Sunday, July 1, 2018

What's the Good Word?

(Here's another missive from CDI land, in which I get to use The Osmonds, Diane Rheim, Gal Gadot, Ed McMahon, and testicles in the same article.)

We’re all about language in CDI World, which is probably why I fit in.  I’ve always been kind of a Vocabulary Nerd, with an occasional spell of Grammar Guy thrown in for good measure.  This is why the song “I’ll Be There” by the Jackson Five.  If you know the song, you’ll recall that twelve-year old Michael Jackson croons in his most plaintive pre-pubescent voice:

“If you should ever find someone new,

I know he’d better be good to you.

“Cuz if he doesn’t

I’ll be there.”

It’s a great sentiment, right?  Because if your new boyfriend is mean to you, you’ll want to fall back on a guy whose closest companion for years was a chimp named Bubbles (who is, according to Wikipedia, now living a quiet life at the Center for Great Apes in Wachula, Florida, where he is said to “enjoy painting and listening to flute music”).  But it’s horrible grammar.  There’s no way to doesn’t is a form of the verb “is” or means “to be.”  If he isn’t good to you, that’s one thing.  But if he doesn’t?  You should stay away from Michael as well, if he can’t figure out why that sentence is so very wrong.

(On the music front, Vocabulary Nerd admits to a certain admiration for The Osmonds, who managed to fit the word “facsimile” into their ballad “Love Me for a Reason,” though Grammar Guy notes it was followed by a dangling participle.  You learn to take the good with the bad.  Plus they’ve got great teeth.)

Here’s a language thing a little closer to home.  As all of us in CDI know, specificity is our friend.  That being said, coding rules recognize that things in medicine are not always cut and dried, and that there is significant fuzziness in everything we do.  We don’t always know what’s causing a problem, but we can make pretty good guesses.  So the Rules of the Game allow a clinician to use words like probably, likely, and possibly to describe what they think underlies and clinical problem even if they don’t know for sure.

There’s a little bit of hair to be split here, however.  (Not mine, in which case there’s a lot.)  My colleague Dr. Douglas Campbell notes that we really should not use the word “possible.”  His contention is that you should have at least a 51% chance of being right before being certain enough to code a clinical diagnosis as being present.  So if “probably” and “most likely” suggests that level of certainty, words like “possible” that suggests less than a 50% chance of being right shouldn’t be used.  After all, anything is possible.  There’s a zero point zero zero zero zero zero zero zero one chance that both Gal Gadot and Ed MacMahon will appear at my front door tomorrow with a check from Publisher’s Clearinghouse.  (Even less so now that Ed’s dead.)   So how can you code with certainty anything that’s less than halfway likely?  Or, as Dr. Campbell put it:

“See that three-day-old taco sitting on your desk? I’d possibly eat it, but I probably wouldn’t.”

The clinical term that always drove me nuts was “appreciate.”  In medical school we were told that we appreciated a heart murmur or some other physical finding.  But did we really?  According to definition, if you appreciate something you “recognize the full worth of” or “are grateful for” something.  So who really appreciates a murmur?  I have heard a lot of heart murmurs, but I have never appreciated one.  I have never been so moved by the whoosh of some blood fighting its’ way through a narrowed channel, nor by the splash of plasma thudding back into the chamber from whence it came.  I have yet to recognize the full worth of a mid-systolic breeze, to completely and utterly envelop myself in the moment.  I have never called my parents to relate the experience to them, have never pulled a sweetheart aside and, in a tender moment, told her that while I have absorbed the full value of the murmur it’s significance is nothing compared to my love for her.  Nor have I been uniformly grateful for the opportunity to listen to a murmur, not for the career in medicine, not even for the trust of the patient in permitting the intimacy of the physical exam…no, I’m usually just trying to figure out what it is I’m hearing because my cochlea have been poisoned by years of monitors with alarms  and bells and from listening to Diane Rheim on NPR, and I’m also trying to figure how just how close I have to be to hear anything if the patient is hygiene-challenged.  We should not say we appreciate heart murmurs unless we really mean it.  We don’t.  Just stop.

(Two, four, six, eight, what do we appreciate?  Aortic Stenosis!” exclaims the Cardiac Cheerleader, pom-poms flying in the Cath Lab.) 

(Speaking of things that drive me nuts, many of you are probably familiar with voice-activated dictation programs such as DragonSpeak.  One of the quirks of these programs is that every clinician seems to have words they slur or accent or are otherwise incomprehensible to the program.  There are two words of mine that seem to particularly vex the Dragon.  The first is “hospitalist,” which the Dragon keeps thinking is “hospice,” and given that a lot of patients admitted to the hospitalist probably need hospice this may be therapeautic guidance.  The other is cardiovascular, which every computer-aided dictation program I’ve ever used seems to think is “testicular.”  So there’s no telling how many female patients in my career have had testicular exams which revealed a regular rate and rhythm without murmur.  Nuts.)

The glamorous process of CDI chart review has added another term to my List of Infamy.  It’s the word “endorse.”  Have you seen this in your shop?  Apparently the new trend is to say that “the patient endorses shortness of breath and a history of CHF” instead of saying the patient has or said it.  I have no idea where this comes from, because when I look up the definition of “endorse” it goes something like this: 

1.         “To declare one’s public approval or support”, or

2.         To sign a check or bill of exchange to make it payable, or to accept responsibility for paying for it.

So when the patient “endorses” a history of shortness of breath and CHF, we might assume they are showing approval or support.  “I LOVE my CHF!  Best pulmonary edema ever!  I’ve got cardiomegaly!  HUGE cardiomegaly!  Bigger than China!  And my love my BNP…five figures!  My ejection fraction is so bad it’s the best of the worst!  Isn’t my LifeVest great!  Admit me for a little dobutamine and we’ll Make My Heart Great Again!  You should get some CHF too!  And I‘m paying my own bill!”

Come to think of it, that sounds familiar.  Wish I could place it.  Must be somewhere in that chart…