מאמרה של פרופסור מאירה וייס: "for doctor's eyes only: medical records in two...

7/30/2019 For Doctor's Eyes Only: Medical Records in Two Israeli Hospitals, Culture, Medicine" :

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MEIRA WEISS

FOR DOCTO RS EYES ONLY: MEDICAL RECORDS

IN TWO ISRAELI HOSPITALS

ABSTRACT. Scientific and craft representations of medical diagnosis can be regarded

as complementary discursive systems used by physicians in order to legitimate and monop-

olize their professional power. This paper examines the medical record as a context for

the interplay of these two discourses. During interviews conducted with 78 Israeli physi-

cians, 94% have refused to give patients access to their medical records. This refusal is

discussed vis-&-vis a reading of the actual contents o f medical records, which are shown to

contain many errors, inconsistencies and ambiguities. The paper concludes by offering an

alternative, anthropological model for medical records as fieldnotes.

INTRODUCTION

Medical knowledge, sociologists have long told us, is a source of profes-

sional legitimacy and power. The medical record, where medical knowl-

edge is traditionally inscribed, kept and reproduced, should therefore be

regarded as one of the principal sources of medical power. This study

focuses on the rhetorical production of medical authority through two com-

plementary discursive systems: medicine as science and as expertise.

The medical record is examined as a context for the interplay between these

two complementary, and sometimes contradictory, discourses of clinical

medicine.The paper is in four parts. First, the sociological literature discussing

the medical record is reviewed. The following ethnography contains two

sections. It opens with a description of doc tors views of the nature and

use of medical records, and their refusal to give patients access to records.

The actual records are then critically read and discussed. Following this

dual ethnography, the polemics of clinical science and clinical sense

within medical practice are introduced as an analytical perspective through

which the medical protection of records can be critically discussed. The

paper concludes by locating the problematics of the medical record within

the context of doctor-patient relationship, malpractice suits, and the recent

interpretive turn in the social sciences.

Culture, Medicine and Psychiatry 21: 283-302, 1997.

1997 Kluwer Academic Publishers. Printed in the Netherlands.


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MEIRA WEISS284

THE MEDICAL RECORD:

A SOCIO-ANTHROPOLOGICAL PERSPECTIVE

A hospital medical record is a co-authored, multi-faceted text. Its basic

form, which has not changed since the days of Hippocrates, contains data

on the course o f the patients illness, arranged chronologically from entry to

discharge. This kernel is also called the chart. The charts serialized entries

are inscribed on a printed form by one or more hands. Also included in the

record is the patients report of the physical experience of illness before

hospitalization. Usually the record contains an itemized list of problems,

following Weeds (1971) problem-centered structuring of the record,

which has been widely adopted. I will return to Weeds problem-oriented

approach in the ethnography. Also enclosed in the record are the results of

physical examinations done at admission and throughout hospitalization,

such as X-rays, bacteriologic and laboratory analyses, various graphs of

vital signs, registers of drugs ordered and discontinued, consultant notes

and so on. The diagnosis and the advice given to the patient generally con-

elude the report (see Reiser 1991 for a review of the historical development

of the medical record).

Sociologists have recently discussed the medical record as one of the

narrative forms of medicine. Learning to do the physicians write-ups

that go into the chart constitutes an important part of the education of

medical students in teaching hospitals. Acquiring write-up competency

is therefore also a formative practice of medical socialization (see B.

Good 1994: 78-81). Write-ups, like case presentations, are a genre of

stories, through which persons are formulated as patients and as medical

problems (B. Good 1994: 79). The record is multi-authored, especially

in the training hospital: Medical students write-ups are read and signed

by an attending physician, and second-year residents brief summaries

are supervised by professors. The chart is therefore also a mirror of the

hierarchy of medical professionalization (Hunter 1991: 8 4-98 ; Poirier and

Brauner 1990). Records have also been discussed in relation to defining

competence within the hospital, through monitoring of records by chief

physicians (M.-J. Good 1995: 40-43). Finally, the influence of malpractice

suits on record-keeping has recently come into focus (Reiser 1991: 984;

Reiser 1993). The fear of malpractice suits and the openness of charts to

review by hospital committees, insurance companies and governmental

agencies, have arguably greatly minimized recorded conflict in medical

records (Hunter 1991: 89; Freidson 1975; Nathanson and Becker 1973).


