In defence of the 4×6 white index card

5 minute read

The rush to technology can at times leave in its wake things of simplicity and beauty, writes Dr Niran S. Al-Agba


You’ll know TMR is a big advocate of technology as a means of delivering vastly improved health outcomes.But we will admit that the rush to technology can at times leave in its wake things of simplicity and beauty. Dr Niran S. Al-Agba makes the case here for the the simplicity and beauty of the white index card

During our dermatology section in medical school, a classmate recounted having had Henoch-Schonlein purpura as a child.  Over a holiday break, he visited his primary care physician and asked if he could review his records out of curiosity.  His family doctor pulled out the index card that served as this man’s medical record.  Yes, you read that correctly.  It was not a chart or computer printout; rather a 4 x 6 white index card, exactly like those we used at school.

My classmates’ name was written at the top of the card and on each line were dates and diagnoses.  Halfway down were the words:  HSP — “classic” rash.  My classmate was disappointed he could not analyse his clinical presentation in more detail; nonetheless, he brought back a copy to show us.  An index card as medical record tool is so extraordinarily simple; it is awe-inspiring.  No insurance company to satisfy, no chart to be audited, and no computer screen between the physician and patient.  Back then, a doctor’s time was spent taking a history, performing a physical examination, and having a conversation.

My father has been a practicing paediatrician for the last 46 years.  When I told him about the index card, he smiled and reminisced how much he loved index cards too; when physicians were compensated for practicing medicine and not just ‘documenting’ their practice.  Combining the art and science of medicine is what many of us love most about being physicians.  Why have we allowed bureaucrats and EMR systems to take away the very thing that brings us the greatest joy?

75 percent of diagnoses can be made on the basis of history alone, 10 percent from physical exam, 5 percent from basic tests, 5 percent from more invasive testing, and 5 percent cannot be answered by any of the above.  This family physician was so confident in his diagnosis, he wrote it on one line.  As physicians, we have completed 11 years of post-high school education at a minimum.  The information we accumulate during a decade spent immersed in science, and the human body is vast.  Our mind is our most valuable asset, yet we are not paid based on what our minds can do.  We should be compensated for completing thorough histories, physicals, and making diagnoses.  We should be reimbursed for listening to patients, providing comfort and conversation; especially when it results in a trusting relationship, with improved patient compliance and better outcomes, which will be inevitable.

As paediatrician in my hometown, I attended high school with my patients’ parents: Iknow them.  Does it improve my diagnostic abilities to inquire about their family history at each visit?  Has any physician actually found anything informative after a review of systems?  I have my doubts.

My father and I are still using paper charts; I am not certain he could handle an EHR.  He still has difficulty sending email.  Our charts are pink and have four dividers: The first section holds dictations, the second lab results, the third has radiology results, and the back section contains consult notes from specialists and records from other physicians.  It is easy to review quickly, allows us to provide comprehensive care and be efficient at the same time.  How on earth does clicking boxes on a computer screen improve actual medical care, increase a patient’s trust, or improve their compliance?

My favorite part of being a physician is using the history and physical exam to diagnose, problem solve, and treat my patients. Disease can often be diagnosed on the basis of history alone, which is a notable feat after years of training and experience; however, we must have time to ask the right questions to be successful.  In reality, a focused history and physical are essential to the delivery of high-quality medical care.  They are cost-effective and avoid unnecessary waste of resources at the same time.

So many doctors are frustrated with the health care system today, with high levels of dissatisfaction and burnout running rampant.  We rescue this profession by standing up and forcing  politicians and administrators who control healthcare delivery to make changes that specifically benefit physicians and patients.  Do not forget, we have more years of education and experience than those individuals who are making the rules.  Why have we allowed them to essentially manage our profession?

Doctors revel in listening, comforting, teaching, and healing others; in fact, we flourish in these circumstances.  Maybe the best place to begin taking charge again is by insisting on documenting care our way: whether using old-fashioned white paper or EHR systems better suited to meet our needs.  Since meaningful use standards are being revamped, let us indeed throw the baby out with the bathwater.  We might rediscover the tangible reward of being healers along the way.

Let us go back for a moment to ponder this ingenious idea of using an index card as a medical record tool.  Low cost, top quality medical care is the Holy Grail for which everyone in the field of medicine is searching.  Is it conceivable we already found it, used it for more than a century, and abandoned it in light of its simplicity?  Possibly.   Nevertheless, it is a reminder we should only settle for a system that allows physicians to determine our own destiny and practice medicine in a more fulfilling way.

Niran S. Al-Agba is a paediatrician who blogs at MommyDoc.

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