A large part of a resident’s day is spent writing interminable “notes.” There is a set format for these, called SOAP (subjective, objective, assessment, plan), and it is pounded into one’s head as a third-year medical student. Ever after it serves as the outline for all communications between doctors, written or verbal. (One of the best ways to realize the difference between doctors and nurses is to compare the format for documentation and reporting that nurses use. It’s quite as stylized as ours, but has a very different focus. I respect them more after looking over some shoulders at inter-shift report forms – but we think very differently.) Even a brief two-sentence statement by the person requesting a consultation has the implied skeleton of this form underlying it, and it’s assumed that the parts not mentioned are not as important.
(Attendings write notes too, but they’re allowed a much larger leeway: A lot of them consistent of scribbling, in letters large enough to fill the page and obscure the fact that few words are actually being used, “Pt comfortable, improving. Afebrile. Abdomen benign. Continue plan per above.”)
Apart from the fact that at least half the doctors in the hospital have completely illegible handwriting, and that it would be nice if we actually talked to each other every now and then, the problem with these notes is that they require you to commit to an opinion, publicly and irreversibly. They’re especially terrifying to medical students and interns, because you have to write down something meaningful about what you think should be done next – when you often have only the vaguest idea. I’m more used to it now, but it’s still a little threatening to be the junior resident writing notes; my plans are supposed to be actually valid, and all the other doctors involved will give some real weight to it. It’s like getting an essay paper back every couple of hours, to go by and see what the attending end up writing, and whether my idea was at all similar to his. And if not, everybody gets to read and compare.