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285FOR DOCTORS EYES ONLY

THE STUDY

This study is based on one-on-one, open interviews conducted with 78

physicians in two internal medicine wards of two large Israeli university

hospitals during 1988. Interviews with all the physicians associated with

the wards (permanent staff, physicians on rotation, consultants and interns)

were taped in their offices and lasted about an hour. I had 3-4 additional

informal contacts with each of these doctors before and afte r the interview,

the total of these contacts reaching approximately 350. In addition, I read

some 1200 medical records written by these physicians. The study was

conducted by an outside researcher, a sociologist living in a suburb of

Tel-Aviv. Access to records was given to me as part of my work in a

governmental committee on patients rights in Israel.1 In the interview,

each physician was asked whether the patient should be given access

to his/her medical record, and why. From that point on, the respondents

took control of the interview, and I only interrupted with questions of

clarification. It should be noted at the outset that 94% of the physicians

argued that patients should not be given access to their records. In what

follows I describe how this common refusal was accounted for, and later

contrast it with the actual contents of the records, which were found to be

characterized by a rather unintelligible and ambiguous writing.

RECONSTRUCTING THE FIELD (1): PHYSICIANS

Let me first describe the common pattern of the interviews. This pattern

was characteristic of 94% of the interviews, in which physicians expressed

the view that the medical record should be concealed from patients. By and

large, these interviews evolved in three consecutive stages. I term these

stages as the spontaneous, the factual and the reflexive. The spontaneous

stage contained a common assertion regarding the confidentiality of the

medical record. Immediately following my lead question, 73 of the 78interviewed physicians emphatically stated that patients should not be

given access to their medical records. The typical answer was that mak-

ing the record available to the patient and his family will destroy medical

confidentiality . . . everything will come out. When asked to elaborate on

the reasons for the necessity of that medical confidentiality, physicians

provided two kinds of accounts, one pertaining to the institution of medi-

cine and the other to the nature o f patients. The following briefly illustrates

these two categories:

1. The institution of medicine. The record, as a senior physician told

me, belongs to the doctor and to the medical institute. It does not


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belong to the patient. I will not take the patients private diary and

read it. ... In the same manner, the patient should not read the record

I wrote. It is my file, my domain. The patient can ask me what is

the color of my underpants, but he cannot unzip my pants and take a

peek for himself. The underpants story, incidentally, kept repeating

as an allegory of the intimate relation between the physician and his

or her files/records. Physicians insisted that while they were always

willing to explain the bottom line of the diagnosis, the record is still

their property. A major part of these accounts derived its legitimacy

from the acclaimed medical function of the record. Some physicians

said they used it for self-correspondence and as a sort of personal

diary. Others considered it a means of passing on information to

other physicians. Finally, the medical file was also seen to relegate

responsibility for treatment. The doctor who makes the entry is held

medically and legally responsible. The confidentiality of the record

is thus directly concerned with the liability of doctors to malpractice

suits (Reiser 1991, 1993). I will come back later to the issue of medical

malpractice and p atients rights in Israel.

2. The nature of the patient. Common answers in this category argued

that the patient will lose the file, that the patient does not understand

medicine, and that the patient will become nervous, and probably

experience a deep anxiety. These accounts were characterized by

a patronizing tendency caricaturing and degrading the patient. The

Jewish patient is already neurotic as it is, why add to this? was a

comm on reply. The doc tors story about their patient is different from

the patients own account, and physicians are no doubt aware of this

fact. In their remarks, however, physicians rationalized the objective

necessity o f reco rds confidentiality as stemming from the need to

protect the patient from the sense of alienation s/he might inevitably

experience if confronted with it. The records mixture of graphs, test

reports, lists and entries would indeed be, it is safe to assume, cryptic

to most lay persons. And the records exclusive emphasis on physical

phenomena (moreover, pathophysiological phenomena) might well

generate a sense of dehumanization o f the patient as a mere m edical

problem (B. Good 1994: 79). As Hunter (1991: 89) wrote, This isnt

m e, patients looking through their own chart are likely to respond .

However, the tone o f the phy sicians remarks is also very patronizing,

constructing the record within the boundaries of a hierarchical doctor-patient relationship. I will return later to the issue of this relationship

in Israeli medical culture.


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When further pressed as to the reasons for their objections to making

medical records accessible to patients, many o f the doctors conveyed factu-

al information which contrasted with their previous, spontaneous respons-

es. Reconsidering the argum ent of medical confidentiality, they also com-

mented that, in fact, the records were accessible to virtually everyone

but the patient, and any information they contained might well be public

knowledge. As one physician stated, I know that even the cleaning staffcan read the records and spread the information around. Indeed, this is

why - physicians claimed - they tended to write so little in the medical

records o f colleagues.

