Recently in a casual conversation in the ward, a doctor asked me why do MSWs write such lengthy entries which may potentially take up a lot of time on our part, when other members of the team may not have the time to read them.

I was mildly disappointed at his question but he cannot be faulted for adopting that perspective. After all, the healthcare system is colossal and sometimes fragmented, with everyone focusing on their area of speciality or expertise especially at the outpatient setting. In the inpatient setting, the burden falls on the primary team to consolidate everyone’s input, and it is the honest truth that we often find other members of the multidisciplinary team copying the “Assessment” or “Plan” sections of our MSW reports into their own notes or summaries, and glossing over the rest of the entry.

To be fair, such a move is not unreasonable. Since we migrated to electronic medical records around a decade ago, there is an infoxication of data, and the act of mining through every single record does take away precious patient contact time. That being said, understanding the rationale behind the remark did not prevent me from feeling mildly discouraged at a personal level. While I did respond with an explanation for the length and degree of details that I put in my social reports, it was only later on when I had the headspace to deliberate further that I was able to formulate a more coherent reply, which I would now summarise in two main points.

Tool to understanding a patient beyond the illness through a psychosocial lens

First of all, I agree that documentation is only meant as a tool of communication to relay pertinent or relevant information and facilitate a better understanding of the patient by other professionals. Hence as a general rule of thumb, we should avoid spending more time on our documentation than the actual contact or intervention with patients or families, and focus on the salient points to our assessment, clinical decision and plans.

For MSW, the realm of our work focuses on the psychosocial needs of the patient and their families. As we examine the interplay between the biological or medical aspects of the patient’s life with their psychosocial domains, we strive to gain a more holistic picture of the patient as a person in their environment, seeing them beyond their illness as individuals nested in an ecological system and chronosystem.

For instance, think of that elderly patient in your clinic as not merely another elderly with multiple comorbidities of hypertension, hyperlipidemia, mild cognitive impairment, cataract, and osteoarthritis of the knees. Beyond her disease lies a fiercely independent 75-year-old retiree, who has worked as a nurse to raise her children, because her husband passed away from a devastating stroke when the children were young. As a young widow with school-going children in tow, financial resources and time were scarce commodities to be carefully rationed; hence despite being a healthcare professional herself, she did not pay extra attention or take extra care of her health or diet. Her work as an inpatient nurse entailed shift work and heavy duties that involved rendering physical assistance to patients who were dependent, the laborious work accounting for the wear and tear of her body in her late adulthood. After her children grew up and moved out to have their own families, the elderly lady now lives alone in her 3-room flat. She still tries to keep herself socially active in the community by attending the active ageing centre in her neighbourhood and serving in church. She also looks forward to the visits of her children and grandchildren on the weekends, as their presence always brings the bittersweet nostalgia of her past where all her children were still living under the same roof. Her main worry for the future is that her increasing frailty would result in her loss of independence and a care burden for her children, and it is in this light that she has become more health conscious and mindful in adhering to her treatment. Even though her late husband’s death was very sudden previously, she takes the perspective that if the same thing were to happen to her now, she would prefer to go peacefully rather than suffer a life of severe disability with reliance on her children for care. She also adopts this view because of her religious faith and her beliefs in life after death.

The eliciting of her social history and the framing of her perspective help me appreciate the patient as a person nested in a web of relationships, with defining life events that shape her personal values and healthcare-related attitudes or beliefs. When encapsulated in a summary report where I highlight nuances and priorities that are central to a patient, it can help the team reach a common understanding of her personhood, and reduce any frustration of having to repeat her story each time she sees a different healthcare worker. It can guide me, and hopefully the rest of the multidisciplinary team, to deliver a more patient-centred care that is aligned with her values, as shaped by her life experiences and psychosocial considerations.

Means of legitimizing and honouring a patient’s life

Admittedly, most of us go through a huge volume of patient load and we do not always have the luxury of time to delve deeper with every patient. Nonetheless there are patients and patient reports where I would always try to put in much more effort in - and it is particularly so for my end-of-life, dying or terminally ill patients. For this group, I always try to set aside time to do a life review with them or their loved ones, even if it is a brief one. Beyond the usual exploration of the patient’s social background, questions focusing on ‘how was their childhood’, ‘how would they describe their relationship with their parents and siblings when they were growing up’, ‘how did they meet their spouse (if they are married) and how did their love story begin’, ‘how did they end up in their occupation or profession’, to ‘what were some of the greatest challenges or setbacks they faced in adulthood and how did they overcome them’, or ‘what were some of their proudest moments or biggest regrets’ provide a window of opportunity to understanding their identity and personhood. It enables me to appreciate how they have become who they are today - through an insight to their formative years, their familial or social relationships, their major losses, their big wins, their strengths, weaknesses and the values, beliefs and worldviews that they have developed over the course of life.

If the patient had already become mentally incapacitated due to the severity of their condition, then my attention turns to the family members’ relationship and journey with the patient, as well as their memories of the patient. By encouraging the family to share stories and perceptions of the patient, it allows them to elucidate the individuality, character and selfhood of the patient as a person. This often entailed the reminiscence of the patient’s life, a recollection of any key events or milestones, the reflection of the patient’s life values, the validation of their social relationships, the reaffirmation of their strengths and the impact that they have left on people around them, before finally inviting the family to share the intangible aspects of patient (such as values, character traits, beliefs, life lessons etc) that they could take with them even when the patient is no longer physically around.

After the session, I always try to weave their narratives and life stories into my report as an attempt to reconstruct the personhood of the patient for the team’s understanding. This often requires compressing a long session of narration into a succinct brief that is not too burdensome for my fellow colleagues to read. By doing so, I feel that it is my way of legitimizing and honouring the patients’ life, and according to them the basic respect and dignity that every human should have. Sometimes, the act of documenting their stories also functions as a means to intellectualise my own emotions as a healthcare worker, including grieving the death of my patients, especially those whom I have journeyed with for a considerable amount of time.

As both a healthcare professional and a consumer of the public health system myself, the experience of healthcare can be dehumanising at times if we, as the provider, go through patients after patients as mere names, identity numbers or disease labels. By seeing the patient through a psychosocial lens with their own stories to tell, it is my hope that our validation of their identity and personhood can uphold their dignity and honour as an unique individual, and make healthcare a more humanising and empathetic place to work and be cared for.

This piece was published without attribution at the author's request.