Professor Lawrence Weed is a scientist as well as a clinician, who has brought to the problem of recording clinical information the true scientist’s respect for precise data handling. He has evolved a system which on one level can solve the foreseeable difficulties of our medical records, and on another level can teach us to think differently about the way we practise medicine. The price for this is discipline, a price that the profession must soon decide to pay.

Medical Teacher Vol 1 No 3 1979

The arguments for the widespread adoption of the POMR are powerful, and are commending themselves to increasing numbers of clinicians and teachers the world over. Authoritative accounts of how to write such records are available (Weed 1968, 1969; McIntyre et al. 1972).

Downloaded by [Deakin University Library] at 00:36 08 November 2015

Should W e Teach Obsolescence? The speed of change in medicine is tremendous, and it places special responsibilities on medical teachers. Important though knowledge may be, it is a perishable commodity in the heat of scientific and technical advance, and it is encumbent upon educators to equip their students with the ability to acquire changing knowledge for themselves, and to instil the habits and skills that will serve them well in their professional lives. It follows, therefore, that we should not teach an inadequate and obsolete skill. It is a challenge to which we must rise, but we must also practise what we preach.

Accessibility and Communication Perhaps the most obvious and appealing feature of the POMR is the accessibility it imparts to information. It is an astonishing transformation. The Problem List is a summary of the development and current state of the patient’s medical history, and the important factors which do or might influence it in the future. It also refers you rapidly and efficiently to more detailed information, as does the index of a book. Changing information, laboratory results or details of follow up, can be displayed visually on flow sheets, which are quick to use, very compact, and make it possible to write the discharge summary for the general practitioner, and not for yourself. The structure of the record ensures that finding any document takes only a few seconds. Communication is revolutionized, and the record can and should contain the contributions from all those who help with the management of the patient.

T h e Ultimate Solution to Auaila bility? I have tried to suggest that the main problem limiting availability of medical records is the number of users. There is no doubt that alert and dedicated medical records staff can make a great contribution, but the odds are often stacked heavily against them. The turnover of staff is high, perhaps partly because they are often asked to work in airless basements, only seeing the light of day to be abused for their inability to work miracles. There is only one ultimate solution to the problemcomputerization. The logic of this is unavoidable; indeed the process has already started. I t is anybody’s guess when it will become widespread-in the UK later rather than sooner -but certainly during the professional careers of our present generation of clinical students. T h e speed of advances is incredible; the cost of electronic storage capacity is reducing tenfold every three years. It is difficult to predict what form an electronic medical record will take, but whatever the solution, using and making entries in such records will require a degree of discipline Medical Teacher V o l 1 No 3 1979

quite foreign to the profession. The POMR is computer compatible and in use today.

A Versatile Teaching Tool The traditional medical record has never been regarded as an important educational tool, though good teachers have always stressed the importance of writing down histories and examination findings, and have looked at patients’ notes. One of the unique features of the POMR is that the record itself becomes a most versatile and valuable educational document. This follows from the need to write specific initial plans for the problems that the student identifies. In other words the student is simulating clinical management, and as such he must specify many details that few doctors ever thought about before they qualified. T h e student is actually doing the work, instead of being relatively passive, and he is responsible for the whole patient, unlike the traditional approach to medical education whereby students learn only fragments of the process of patient care. Permitted activity, frequency of nursing observations, details of diet and many other practical matters must be considered and written down and the teacher must provide feedback on the student’s performance. This system of education is likely to produce doctors who make fewer mistakes and who are open to comments on their performance. It is a constant cry that medical students want responsibility, but in the same way and for the same reasons as airline pilots learn much of their skills on simulators, we cannot grant students real responsibility for clinical decisions until they have demonstrated their ability to cope with them. Nevertheless, the POMR can give students a certain measure of responsibility, albeit vicarious. T h e student must collect information about patients, identify their problems, decide which problems require action, draw up a plan of action, and follow up the patients. By committing decisions to paper, and preserving the logic underlying them, it is easy to see where they went wrong and why. Investigation, decision making and therapeutics become practical and accountable, rather than theoretical and without consequence. Each set of notes, no matter who wrote them, becomes a document which can be the basis of relevant and immediately applicable teaching. This concept can be extended, and within a framework of problem orientated learning goals and objectives both theoretical and practical examinations can be devised. The notion of a problem orientated final examination would fill many with horror, but the idea that a student should take a history from a patient, examine him, decide what the problems are, and how they should be further investigated and treated seems excellent: yet the two are the same, and would test a wide range of the student’s knowledge and skills. It is possible to teach students in an interesting and practical way about conditions to which they have not yet been exposed by giving out typed histories and examination findings of patients with such conditions, this information perhaps gathered and written by previous students. These are studied, and problem lists 149

and initial plans for investigation, care and treatment drawn up before group discussion. The flaw of most textbooks-they start with a given diagnosis rather than a patient with symptoms and signs -can thus be bypassed.