Similarly, physicians who formerly insisted that patients migh t lose their

records admitted, after further consideration, that the pati en ts chances of

losing the records are no greater than the chances of it getting lost in the

hospital. As for the patients lack of medical knowledge, the fact was

that even nowadays, many of the people permitted to view the records

lack sufficient medical kno wle dge .. . . Moreover, the prospect of stress

and panic exists during doctor s rounds, when the patient can hear the

content of the medical records, and nobody has ever suggested canceling

the rounds.The common medical conviction that the record is a means of com-

municating with other doctors and of identifying the staff responsible for

a given treatment was refuted by physicians. Respondents voiced worries

that patients would discover, during their reading of the medical record,

that each physician recreates the interpretative process involved in diagno-

sis and treatment, and that communication between physicians is virtually

nil. During this stage, some of my respondents (about 30%) conveyed

their actual views on the uses and construction of the record. This group

spoke with frankness about the imperfect nature of the record and how it

originated. This frankness, however, did not stop that group from arguing,

in later stages of the interview, in favor of preventing pa tients access to

the records. One physician said that a lot of what you were hearing (inthese interviews) is a smoke screen erected to protect the imperfect nature

of the record. You see, said another physician, The record is like the

backstage o f medicine. If you let your aud ience see the backstage, you ruin

the show." When asked to elaborate, physicians described what they felt

was imperfect in the record, namely a combination of necessary brevity,

repetition, use of ambiguous, unmedical diagnostic terms, and chart

wars between physician-scribes. Several physicians mentioned that the

fact that concise notes are more highly valued might be interpreted by

external readers as sloppiness and glossing over. I don t write sentences

that are made up of words, told me one physician, Im just scribbling


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MEIRA WEISS288

letters which substitute for medical jargon. Thats probably unintelligi-

ble for patients, but you c ant expect doctors to change because o f that.

Another said, You know the Weeds problem-oriented record: Write a

list of so-and-so medical and social problems characterizing the patient.

Its a guesswork of possible diagnoses and symptom-related information,

really. Well, we sure studied Weeds system at school, but if you look at

actual records .. .these lists are getting more brief each day. You dontput in everything because it takes time and pretty often you wouldnt

want to be judged for it later, and some of the stuff they do put in is

. . . well, characterizing the patient as a nag or a hypochondriac and so

on. It is sure to be considered a lack of medical competence if seen by an

outsider.

The factual stage of the interview was generally followed by a period of

silence. Then, physicians would reintroduce my opening question, under

closer scrutiny: So, if such is the case, why do we object to letting the

patients see their records? While they did not alter their negative response,

they nevertheless qualified their answers, adding more reflections. In doing

so, respondents tended to divide the medical record into several categories

of information: 1. Opinions and subjective impressions concerning thepatients character (e.g., hypochondriac, nag, schizophrenic, hys-

terical). This material was regarded as not medical information per se, as

it was not founded on facts. 2. Hypotheses concerning the diagnosis and

suggestions for treatment, dilemmas, doubts, suspicions, indecisions, and

differences of opinions among doctors. 3. Test results (both physical and

laboratory tests), diagnoses and prognoses.

Physicians appeared to have no objection to a disclosure of the final

diagnosis or case history, except in the case of cancer (for discussions

of cancer disclosure as a mark of the relativity of biomedical cultures,

see Gordon 1990; Good 1988). Rather, physicians objected to the patient

seeing those parts of the medical record that contained opinions about

the patients character, conjectures, dilemmas and doubts. In the wordsof one physician: The patient must not be involved in doubts, question

marks, thoughts, and hypotheses. He or she should only receive conclusive

information. Another physician stated, The patient need not know that

medicine is not mathematics.

Moreover, physicians encouraged the concealing of information where

a question of malpractice could be raised, as the following quotations -

uttered by various physicians, sen ior as well as junio r - illustrate:

- It is more convenient if I keep the records and the whole process is

handled by our legal department.


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- This way they cannot use the information against us, they cannot go

and complain to the senior physician, the director of the hospital, and

most frightening o f all, to the press.

- I d feel uneasy if the patient found out an expensive test was recom-

mended and not carried out.

- Operation reports are the most secret and most fiercely guarded infor-

mation, particularly if there were any deviations [from proper treat-ment] or bungles.

At this point in the interview, many respondents explicitly used the term

power, either spontaneously or in response to a question such as: Why

shouldnt the patient see you in doubt or in error? For instance, respon-

dents made the following comments:

- When the patient reads the record, he will have enormous power,

which may interfere with the doc tors work.

- We have pow er when the patient believes the doctor knows best.

- I know it serves the physicians ego. The patient looks up to him as

though he were God ... but it also benefits the patient.

- The patient perceives me as powerful, omniscient, not given to

doubts.

- The patient expects the doctor to be omnipo tent and omniscien t.

