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June 2015

Political Correctness of Medical Documentation

Author Affiliations
  • 1Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Neurol. 2015;72(6):624-625. doi:10.1001/jamaneurol.2014.4535

Having relocated to a new academic institution, I was certain that I would have to learn some new things but revising how I wrote the history and physical examinations of my patients was hardly anticipated. The template I used was largely unchanged in more than 4 decades and it had served me well.

While discussing a complex patient with one of my esteemed colleagues, he expressed his opinion that it was inappropriate to include terms describing the patient’s race/ethnicity or country of origin in the medical documents. He regarded it as antiquated and reflective of having practiced in the South. On the contrary, although I had practiced in Kentucky and the very far south—Miami, Florida—the template I had used for writing a history and physical examination was learned in Philadelphia, Pennsylvania, the same city to which I had relocated.

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    1 Comment for this article
    WHO are our patients?
    James Dickinson | University of Calgary
    Osler said \"The good physician treats the disease; the great physician treats the patient who has the disease.\" By removing characterization of the person, we remove much of the important information, especially for the many diseases that affect particular patient groups. Dr Berger particularly notes genetically-related diseases. I would suggest that even more diseases are related to social circumstances: poverty, crowding, poor nutrition. Absence of information about such circumstances not only in clinical notes but then in journal articles that report on such patients handicaps us in understanding and focussing our efforts on those at highest risk for specific problems, and may mean investigations being performed that are irrelevant to many. An example is rheumatic fever, which used to be common, (and still is in many parts of the world) but in north America appears to be largely a disease of lower social classes (if we are allowed to use that word). If we do not note that chorea occurs more commonly among certain groups, we will be unable to move forward in better diagnosis and prevention.