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Viewpoint |

Political Correctness of Medical Documentation

Joseph R. Berger, MD1
[+] 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.
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This Viewpoint discusses the use of racial and other descriptors in medical histories.

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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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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WHO are our patients?
Posted on May 9, 2015
James Dickinson
University of Calgary
Conflict of Interest: None Declared
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.
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