The minority opinion, let us recall, was that of physicians in favor of

exposing medical records. A closer look at the minority opinions of the

five physicians w ho advocated medical record accessibility (all originating

from English-speaking countries) reveals that such doctors attempted to

involve their patients in the process of medical treatment, sharing with

them their fears, uncertainties and personal observations. As the excerpts

below demonstrate, each o f these physicians perceived the medical record

as the patients private property, and believed the medical treatment would

benefit from this open approach.

Senior cardiologist(age 51, male, an American immigrant): Id let the

patient read the record. Why not? In any case I tell them whats written

in there. Even when it is a difficult case, even when I am undecided, or

in doubt, even when I talk to a patient before I have reached a conclusive

diagnosis, I tell him of my deliberations and discuss my suspicions ... I

am a person, just like any other, I have no special status and if the patient

chooses to see me as an omnipotent God, thats his problem. However, I

try to emphasize to my patients that there are no such things as miracles

and hocus-pocus, and when a disease is unbeatable I do no t try to deceive

the patient. I tell him immediately that a treatment has yet to be found. It is


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MEIRA WEISS290

better than giving him false hopes ... I also tell the truth when the patient

has cancer, and write it in the medical record .

In tern (age 40, female, of American origin): Yes, I do allow [the patient] to

read the record. I also tell him/her whatever I write in the record, including

personal comments. If I think he visits the clinic too often I tell him so.

And if I think he is a hypochondriac and theres a mental problem, I tellhim so and recommend the appropriate consultation. I even recommend

allowing the patient to take the medical record home. In this way, he can

bring it with him when he goes to consultations with surgeons or to the

emergency room. If they [the other physicians] add to the record, I can

know what they think, since they don t write letters any wa y.. . .

Ju nior p hysician (age 35, male, a South African immigrant): The entries

in the medical record should include only those things that the patient may

also hear. D ont write what you c ant say to him. Unclear, uncertain details

and expressions such as odd general appearance should also be omitted.

The patients are certainly entitled to read the record, and I let them read

it. The medical record belongs to the patient, and to him alone. It containssecrets, and they are the patien ts. Hence, the record should not be handed

automatically to members of the family. The patient should determine to

whom we may reveal his secrets.

Senior neurologist(age 55, female, a South African immigrant): The

patient has ow nership rights ove r the record and he is certainly entitled to

look at it. Currently, fanatic and misconceived social conventions forbid

that he read the record. However, the patient is in charge of himself and

his own body, and has the right to read any written information pertaining

to him. In my opinion, the patient should know exactly what the medical

staff thinks about him - even if they think he nags, or is a hypochondriac.

I think the patient knows his diagnosis without being told explicitly -he senses it in the behavior of the staff, and through slips of the tongue

of people in the system. Everyone knows whats written in the record

- students, nurses, doctors, physiotherapists. Besides, he can hear it all

during doctors rounds.

It thus becomes apparent that the record, seen as part o f the doctor-patient

relationship, is constructed differently by physicians who have different

backgrounds (see also Lock and G ordon 1988). The Israeli medical system

was founded by European immigrants. Its sense of patronizing elitism is

arguably rooted in the European biomedical culture (Shuval 1992: 271-

273) - a culture based on a distinct hierarchy of power between doctor


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and patient, in which (as remarkably described in Tolstoys Death o f Ivan

Illich) treatment is to be applied without explanation and asking for a

second opinion is regarded as mutiny (Glick 1985). The majority of my

respondents were of European origin.2 Their negative approach to disclo-

sure of records could therefore be connected to the hegem ony o f European

biomedical culture in Israel. The American and South-African physicians,

in contrast, were arguably educated in a different biomedical culture.3

Senior cardiologist (age 53, male, of a South African origin): Unlike

South Africa ... here, in Israel, the physician is not respected. Therefore,

the Israeli physician has developed techniques that place the decision

regarding the patients medical fate solely in his [the doc tors] hands. One

of those techniques is the ownership of the medical record. The Israeli

physician does not share his decisions and deliberations with the patient,

and as a result the patient is left with the feeling that the physician is

omnipotent.... I allow my patients to read the medical record as a part of

my attitude of involving the patient.

RECONSTRUCTING THE FIELD (2): RECORDS

At the hospitals observed, as in other Israeli hospitals, the medical record

was generally written down, after the encounter with the patient, in a loose-

leaf binder which usually contained up to 10 pages (4 on average). Occa-

sionally there was a separate volume of investigation results from previous

admissions. If a new patient arrived on the ward, the folder included an

Emergency Room note (sometimes with the results of the initial diagnos-

tic investigations), or a referral letter. The admitting doctor would usually

wait until a nurse completed the initial admission notes (traditionally a very

brief social, family and dietary history, with routine observations of tem-

perature, blood pressure, pulse and urinalysis). The medical notes consistof two history sheets (virtually blank) and two examination sheets. At the

end of the physical examination sheets, or at the beginning of the progress

sheet, the admitting doctor was expected to write the tentative differential

diagnosis.

