Medical Teacher

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

The Problem with POMR Michael A. Simpson To cite this article: Michael A. Simpson (1979) The Problem with POMR, Medical Teacher, 1:4, 195-196 To link to this article: http://dx.doi.org/10.3109/01421597909012600

Published online: 03 Jul 2009.

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Date: 08 November 2015, At: 13:58

CONTROVERSY

The Problem with POMR MICHAEL A. SIMPSON

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Michael A . Simpson, M B , BS, MRC.PSYCH, DPM, is Associate Professor of Psychiatry and Associate Professor of Family Practice and Community Health, Temple University School of Medicine, 3401 North Broad St, Philadelphia PA 19140, USA.

I n this article, D r Michael Simpson argues the case against unquestioning acceptance of problem orientated medical records, i n reply to the article which appeared in the last issue of Medicd Teacher (1979, 1, 147-1511. During the past few years, a great many very repetitious papers and books have been published about Problem Oriented Medical Records (POMR). There can be few techniques in the recent history of medicine for which so many glowing, exciting claims have been made with such a striking lack of supporting evidence. Although the technique is claimed to be ideally suited to producing data, there have been astonishingly few serious attempts to test the flood of hypotheses that arise from the assertions made in the ‘hard sell’ approach typical of the advocate of POMR (Hurst 1971; Hurst and Walker 1972; McIntyre et al. 1976). Consider the claims of Hurst (1971; 1972), for example: POMR “encourages the student, house officer and practising (physician) to use sound logic in his thoughts about patients”. Does it really? It “enhances the continuing education of the physician and all who assist him”. Does it? It “will improve the medical care given”. How firmly and generally has this been established? It “will improve patient care by making it possible to do more accurate clinical research”. Did it? Where, and when? It “encourages a more meaningful way of talking about patients”. How was this proved? According to Mclntyre et al. (1976) “we are less likely to miss important items of information, to ignore significant problems or to overlook potential interactions; we are less likely to neglect patient education. We are forced to act logically”. These are all heroic, glorious potential benefits, undoubtedly. But after all this time, after the adoption of the system by so many very able men in major clinical units, why are there so few data to establish the veracity of all these claims? In over 17 years, there has yet to be any major clinical Medical Teacher Vol 1 No 4 1979

problem that has been uniquely illuminated by the use of POMR. As Feinstein (1973) has emphasized, “the superiority claimed for the new records has not been demonstrated with any scientific evidence obtained from direct tests of the new system versus the old”. While such studies could be difficult (any good and meaningful evaluations are difficult to achieve), they would be possible, though the advocates of POMR argue with faulty logic and poverty of imagination but sincere conviction that POMR is so good, so obviously itself the ideal criterion, that it is impossible to compare it with any other system, or even to evaluate it critically, in a scientific study. How strange that a major data management technique should be so fiercely urged upon us without data, though replete with rhetoric and polemic and uncritical ardour. Unquestioning Belief i n POMR Most of the literature on POMR has a monotonous similarity. Much of writing on the subject begins by describing how ineffective medical records are in their typical state, for most purposes. This criticism (although not supported by much organized data) is accepted by most of us: records are usually sloppily written and badly kept. Then there is a detailed description of how POMR should be written in ideal circumstances, and then a few ringing claims for the efficacy of the system-but no data, for the case seems to be regarded as self-evident. Yet it is not a self-evident case. I have worked with POMR in several countries and several clinical settings, from primary care to tertiary care. I have recently had the opportunity to observe closely the introduction of POMR in a major teaching hospital. The situation was an ideal one in which to establish and assess its benefits, and the factors in favour of its success were most unusually propitious (to an extent far beyond that which most of us could hope for when trying to introduce the system elsewhere). The effort was led by a senior and distinguished clinician with a senior administrative 195