Downloaded by [Deakin University Library] at 00:36 08 November 2015

The Record as a Tool in Quality Control There is no conclusive evidence that good records and good care are correlated. It is a difficult line of enquiry, but, especially when more than one clinician is involved, it is likely that the two are related. Assessment of the quality of care is an important subject with which the profession must grapple successfully if it is to avoid having the matter taken out of its hands by mounting pressure of public opinion. Although by no means the only way of doing this, review of a good record gives good evidence of sound care or otherwise. The POMR goes further, however, in that the necessity to display the logic of decisions and of the actions taken both increases the ease with which the record can be audited, and acts as a constant and positive inducement to good clinical behaviour, which most of us need from time to time. Whether or not the use of POMR leads to any measurable improvement in clinical care is also a much debated point. It is a very difficult hypothesis to test, but there is some evidence which gives cautious support to this view (Fernow et al. 1978). The findings of such studies are obviously influenced by the extent of acceptance of and compliance with implementation of this type of record. Those factors which influence use of this format have also been investigated (Fernow et al. 1977).

Integration of Management Specialization is a fact of life with which we have learned to live, but it does have potential dangers. A patient is too often treated as an organ system which is malfunctioning in some way, in each of several clinics, without adequate overall consideration of the patient as an individual. Each of the various treatments prescribed may be admirable in and of themselves, but result in unrealistic or even dangerous drug regimens and inappropriate demands on the patient. When this occurs it is due to a failure of communication, resulting from inaccessible information, and the consequent disintegration of care does not serve the patient well. The accessibility of information, particularly provided by an up-to-date Problem List, makes integrated management easier.

Influence of Social and Emotional’Factors on Symptoms So much perceived ill health in society today is not primarily organic but is the consequence of social or emotional disturbance deeply rooted in many of the inadequacies and difficulties of present day life. In a recent study at a London teaching hospital, 84 per cent of patients presenting with abdominal pain to a general surgical and gastroenterology clinic were found to have no organic cause for their symptoms, and most had discernible emotional or psychiatric illness which was felt to account for the pain (Gomez and Dally 1977). In so far 150

as the factors underlying the production of these and other symptoms can be identified, they can be given the prominence they deserve as potentially important influences on present or future illness. We may be powerless to do anything about dreadful housing, wives who are physically abused, or sexual problems, but we must recognize their impact on health, which the POMR does, by identifying these factors as problems. The POMR also stresses the preventive aspects of medicine. Smoking, obesity, a family history of polycystic disease of the kidneys and other facts are presented to us every time we open the record, and this is likely to result in us emphasizing the importance of persuading the patient to stop smoking, to reduce weight or to watch carefully for renal enlargement. In the long run preventive medicine must command the attention of the profession more than it does today, and the POMR is particularly well adapted to such a purpose. T h e Future The advocacy of one type of medical record over another is like extolling the benefits of death by drowning over death by exposure. The majority of the profession, while perhaps not happy with the present situation, do not intend to change their habits, and hence they see no purpose in discussing an alternative. It is not easy to teach doctors or even students to write good POMRs, but it is not easy to get people to write good records of any kind today. It is unrealistic to suppose that there will be any widespread, consistent or rapid conversion to the use of POMR, and the pity of it is that some of the benefits are only reaped when there is a high level of commitment in an institution. The way we manage our affairs in the UK is unlikely to foster a change of this kind. As yet, we do not have sufficient teachers who are committed to the system to make a major impact. These are simply difficulties in the way, but nothing worthwhile is ever achieved without a struggle, and I believe that this is an overwhelmingly worthwhile cause. References Fernow, L. C . , McColl. I . , Mackie, C. and Rendall. M . , An analysis of the use of problem orientated medical records (POMR) by medical and surgical house officers: factors affecting use of this format in a teaching hospital. Medical Education, 1977, 11, 341-346. Fernow, L. C . , McColl. I . . Mackie. C . and Rendall, M . . The effect of Problem Orientated Medical Records on clinical management controlled for patient risks, Medical Care, 1978. 16, 476-487. Gomez, J . and Dally, P . , Psychologically mediated abdominal pain in surgical and medical out-patient clinics, British MedfcalJournal. 1977. 1, 1451-1453. McIntyre. N . . Day, R. C. and Pearson. A. J. G . . An introduction to

Problem Orientated Medical Records (the Weed approach), British Journal of Hospital Medicine. 1972, 7, 603-611. Weed, L . . Medical records that guide and teach. N e w EnglandJournal ofMedicine, 1968, 278, 593-600, and 652-657. Weed, L.. Medical Records, Medical Education, and Patient Care, The Press of Case Western Reserve, 1969. Further Reading McIntyre. N . . Wyn Pugh. E. and Lloyd, G.. The Problem Orientated Medical Record and its Educational Implzcatzons. ASME Educational Booklet No. 6. 1976.

Medical Teacher Vol 1 No 3 1979

Controversy: pomr-the case in favour.

The subject of medical records is not popular with clinicians these days. Having to see patients in the clinic without their notes is too common an ex...
667KB Sizes 1 Downloads 0 Views