The Cares of Medical Care

While medical charts have become more formulaic, they always have at their core an emphasis upon the essential patient concerns and these are usually summarized in the opening of the document. A patient office visit summary recently came across my desk beginning: "..is a 65 year old man whose lifestyle is remarkable for no history of physical abuse, no history of sexual abuse, no history of verbal abuse, normal amount of stress and regular seat belt use." The medical history goes on to discuss the patient's diet, exercise patterns, tobacco and alcohol habits, and contraception practices. In the second paragraph it is noted that he has blood in his sputum of recent onset.

This is a revolutionary document. True, the physician is following a template dictated by some agency and is filling his obligation to that agency (to get paid) and then is moving on to the meat of the matter. But the distortion is real, the agency's imprint is real and the change in the emphasis of patient care is real.

A social fraction of the medical whole is being made the reciprocal.