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position in the medical school, an unusually forceful and determined character with unequalled knowledge of POMR. For much of the critical period, additional external funding was available for additional research registrars, a research psychologist, and generous secretarial support and equipment; facilities were generous, and the school had agreed to the use of POMR by the students as official policy. And it does not work. The standard of clinical records written by the typical student (and still worse, by the typical doctor) was undistinguished, despite prodigious expenditure of man-hours on teaching POMR and careful and regular auditing of clinical notes. Similar and, at times, better notes are kept by normally supervised students in other schools using traditional forms of medical records. As part of a research project, I have recently closely reviewed the notes kept by the students on some units throughout their basic medical clerkship. Significant items of information are frequently omitted (little things like the cause or even the fact of the patient’s death, for instance); very significant problems are ignored; logical planning is rarely apparent; and no substantial change or improvement was apparent through the course of the three-month clerkship, despite regular audit. Such psychosocial data as are recorded are rarely if ever used or acted upon. Zeleznik et al. (1974), though somewhat more optimistic, have described similar experiences. Educational Benefits Many of the educational benefits claimed for ‘chart audit’ are due to the Howthorne effect (the well-substantiated benefits of simply paying more attention to a system and its workers). Other benefits are due to the fact that the ‘audit’frequently becomes a one-to-one personal tutorial, following the student’s problems and interests. We already knew that such tutorials were useful though very expensive, but POMR is unnecessary if it is simply an excuse to hold tutorials. Problem-oriented records clearly do take the student (and most clinicians) a good deal more time to write, in most normal circumstances. It has yet to be demonstrated that POMR (as used by normal doctors in normal circumstances, rather than by specially trained enthusiasts with special incentives and facilities) does reliably have sufficient benefits to be worth the extra cost and effort involved. It is possibly so, but no truth is wholly selfevident. Let me be clear that I recognize some advantages to the system in theory. To attempt an explicit statement of the taxonomy of patient problems is useful-though it may take various forms. The potential attention ‘to ‘patient education’ (a rather condescending term) is encouraging, though rarely well used in practice. Some advantages are more illusory. Feinstein (1973) has stressed, as I do, that they arise either from “the vigorous supervision needed to make the system work or the previous attitudes of the people who elect to use the system. The benefits do not and cannot arise from the structure used for recording medical data”. Quality and continuity of medical care are not capable of being in196

fluenced by records themselves. Audit, as has been said, can be useful, but can be just as usefully conducted with conventional records. POMR does not record such essential components as concern, understanding and compassion; qualities which may be lacking from the performance of the physician excessively preoccupied with the obsessive correctness of form of his datarecording. Feinstein (1973) also complains of the emphasis on what he calls “library technology”, the cataloguing and indexing of data, rather than on clinical skills. And the emphasis, as I have clearly seen in practice, is on the teacher’s review of the student’s idealized and polished written account of part of whatever data they may have obtained from the patient (and from other sources, including someone else’s notes) rather than on actual clinical skills as practised. There is a tendency to undervalue essential skills that are not readily recorded directly in chart form. Many of the POMR-zealots are enamoured of the computer, which would seem to represent potentially their model clinician: always reliable and complete in its data-gathering, and impeccable in its lay-out and typography. Where the use of POMR seems to show benefits, are these effects inherent in the nature of POMR (in distinction to all other possible ways of keeping records) as is suggested; or are they simply the benefits of using any system carefully and well? It is already clear that POMR can be sloppily used and that badly kept POMR can be as inadequate as any other bad records. In the words of Dunea (1978), “It was a brilliantly conceived system, seemingly foolproof, and based on an irrefutable theology, with ready answers for every objection”. Like a cross between Pitman’s shorthand and Werner Erhards EST, it is supposedly effective and morally good for you. But is the primary fault in medical records the human failing; the way in which busy doctors, with little support or logistic assistance, are likely to keep any records? Are the real educational benefits derivable by keeping our records more carefully, treating them seriously, and critically reviewing their contents; rather than by adopting any special literary style? Perhaps those who take the Weedier than Thou approach have committed the primary error of McLuhan -they have confused the medium with the message. References Dunea, G . . Confusion orientated medical records, Eritzih Medical Journal, 1978, 1. 1686-1687. Feinstein, A. R . , The problems of the problem orientated medical record, Ann& of Internal Medicine, 1973, 78. 751-762. Hurst, J. W., Ten reasons why Laurence Weed is right, New England J o u m l o f M e d i c i n e , 1971, 284, 51-52. Hurst, J . W. and Walker, J . W. (Eds), The Problem-Orientated System, Medcom Press, New York, 1972. McIntyre. N . , Pugh, E. W. and Lloyd, G . , The Problem Orientated Medical Record and it5 Educational Implications, ASME Medical Education Booklet No 6. ASME, Dundee. Zeleznik, C., Brucker, P. C., d’Amato, G . and Goldfard, A. F.. Utilization of the POMR approach in identifying socio-medical problems. Paper presented to the 13th Research in Medical Education Conference, AAMC, Chicago, 1974.

Medical Teacher V o l l N o 4 1979

The Problem with POMR.

In this article, Dr Michael Simpson argues the case against unquestioning acceptance of problem orientated medical records, in reply to the article wh...
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