Reading the contents of about 1200 medical records in two (and more)

wards of two Israeli university hospitals revealed an intriguing picture.

Entries were far from being accurate and detailed, the identity of the

writer was often missing, the handwriting illegible (although probably

identifiable by the medical and nursing staff), the phrasing largely incom-

prehensible with numerous abbreviations which were often ambiguous. I

consulted some of my more cooperative respondents about the meaning


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MEIRA WEISS292

of other (anonymous) phy sicians record entries; according to my respon-

dents, much of the information contained in these records was confused

and incomprehensible, vital data was sometimes lacking, and there was an

abundance of scientifically unfounded gossip. Furthermore, the contents

of the medical records did not attest to any communication between the

various people entrusted with medical care, or any continuity in treatment

of the patient. Some records presented recommendations for certain tests

which were later ignored without any explanation. In some cases, consul-

tant specialists were consulted by the patient, but their recommendations

were not attached for various reasons - failure to bring the proper bureau-

cratic form, independent consultation or plain negligence. Many medical

files were lost within the system, and the medical record contained almost

no reference to previous records. All this contradicted, of course, the for-

mal guidelines of the Israeli Ministry of Health. The following contains

some typical illustrations of the state of records.

Medical records language is a cryptic code interpreted differently by

different physicians. For example, in several wards I found the charac-

teristic abbreviation C.D. Several physicians told me it stood for Chief

Disease, while others said it was Current Disease. In a parallel manner,there was also the abbreviation C.C.: some doctors said it stood for new

patient (chole chadash, in Hebrew) while others insisted it was a return-

ing patient (chole chozer). Sometimes a distinct technical language would

develop in certain wards. For example, in one of the orthopedic wards the

diagnosis suspicion o f a pathological fracture meant a clear-cut diagno-

sis of cancer. Physicians from other wards, who were not familiar with this

terminology, could not but misinterpret it.

Many records were lacking vital data. In one of the psychiatric wards I

examined, records were usually left blank. Proper entries were registered

in the record only months after the administration of psychological tests

to patients. Many records lacked operation summaries, medical history

or plan of treatment. In addition to the lack of vital data, unimportantinformation seemed to be cropping up in the records. Many records had

an entry regarding the social standing of the patient, for instance whether

he/she holds a prestigious profession. Some records mentioned the patients

economic status. Other contained stigmatic labels such as adopted child,

suspicion of schizophrenia, or simply looks odd.

Records are supposed to document the temporal unfolding of the dis-

ease. Many of them, however, did not provide any help in this direction

because of fragmentation and inconsistency. In several records, there was

an entry made in the evening stating no change while the morning entry

was missing. Many records held an entry mentioning tests that should be


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performed during the day, but lacked any references to the results o f these

tests. When plans of treatment were written down, there were no entries

regarding the actual implementation, its success or failure. Many forms of

laboratory results attached to the record lacked any identifying date.

Interestingly, the quality o f records of chronic, recurrent and old patients

was much poorer. In many of these records, history taking and physical

examination were much shorter. These records contained a relatively smallnumber of referral letters, cross-examinations and second (or third) opin-

ions. Expensive laboratory procedures were usually not implemented, even

when recommended. By contrast, records of hospital personnel also con-

tained relatively little information. In this case it seems that physicians

were careful to write down only the most necessary details because they

knew that the record could be seen by the hospitals staff.

The quality o f the record also depended on the seniority of the physician.

Medical histories, diagnoses and daily reports were found in a detailed and

elaborated manner among young physicians. It is possible to say, with the

risk of over-generalization, that the older the physician, the shorter the

record. This was expected since senior older physicians do not comment

on the patient as a whole. It is also true in most cases that the olderthe physician, the more unintelligible his handwriting. Younger physicians

paid attention to various organs and tissues, while senior physicians focused

on their area of expertise and skipped over other details. Records written

by senior physicians often lacked references to issues such as sensitivity to

medications, family history of various diseases, etc. In addition, younger

physicians usually wrote down multiple diagnoses while senior physicians

contented themselves with a single, main diagnosis. I now turn to interpret

the combined findings of (a) the phys icians demand to keep records away

from patients, and (b) the draft quality of the records, in the light of the

rhetorical self-presentation of clinical medicine.

MEDICAL RECORDS AND THE BACKSTAGE OF MEDICINE

Medical records are the locus of knowledge and authority, two major

issues at the heart of medicine as a social institution. Let me first define

in more detail how the record embodies knowledge and authority, before

comm enting on these issues in the light of the studys findings. Let me begin

with medical knowledge. Does clinical work constitute an exact science?

