Joel Diamond 7/31/09

More About Controlled Medical Vocabularies

I remain an advocate of structured data. I believe that it is the foundation for connected healthcare. As I have pointed out in previous posts, the art of medicine often rests on the nuances of communication. The patient’s chief complaint and the physician’s history of present illness can often tell a much richer story than drop-down lists and templates. We were taught in medical school to use the patient’s exact words whenever possible.

When I was in training, my fellow residents and I would often debate about the very best encountered chief complaint. Many of these involved malapropisms of medical terms used by patients in overcrowded emergency rooms.

It was not uncommon for women to complain of problems related to the “fireballs in my Eucharist” (fibroids of the uterus). Sometimes I think the gastrointestinal complaint of “die-a-rears” is more descriptive than the actual term (diarrhea), and certainly “sea roaches of the liver” seems more ominous that “cirrhosis”. One of my favorites, though, was a mother who was afraid her son might have a case of “smilin’ mighty Jesus”. It took me awhile to realize that she wanted me to rule out “spinal meningitis”.

The perennial winner chief complaint contest goes like this. An 85-year-old woman once presented to the clinic with “leaves growing out of my vagina”. Shockingly, physical exam confirmed this as true. Further history revealed that the poor lady had suffered from severe uterine prolapsed. For those less familiar with medical terminology, a pessary is a device that is inserted to hold up the cervix and uterus in order to keep it from “falling out”. This enterprising octogenarian decided to improvise and use a potato for this purpose. Potato… dark place… sprouts…. you get the rest.

My all time favorite (and true) encounter documentation would be completely lost of meaning (let alone humor) if it was documented with structured data.

Two seemingly unrelated traumas arrived within minutes of each other: a man with a severe laceration to his penis and a woman unconscious due to head trauma. The history of present illness is similar in both charts. The man and his girlfriend are “involved” on his kitchen table. Unfortunately for him, her poorly controlled epilepsy results in a grand mal seizure and unrelenting jaw-clamping. Frantic, he grabs a nearby cast iron skillet and whacks her on the head to make her stop. .. you get the rest.

Continuity of care and a patient-centered record are the holy grail of connected healthcare. Accurate and timely access to patient data is the foundation, but clinicians should not abandon essential storytelling just because of IT adoption. Documents, with appropriate free text, must be preserved, but … only when intelligently associated with overall workflow, can the art (and humor) of medicine endure.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.