Teaching Doctors to Write for Patients

Over just five years, from 2017 to 2022, the percentage of Americans who accessed their medical records online through an app or patient portal more than doubled, reaching 57 percent by 2022.

It’s likely that number has continued to climb more recently, in part due to the implementation of the 21st Century Cures Act. Since 2021, the law has required health care organizations to give patients digital access to their medical records. But the law did not mandate any change in how clinicians approach writing the notes that the patients would find in their records.

At the time that particular aspect of the 21st Century Cures Act took effect, Anita Vanka, an HMS assistant professor of medicine at Beth Israel Deaconess Medical Center, was co-director of a clinical skills course for first-year students at HMS, The Practice of Medicine. She remembers that Thomas Delbanco, the HMS John F. Keane & Family Professor of Medicine at Beth Israel Deaconess Medical Center and a pioneer in promoting patient access to medical records, asked how students would be taught to write patient notes given that patients would now be able to read them.

“That was a great question,” Vanka says. It prompted her and her colleagues teaching the course to step back and reflect on how to prepare students to write notes with patients in mind. One problem, Vanka realized, was that there were no clear guidelines available on how to do that. What did it mean to write a patient-centered note? And was it even possible for a single note to serve multiple purposes?

In a recent paper, Vanka and coauthors detailed their attempt to develop guidelines for patient-centered documentation that could be used to teach students — as well as other clinicians — how to write patient-centered notes. Vanka talked with Harvard Medicine editor Amos Esty about their findings. The conversation has been edited for length and clarity.

What prompted your recent paper on guidelines for patient-centered documentation?

There was a lot in the literature that Tom [Delbanco] and his colleagues had published via OpenNotes about why open notes are so helpful, what patients like to see in their notes, and so on. But there were no readily available best practices. And as a medical educator, it’s really helpful to anchor a curriculum on a checklist of best practices or concrete tips that I can give my learners. 

How did you carry it out?

We did four focus groups. They included patient advocates who were familiar with open notes, physicians who are very familiar with open notes, medical education leaders who teach students these same clinical skills, and resident physicians who had not received any formal curriculum around this but worked with students on a regular basis and are usually the frontline teachers for a lot of our students.

We developed a structured questionnaire of seven specific questions that we would ask our focus groups. We met with them for 90 minutes each via Zoom and then essentially did a thematic analysis of their responses to come up with our checklist of ten best practices. And that is what we anchor our curriculum on. After we developed the checklist of ten best practices, we developed the workshop that we implemented for the first-year students, and this is what we teach our students, as well as their faculty preceptors.

Did any of the guidelines that emerged surprise you?

Because I had been doing some of my own reading and looking at some of the data that had been published, it didn’t really surprise me. I think what we did learn, though, is that guidelines are just guidelines. Every patient is different. So when we think about using person-first language, we want to understand what our patients want and represent it accurately. It’s not going to be the same for everyone.

You have also written about the use of stigmatizing language. One of the interesting things you’ve mentioned is that it’s not just about semantics — the language used can actually make a difference in the care that patients receive.

One of the studies in this space looked at how clinicians respond to a note of a hypothetical patient case. They randomized residents and medical students to two different groups. One group received a patient-centered note of the patient’s presenting symptoms, and the other group received a note that had kind of the language we’re used to seeing, including a lot of stigmatizing language. And what they found was that the group of trainees who read the note with the stigmatizing language was less likely to treat the patient’s pain and had a more negative perception of the patient. So it not only affects our relationship with the patients or how we may view them but can impact care as well.

I think about this in my own practice. If I see a note that says, “The patient was here a week ago; they left against medical advice,” I’ve already built a narrative in my head, and it biases me whether I want to admit it or not. If that same note said that the patient was here last week with similar symptoms and had to leave prior to the rest of the hospitalization due to work obligations, I’m going to have a different narrative in my head.

One interesting guideline was to try to empower patients with encouraging words and clear next steps, which seems like a really different goal than communicating as concisely as possible with other clinicians. How do you balance the different goals of a note?

I think it honestly can just be a change of simple words. Let’s say you’re seeing a patient for management of their blood pressure, rather than saying something in your note like “the patient has failed three different medications” or “continues to not achieve optimal blood pressure,” which sounds very negative, you might say, “We have not achieved our target yet. We will continue to work on this.”

You’re still communicating that same message to other clinicians, you’re only changing the words a little bit. It’s a bit more positive framing of what you and your patient are trying to work on together.

There’s a comment in the paper from a physician about using the first person when writing a note. I don’t think I’ve ever seen the first person used in any note I’ve read for myself or a family member. Do you think physicians should use the first person when writing notes?

I don't know if I would say it should happen. But the reason I like it is that when I think about the note we're capturing, we have what we call our subjective data — the narrative and patient experience we receive from our patients. And we have our objective data — things like the physical exam, lab data, and such. And then we have the physician’s assessment and plan, which is subjective — it's our experience of processing the information and coming up with a plan.

I started using the word “I” to be transparent about my own thought process. So saying something like, “Based on our conversation today, I think most likely the shortness of breath is due to a pneumonia and this is why. If things don't improve, we should consider X, Y, and Z.” It gives room for the fact that this might change if the patient comes back three days later and symptoms are different, rather than sounding absolute.

Have you noticed a change in the way physicians are writing notes since the law went into effect? Has there been a change already or is that kind of the change you’re trying to drive with these sorts of studies?

I see it with my medical students. Unfortunately, I don’t see it yet in the clinical space. Due to time and other pressures, we tend to see notes being copied and pasted, and information forwarded to the next note. We have this concept of what’s called note bloat, where every note just contains prior information that may or may not have been verified. It contains language that we probably don’t want in there, but we simply haven’t paused to think about it.

You mentioned you developed the guidelines in part to help with the curriculum for first-year medical students. How did it go when you used the guidelines in that curriculum?

We implemented this in 2021 with medical students who had been in medical school for about a month and had just started our clinical skills course. It was fascinating to see that this was not surprising to them because they’re coming into this curriculum from a vantage point of being a patient previously. Maybe they’ve read their own notes or notes for their loved ones. They haven’t yet been indoctrinated into the medical vernacular. It was almost like this curriculum was not needed. They were like, “Well, of course, saying ‘patient complaint’ sounds terrible.” I don’t think we were expecting that at all.

One guideline recommends avoiding the use of jargon or shorthand as much as possible. How practical is that on a daily basis where you’re seeing lots of patients and writing a lot of notes?

I think that’s the toughest one to combat. Our medical students who are writing notes for practice during their first year have the ability to spell things out, and I think it’s good for them as they’re learning. But I’ll tell you that in our clinical spaces, it’s really hard to do it. I’m guilty of the same thing. I think I definitely am more intentional about it. I think about my abbreviations before I put them in. But yeah, because you’re crunched for time or you’re writing many notes, we see this happen.

Where do you think this discussion is headed in the next five to ten years?

Physicians aren’t the only ones documenting in the medical record, right? We have nurses and social workers and physical therapists and others. How do we extend this curriculum’s teaching to all health care professionals? And how do we also think about educating patients too? Because the goal is for patients to partner with us, but we still find that regardless of the 21st Century Cures Act, we have a decent subset of patients who don’t know that they can access their own notes. How do we ensure that patients are able to do so and to partner with clinicians and ensure the note is representative of what is actually happening?

This is just a really exciting area where we’re all learning.

Images: stphillips/Getty Images (medical records); courtesy of Anita Vanka (Vanka)