Saturday, April 9, 2011

Death of the S.O.A.P. Note?

While shadowing a local family doctor in high school, I was given my first instructions in the art and importance of a good history and physical and the classic documentation of a S.O.A.P. note. At the time, he explained to me how powerful, yet simple and elegant this note could be – no more than a few dozen words to define the impression of an entire patient visit. For the uninitiated:

S = Subjective (What the patient tells you)
O = Objective (What you gather from inspection and exam)
A = Assessment (What is likely going on)
P = Plan (What is to be done for the patient)

In many ways, this format allowed physicians to distill the extent of an office visit into a focused assessment of pertinent positives and goals. It was quick, efficient, and most importantly – it worked.

The irony for me? I haven't seen a single S.O.A.P. note in nearly three years of medical school.

Sure, physicians will comment that modern documentation is an extension of the format of the classic S.O.A.P. note. That, we still rely on the subjective and objective examination to formulate an assessment and plan. But medicine has moved away from the quick and distanced itself from the intuitive. The risk of error is too great.

In no way am I supporting shortcuts in medicine, or worse, decrying technological advancement. This couldn't be further from the truth. In fact, I am currently working on a future blog post in which I hope to extol the value of EMRs and the medical community's embrace of such technologies. Rather, I'm attempting to paint a picture of swift progress – of how quickly we are shifting the function and duty of the physician.

Think of it this way – can you imagine another profession in which the field of practice differs so drastically from the time one decides to enter, to the point in which one actually begins? Modern medicine may see the greatest such shift of nearly any profession in the history of man.

To illustrate my point, take my path along the road to medicine for example:

1995 - age 11 – First inspired by my uncle, who was a family doc, to dream of following his footsteps
2000 - age 16 – First shadowed local physicians
2002 - age 18 - Declared pre-med intentions
2004 - age 20 – Took the MCAT exams
2008 - age 24 - Entered medical school
2012 - age 28 - Graduate from medical school
2015 - age 31 – Begin practicing as a family physician

How much medicine will have changed in those 20 years! I could go on and on about the politics and policy of medicine in the intervening period, but think of the sweeping technological innovations! I used the hand written S.O.A.P. note as an illustrative mechanism for these changes. Today, as I am engaged in a clinical rotation at a modern health system, I have instantaneous access to any patient's every clinical note, lab value, and imaging test at the touch of a button. The system is designed to remind me of best practice initiatives when a patient is due for a health maintenance test and built in redundancies prevent me from ordering conflicting medications. If I wanted to be bold, I could forget how to use a pen entirely, and still excel in the care of my patients.

This all begs the question of what awaits us in the coming years? Thinklabs and 3M are designing “smart” stethoscopes that can interpret heart sounds digitally, GE has developed a hand-held ultrasound, and genetic testing is targeting the most precise variables of disease. As we move away from the era of intuitive medicine and the likes of the S.O.A.P. note, where does the family doctor fit into all of this?

These are all wonderful and valued additions to a health care system that demands efficiency, precision, and cost-saving mechanisms. But, BOY – what a difference from the office of my uncle, or that of the family physician I first shadowed in high school! Just think about how the clinical setting in which I was first inspired will bear little resemblance to the one in which I begin my first practice. The classic S.O.A.P note may be a relic for historical medicine soon, but as long as the spirit of the family physician endures – I know I'll be overjoyed to enter the profession.

1 comment:

  1. The SOAP note was first developed by Larry L Weed as a systematic way for attending physicians to keep track of the thought processes of medical students, interns, residents in charge of patient care. The SOAP note also was handy in keeping a running record of the resources used. The SOAP note was something that only rookie physicians or physicians in training did, NOT for established physicians. In fact, the SOAP note can be ponderous and takes 5 to 6 minutes longer to write compared to the traditional notes that fully trained, established physicians wrote. However, the U.S. federal government found that the SOAP note makes it easier to audit physicians and keep track on them, especially in regards to healthcare fraud. And the feds made it a requirement that all physicians caring for medicare and medicaid patients write notes using the SOAP pattern, if the physician did not, then the feds could refuse to pay the physician. Moral of story: The SOAP note is used by the feds to keep an eye on you. Big Brother has his sights set on you.