It was one of the slower nights in December. The ICU PA and I were making small talk, and he handed me an AI-generated Christmas carol composed for ventilated ICU patients. Skimming through, I found the lines mischievously fascinating, if a little macabre. My musings were quickly interrupted by an inner prompt to complete my notes.
The prompt did not indicate a preference for note writing over Christmas cheer, but rather a muted alert to the lives suspended in the wet ink of my unfinished record. Not to mention the impassive clock ticking away incessantly, largely indifferent to the weight of my notes.
One record has played countless times. It almost feels like it’s on auto-repeat: “If you don’t promptly wrap up your notes and leave the dictation room on time, your colleagues will consider you slow and inefficient.” Track 2: “You really don’t want to hear that mindless refrain, ‘why are you still here?’ all over again.” Hello somebody, does that monologue sound familiar?
Possibly the three biggest joy-killers for medical providers today are the ever-looming task of note completion, non-clinical pressures on patient care decisions, and the well-advised fear of medical litigation. Don’t get me wrong, there are certainly many more sore points that can be catalogued, but these seem to be most pervasive.
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If asked to narrow down, most clinicians would readily admit that note writing is the bane of their professional existence. Long gone are the days when one-liners, rapid bullet points, and hieroglyphical scribbles were considered acceptable documentation.
Jolted out of my reverie, I am aware that the clock is counting down and there are still three more notes to finish. Still, I am convinced that note writing should be a thoughtful, methodical task, one that should not be relegated to the drudgery of “copy and paste” or, if you like, “rinse and repeat.”
Far from being a still photo, the medical note is more like a movie reel, which implicitly demands a certain dynamism simply because the events and drama of each day are unique to it alone. Like the chronicles of a diary, it is a repository of the good, the bad, the ugly, and the sometimes seemingly endless flux around the baseline where nothing else seems to be happening.
Indeed, no two days tell the same story. A patient’s hospital course can look like a montage comprised of losses and wins, pain and relief, fear and hope, predictable decline and miraculous recovery, all sprawled out against a backdrop of competing needs for time. Time leveraged to gain ground against virulent pathology, time spent racing against the clock to perhaps limit length of stay, and yes, the time to complete notes.
The time necessary to cumulatively document the twists and turns of patients’ hospital layover, and sometimes intricate biographical details of their personal lives, can be substantial. A myriad of events transpire or are recounted within the walls of health care settings. These vary in magnitude and significance across the entire spectrum of outcomes, from mundane to magical, depending on which side of the viewing glass you stand.
Wins and losses, celebration and frustration; red herrings, false positives, the patient finally had a BM, the MRI was completed, tumor margins were negative, the mass was benign, A1c is coming down, renal function is turning the corner, a daughter graduated from college, the newest grandchild arrived. Or, on the contrary, an unexpected deterioration occurs, insurance denied the request, an addiction relapse happened, a house fire befalls, an eviction notice was served, the cancer has spread, a dialysis chair was assigned, and the list goes on.
Much of this oral history distills its way into the medical note. Yet in all of this, the medical records remain stoic, taciturn, mysterious, sworn to an oath of perpetual secrecy and never bereft of vacant pages for fresh entries. If the practice of medicine is a rollercoaster of experiences, note writing is its unlikely anticlimax.
Then struts in AI, from outfield to mainstage in a flash, all the while mesmerizing and dazzling, delivering on metrics in uncontestable fashion. On top of its game. A no-brainer. An idea whose time has come. Autonomous. Seductive. Ushered in with welcoming arms into the chambers of our erstwhile conservative conclave.
AI has made its flattering entry, and as its adoption across the health care industry inevitably continues to increase, we are learning more about its promises and pitfalls. One thing seems to be glaringly evident: AI in its current form may not be that emotionally intelligent, and possibly performs worse in recognizing non-verbal communication.
AI misses the unsaid words, furtive glances, furrowed brows, silent tears cascading down a cheek, subtle hand gestures that signify “let’s meet outside the room to discuss the truth about his drinking habit,” the heightened tension in a room that can be cut with the proverbial knife.
Medical AI in its future iterations will be equipped to recognize and analyze verbal patterns, voice strain, body posture, and facial expressions. It is anticipated to have the ability to triage emotional states by granular scrutiny of microfacial elements, and even be able to extend empathy when prompted.
Empathy that resonates deeply would be the hard part. I doubt that AI would ever be able to hold a trembling hand lovingly like one human to another, cry a tear, or give a warm, lingering hug, beating heart to beating heart.
The trick question of one of my favorite attendings, to any group of residents, was, “Who here is your best friend?” It was always a cringe-worthy moment whenever he asked that. The question was a prelude to his oft-repeated homily that “your best friend is the medical note.” He espoused the doctrine that good documentation of a patient’s hospital course under your stewardship was a resolute and trustworthy ally if asked to defend your medical decision making in a court of law. It seems incredulous that AI, the scribe and material witness, nebulous as it is, can engender sufficient confidence in medical providers to be fully relied upon in legal situations.
Yet, even if we think that there is something that just seems contrived, sterile, almost plastic about AI-generated clinical notes, the reality is that they are the future. Our future is AI. AI has sounded the death knell of the medical note as we know it.
I am grudgingly coming to terms with the realization that the inexorable destiny of the medical note lies in AI. The Nunc Dimittis is sung. The cat is out of the bag and playing around. Nonetheless, until then, like a drowning man grasping onto a straw, I will continue to type as furiously as I can.
It is almost morning. I get startled from my forty winks. I had a dream. It was a beautiful sunny day, bright and breezy, and I am walking along a sandy beach with pristine turquoise waters stretching far into the horizon. Lifting upwards into the sky is a diamond-shaped kite, and as it transits away, I can barely make out the letters MN monogrammed on it. The font, vintage and alluring. Emblazoned golden letters from an age gone. I am down to my last note for the shift. So long, medical note.
Appreciation to Rotimi Komolafe, MD, for reading through the draft of this piece.
Ope’ Komolafe is an internist dedicated to delivering compassionate, effective patient care at the bedside and beyond. His interests include critical care, CPR, and improving resuscitation outcomes through evidence-based practice, team training, and quality improvement.
Beyond the walls of the hospital, he is a champion for physician wellness, recognizing that sustainable, healthy clinicians are essential to the delivery of high-quality care. His work integrates clinical excellence with empathy, equity, and a deep respect for the human side of health care. By bridging medicine and health policy, he hopes to contribute to building health care systems that protect both patients and the professionals who serve them.
Komolafe has a deep fascination with medical history and the humanities and is a recipient of several undergraduate awards for excellence in public health. Outside of work, he is typically a homebody and a bibliophile, but he won’t miss an opportunity to escape to an enchanting location.