The answ er offered by both clinicians and sociologists o f medicine is often

a polemical one: Clinical work is both scien ce and art, rational logic

as well as learned intuition.4 While the former expresses adherence

to a logical-rational method, the latter gives prominence to the acquired


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MEIRA WEISS294

diagnostic experience and personal knowledge of the clinician. Studies of

medical practice, particularly o f medical education, regularly describe two

sources of medical knowledge and medical legitimation: clinical science

(or simply the textbook) and clinical expertise (or clinical judgement

or clinical experience). In clinical practice, as many medical students

find out, senior physicians may overrule the textbook on the authority

of their clinical judgment. Students who justify an action by citing the

textbooks are sometimes surprised when the attending physician (clinical

faculty) says, well, Harrison (a famous textbook of internal medicine)

may say that, but in my experience . . . (see Carlton 1978). The record

exemplifies the polemics of clinical science and craft. It is a place were

both meet. Science is evident in the objective, quantitative test results

attached to the record. Craft lurks in the interpretive act leading from

examinations to treatment and diagnosis. The rough, draft character of the

record becom es a literal illustration of the polemics of clinical science and

craft.

Medical knowledge, whether an art or a science, is appropriated by

the doctor as a source of professional power. The phys icians possession

and use of medical knowledge constitute their scientific authority ; physi-cian s power derives from their ability to create objec tive representations

of the patients health or illness (Gordon 1988: 275). It is therefore likely

that while physicians might acknowledge the role of clinical intuition in

private or professional discussions, they would accentuate the significance

of medicine as science in the face of the larger public. The scientification

of medicine, in a similar manner to other modem professions, serves as a

powerful source for public legitimacy, authority and monopolization (see

Bourdieu 1981: 257-292; Aronowitz 1986). A scientific self-presentation

is therefore used by physicians as a gate-keeping strategy in their contacts

with the public, especially with patients. Some physicians have attributed

the general reluctance to reveal the medical record to a fear of a loss in

power over patients (Waitzkin and Stoeckle 1974). The medical recordis considered the unassailable bastion of doctor power. ... In a funda-

mental, sociological (and therefore to most doctors deeply suspect) sense,

records are power (Metcalfe 1986: 577). This logic is again illustrated

by my responde nts insistence on the confidentiality of records, and their

rationalization about the imperfect nature , the backstage of the record.

In that sense, physicians determination to conceal the record from the

patient might be compared to the anthropologists refusal to expose his or

her fieldnotes to the gaze o f the native. I will come back to this comparison

in the following section. Refusal to share records with the public, however,

may well have more reasons, in particular fear of malpractice suits as well


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as a rigid doctor-patient relationships. Let me describe in brief how these

two issues present themselves in Israel.

The two hospitals in which I conducted fieldwork belonged to Kupat

Holim (Israels general public sick fund) which engages physicians and

other staff on a regular salary basis. These salaries, nationally standardized

by the Histadrut (Israels general confederation of Labor), are relatively

average. This situation has resulted in recurrent episodes of strikes bythe medical profession, to which the Israeli public has gradually become

accustomed (see Shuval 1992). The medical profession in Israel, howev-

er, regards itself as elite, and presents the highest criteria for academic

admission. Nevertheless, it is still the most sought-for academic disci-

pline by Israeli undergraduates. The recent wide-spread questioning of

the professional standards of Russian immigrant physicians attests not

only to differences in medical competence, but also to that sense of elitism

rooted in the European medical culture underlying modem Israeli medicine

(Shuval 1992: 271-273). American and European-educated physicians are

arguably at the top of the Israeli medical hierarchy, while East-European

and particularly Russian immigrants have become, to a large extent, their

subordinates. If we were to cons ider Israe ls place within the cross-nationalspectrum of biomedical culture in terms o f medical authority, then it would

seem that it is located nearer to the pole of patient compliance and obe-

dience than to that of patient participation. Authoritarian-style practice is

also the prevalent mode in most Israeli university hospitals where students

spend long periods of training. Israeli biomedical culture would therefore

accentuate the confidentiality of records. As for pa tients rights, the Israeli

situation today is parallel to that of the USA in 1974; to this day, a law

concerning patien ts rights in Israel does not exist, and the existing provi-

sional legislation proposals concerning it are notably limited in their scope

in relation to the American standard (Glick 1985).

That medical records are in fact fieldnotes, rough and sketchy material

disclosing ambiguity and uncertainty, is not new. The large record , wroteReiser (1991: 984),

is filled with undigested details of laboratory, progress, and nursing notes that present a

daunting challenge to clinicians trying to discern trends or gain a comprehensive view of

events. Despite this bulk, significant data are often left out, most notably a well-drawn

narrative account of the illness itself. That narrative part of the record often seems to

remain an aide-memoir for the physician writing it, rather then a clarifying note to others

(for similar descriptions, see Bumum 1989).

