September 07, 2013
The SOAP note: Subjective, Objective, Assessment and Plan, a succinct and emotionless condensation of a patient's pains and worries into a set of specific, terse words. Each word has a unique meaning and purpose, a little packet of health information creating a physician's Morse code. With each phrase holding so much specific meaning, physicians tend to be quite protective of this writing system, scolding medical trainees for misusing words or writing with flowery language. Dyspnea is not the same as labored breathing. Fatigued is an inconvenience, whereas lethargic is a medical emergency. Obtunded is a fairly meaningless term somewhere on the spectrum of confusion, and should be avoided. But most of all, brevity is supreme. Bullet points are even better than complete sentences. This system of heavy terms creates a Zip-file for our medical language that is subsequently decompressed in the minds of doctors. By the end of medical school, students are writing notes like computer programmers, thoroughly trained to leave out everything superfluous with a minimalist form of grammar. Yet the compression can be squeezed further.
Acronyms can take these medical super-words and fold them origami-style into tight, neat abbreviations that carry the pain and discomfort of patients: SOB, CRF, CHF, N/V/C/D, BRBPR, BPH, GERD, DNR. These encoded units of letters bespeckle the pages of clinical notes, protecting physicians from the curious eyes of patients. Once these words and abbreviations are mastered, they can be bent to the sharp frame of the SOAP note, creating a kernel of succinct and vital information to support transitions in the fractured care of modern medicine.
Yet, something is invariably lost in this process. The SOAP note tends to deliver the patient's complaints, exam findings, and the medical plan, but not the conditions surrounding the medical problems, the context of the patient's life beyond acronyms. While it is true that “Mr. Barnett” is a 68 y/o M pt w/ h/o COPD, CRF, CHF and 80 packyr hx of smoking who c/o exacerbation of SOB at night x 2 wks, this reduction loses much of the context. For example, it does not tell us that Mr. Barnett grew up in a low-income black neighborhood, where his father worked himself nearly to death to provide opportunities for his children. Young Mr. Barnett was the only child on his block who had a musical instrument, a violin that his father had purchased third-hand. He took to the instrument immediately, envisioning a career and life built from the notes created by the small instrument. Yet, being a black man in Jim Crow America did not provide many opportunities, so he saved just enough for a passport and a ticket to escape to Europe. He traveled as a vagabond musician across Europe for nearly ten years, looking for stability but only finding small gigs here and there to pay for food, wine and cigarettes. Over time, the traveling life began to wear on him, and he was poorer and more tired by the day. Then he heard the news that his father had died from lung cancer, the final nudge that sent him back across the ocean to his home country. He threw his cigarettes away before the trip, but only made it three days before scrounging money for a fresh pack.
After moving back from overseas, he packed his violin away, ready to move on to the next part of his life. He took a blue-collar job that calloused his fingers in a different way, and quickly afterward got married and started a family. He was able to give up the violin, but never cigarettes. Now he has gotten to the point in life where he sees the end coming and he just wants to be comfortable during the time he has left. When he lies down at night and the fluid rapidly soaks his lungs, a panic fills his chest. He pushes himself up from his four pillows and coughs up a pink froth. The only thing that calms him is sitting in his recliner and smoking a cigarette.
Granted, it is more efficient as a healthcare provider to see Mr. Burnett as a 68 y/o M pt w/ nightly SOB, but this captures the patient's symptoms without capturing the patient's story. A fond mentor of mine recently tried bucking the trend of the traditional SOAP note by adding an addendum that provided a more personal view into the patient's history, similar to the story above. He then dared me to do the same for some of my patients in the future, not every day, but occasionally. He dared me to take a few minutes to collect a broader view of the patient's life and to transpose it in the chart as part of his medical story.
Certainly the busy life of medicine would preclude us from adding this personal section to every history and physical, but even the occasional addition of the patient's broader story to the SOAP note would provide a rich source of humanity to this mechanistic and algorithmic side of medicine. It could serve as a prompt to better know patients, giving them personhood in the archives of their medical files. In the words of my mentor, asking healthcare providers to do this once a month could “help to keep the empathy pilot light on.”
As the dare was passed to me, now I pass it further. Take five extra minutes, at least once, to fill out the extra “P” at the end of the SOAP note, the “Personal” section. Show your patients and your colleagues that your empathy continues to burn un-snuffed. Use SOAP2 to wash away the veil of reductionism in medicine, exposing the true patient beyond the signs and symptoms. And if you like what you find, then pass the dare along.
Bryan Sisk, MD
Deputy Editor, The Living Hand