The record, of course, is far from being raw data. It is an edited,

orderly patterned re-presentation of the patient as a medical project. B.

Good (1994: 77), observing the socialization of Harvard Medical School


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students, quotes one of them as saying that you distort the real world a

little bit to make it fit that nice pattern. Anderson (1992: 658) describes

the inevitable conditions leading to this situation in the following manner:

With clinical experience, junior doctors were expected gradually to learn how to piece

together the clues observed in an individual patient, and thus to assemble an acceptable

explanation of the case. The clues were not organized according to precise rules; their

very designation as evidence depended on the idiosyncrasies of the patients presentation,and their association into a diagnosis was a result of skilful selection and interpretation.

Diagnosis was supposed to be a perceptual skill: one had to discover for oneself the right

feel of the accomplishment. The traditional record, which by the 60s and the 70s appeared

natural and compelling, represented the traces of this common understanding of diagnosis:

a few salient symptoms and signs, ad hoc reasoning, and tentative schemes of action.

Diagnosis, that weakest link in the therapeutic chain joining patients

and health (Laor and Agassi 1990: 6), could perhaps only be documented

within a half-baked, tentative, sketchy medical record. Performing diag-

nosis meant that,

The physician poses questions and transforms the pa tients responses into general or specific

categories or facts (. . . ) It is this largely unexamined, historicized, interpretive, summariza-

tion process that produces a crisp and factually oriented account of the patients medical

history and physical status. Yet the verbal and nonverbal interaction sequence virtually

always contains elements of confusing, ambiguous, factually misleading or incorrect data

( . . . ) The physicians written medical history is constrained by a limited time frame and

his or her own and the patients selective attention to questions, answers, memory searches,

and problems that emerge unexpectedly over the course of the interview (Cicourel 1986:

96-97).

These accounts portray the inevitability of the imperfect, backstage

nature of the medical record. They can thus explain and strengthen the

studys findings regarding the actual ambiguities of the record. Sharing

such a record is problematic in at least three significant senses: (1) the

dominant scientific model of medicine, (2) the authoritative doctor-patient

relationships in Israeli medical culture, and (3) the growing exposure to

malpractice suits. All those are powerful reasons for keeping the confi-dentiality of records. Their general presence in medicine has probably

made records a lot more confidential.6 Having this in mind I now turn

to discuss, in the concluding part, an alternative model for the medical

record.

EPILOGUE: MEDICAL RECORDS AS FIELDNOTES

This paper has treated the scientific and craft representations of med-

ical diagnosis as complementary discursive systems used by Israeli physi-

cians in order to legitimate and monopolize the ir professional power. While


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craft could be part of the socialization process of medical students, it was

obviously science which predominated in the self-presentation of doctors

before the larger public. In the face of public demand for record accessi-

bility, it was therefore prec isely its craft characteristics that required the

concealing of the record from the public gaze.

The interviews reported here demonstrate the Israeli physicians adher-

ence to the scientific model of medicine. The interview, it should be

noted, is in itself a frame for self-presentation in public. A (usually latent)

postulate of the scientific model o f medicine is that several physicians, giv-

en the same medical history, symptoms and examination results as data,

would arrive at a basically similar diagnosis. In other words, medical diag-

nosis is not contingent upon the physician performing it. It was, however,

these personal contingencies - the inconsistencies and ambiguities of the

clinical craft - which the record could disclose. What the Israeli physicians

arguably refused to reveal was the rough, interpretive process leading from

history-taking and physical examination to diagnosis.

The anthropologists fieldnotes could now be brought up again as a

useful analogy for discussing the medical record. Fieldnotes are anthropol-

ogys records; like medical records, they represent the raw data (whichare not raw in both cases), comprising incomplete and often inconsistent

observations, history-taking, interviewing and diagnoses (see Sanjek

1992). Although anthropology presumably presents itself a-priori as more

of a craft than a science (see Atkinson 1992; Ruby 1982), anthropologists

have been - just like doctors - traditionally reluctant to expose their notes in

the open. Both deny the natives (or patients) access to the notes/records.

Both would prefer their records to be protected from scrutiny. As the recent

(in)famous publication of Malinowskys diary (records) has revealed, both

would probably want their personal opinions regarding the subject of their

writing/diagnosis to remain private. Above all, fieldnotes - like medical

records - are a source of authority. Having fieldnotes is an evidence of

being there. Fieldnotes reflect local knowledge of local cultures. Howmuch these notes are indeed a matter of objective science, or even of par-

ticipant observation, is of course a matter of contention. This brings us

to another parallel between records and notes: the question whether two

anthropologists in the same field at the same time w ould necessarily arrive

at similar ethnographies (diagnoses) is as burning in anthropology as it is

in medicine.7

The authority of the anthropologist stems from his or her claim for

authentic representation (Clifford 1983). One source of this presumed

authenticity is, no doubt, the notes. However, the notes are better left

in the dark, referred to but actually kept away from external scrutiny.


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Their exposure, as has been shown time and again, could well disclose

further issues inherent in the ethnographic practice, such as personal con-

tingencies, cultural translation, gendered identities and (mis)representation

(see Clifford and Marcus 1986; Marcus and Fischer 1986; Caplan 1988;

Kirschner 1987). This recognition has led ethnographers in the direction

of replacing their former ambitions of ethnographic holism (see Thom-

ton 1988) with a more modest, intertextual, and necessarily fragmentaryrhetoric (see Tyler 1987). This (post?)modem ist view would be applicable

to the rhetorics of the medical record as well.

Objections to this analogy would probably state that while anthropolo-

gy is not scientific and objective, medicine is (or at least should be). But is

it? My point in making the analogy to anthropology is that both disciplines

are constrained by an uncertainty principle of multiple interpretations

and a cultural/personal bias. While this predicament has always been part

of the anthropological consciousness, it still seems to be largely repressed

by physicians. Physicians could perhaps make use of Geertzs (1973)

now classic definition of fieldnotes as the product of the anthropologist

choosing anything that strikes his attention and then filling in the details.

It could then be realized that anthropological concepts such as textual-ization, open-endedness, levels of approximation, experience-near

and experience-far are in fact equally pertinent to the making - the

filling in - of a medical record.

ACKNOWLEDGMENTS

I would like to thank Erik Cohen, Judith Shuval, Moshe Tirosh and Daniel

Breslaw for their help.

NOTES

1. In 2.11.87 a Governmental Committee, o f which the author of this paper was a member,

was appointed by the Health Minister in order to prepare a law proposal concerning

patien ts rights in Israel. The findings presented in this paper were also presented

before the committee, and served as the basis for several of its meetings concerning

the confidentiality of the medical record. After working for two years, the committee

submitted its conclusions, which were then rejected by that same Minister, subsequently

leading to the resignation of the committee.

2. Physicians in the majority group (94%) were of different origins - Russia (20%),

Eastern Europe (25%), Western Europe (25%), USA (20%), and South Africa (4%).

Most of these physicians had at least part o f their medical education in their respective

countries of origin. The minority group contained only American and South-African

physicians, who were also mostly educated in their respective countries o f origin. When


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I refer to a physician in parenthesis as an immigrant it means that s/he has moved

to Israel only recently, and therefore that all his or her medical education was done in

his or her country of origin. No further group-specific difference in age or professional

position was observed among respondents.

3. For a similar view of that continental oppositional of biomedical culture in terms of

medical authority, see Gordons (1990) study on Italy as a representative of the pole of

patient compliance and obedience, and M. Goods (1988) as well as Ericksons (1987)

studies on the US as typical of patient participation.

4. The interplay of science and clinical experience in the formation of medical knowledge

has been widely discussed (Gordon 1988). For arguments in favor of a more scientific

approach to diagnostics and patient care, see Armstrong (1977); Cebul and Beck (1985);

Gale and Marsden (1983). The scientific approach to medicine has recently re-surged

in the introduction of computerized diagnosis into hospitals; see Anderson and Jay

(1987); Anderson (1992). The opposite approach states that clinical work cannot be

reduced to a logico-deductive method and that computerized expert systems could

never replace human clinicians. See Dreyfus (1979); Dreyfus and Dreyfus (1986).

5. For classic discussions on the role of the textbook versus clinical experience in

medical education, see Becker et al. (1961); Bosk (1979). The philosopher M. Polanyi

(1962), himself also a physician, has some interesting insights regarding what he terms

as the intrinsic nature of medicine as ineffable knowledge (that is, based on personal

experience).

6. See Medical Records in Patients Hands, editorial, Lancet 2(1985): 872; Whats inMy File? editorial, Lancet 2(1985): 872. These are also discussed in Jacoby (1986).

7. One of the most burning anthropological debates concerning this question has focused

on the contradicting studies of Margaret Mead and Derek Freeman in Samoa. See

Freeman (1983), and Rappaport (1986).

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Address for correspondence: Mira Weiss, Department of Sociology and Anthropology,

Hebrew University of Jerusalem, Israel

מאמרה של פרופסור מאירה וייס: "for doctor's eyes only: medical records in two...

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