February 18th, 2019

Yes, Many People Are “Pleasant” or “Delightful,” Even “Lovely” — But Should That Be in the Medical Note?

Isn’t she “lovely”? Could be, but keep it out of the note!

When writing medical notes, some clinicians include an appreciation of their patient’s personality and disposition in their opening line (the “Chief Complaint”), or when they’re wrapping up (in the “Assessment and Plan”), or in both locations.

You know — it goes like this:

“CC:  Ms. Smith is a very pleasant 62-year-old woman admitted with …”

or:

“A/P:  To summarize, Mr. Jones is a delightful 89-year-old man presenting with …”

or:

“CC:  This lovely 74-year-old retired school teacher was in her usual state of health until …”

Yikes, not a fan of this practice.

Am I just being curmudgeonly and negative? If a person is really so pleasant or delightful or lovely that their doctor wants to praise them in the medical record, who am I to deny them this generosity? Or deprive their patients of this honor?

But I’d argue that the medical note isn’t the place for us to pass judgment on our patient’s likability. What does this imply about those we don’t call pleasant?

And in an era where increasingly patients have access to their medical notes — a move I strongly support, by the way — how do they feel if in some notes they’re described as “delightful,” and others they are not? What if they’re having a bad day, reducing their loveliness? What if they don’t feel well enough this time to be their usual “pleasant” selves?

Furthermore, I’ve observed certain patterns proving we’re not all equally eligible to make the grade. First, women earn way more “praise” (ahem) than men:

  • “Pleasant”:  60% women
  • “Delightful”:  75% women
  • “Lovely”:  90% women

(Data from a highly scientific review of several thousand medical charts. Really.)

Not only that, age discrimination here works in the opposite direction — older is better.

In fact, every decade beyond age 60 yields a greater likelihood of earning one of these adjectives. Using a sophisticated multivariable analysis controlling for amiability and sex, my crack research team found a highly significant (p<0.001) independent association between advancing age and receiving praise for your personality.

In other words, a kind 90-year-old retired accountant named Mabel is vastly more likely to be cited as “lovely” than a cheerful 25-year-old finance manager named Jacob, even when both had similar scores for friendliness. Is that fair?

But — if you think about it for a moment, doesn’t this “lovely” imply something demeaning and patronizing about the label? Of course it does.

Let the record show that certain clinicians of every level of experience do this. Ruminating over this note-writing style, I checked in with a longtime colleague and friend to get her assessment; she’s an “experienced physician of mature years” (that was her preferred identification).

In a twist, she wrote back the following:

Hi. Generally I agree with you.
… beat
… beat

er, except for this.  Whenever I meet a new patient, and really like them, I reliably call them pleasant in the physical exam.  (Note:  I never ever called anyone delightful or lovely. That seems patronizing.) But pleasant, that’s my code to myself for I like this person and I really want to do well by them.
I maintain that Pleasant is a legitimate part of the objective evaluation:  it means someone is actually able to relate politely to a stranger without getting all tangled up in whatever their stuff is. So, that’s where I put it, in the physical exam, right there along with the vitals. Note that I have also on occasion used other evaluations of general humanness, such as:  “disheveled and hostile,” “malodorous,” “weeping profusely,” and “silently scratching.”  All germane, if you ask me.

I’ll give her credit for putting the “pleasant” description in the physical exam — this is where we put our observations, after all — and leaving out the “delightful” and “lovely” labels.

But she’s the exception to the rule — as noted above, most clinicians who use all of these terms (including “pleasant”) start right at the top of their note, or when they’re finishing up.

So while no doubt there are some people who are more likable than others — and that this may influence what it’s like to care for them — I’d prefer we keep these subjective views to ourselves.

38 Responses to “Yes, Many People Are “Pleasant” or “Delightful,” Even “Lovely” — But Should That Be in the Medical Note?”

  1. Libby Hohmann says:

    I agree and find this patronizing/ooky esp as I get older, though I freely acknowledge that hell will freeze over before I’m called “delightful.” It is relevant to note a patient’s occupation or other context or observation on occasion, in SHx. I have a different speech about FMT for the PhD microbiome scientist than I do for the plumber, though they can be equally interested in the details.

  2. Libby Ernharth says:

    I sometimes bore of our generic ways of describing our patients physical selves. I do agree that I leave codes for myself un the words that I chose for both my team and myself. I have also described screamers, those actively hallucinating in my presence, those who will not make eye contact and others who cannot be bothered to get off of their phone. I leave the judgement to whomever needs make it (maybe the dishelveled person talking to Ralph who is not there might not be capable of caring for their own wound in the home setting.) But i do appreciate that I have used lovely for woman and never men. I have used in the case of a 40 year old female so it doesn’t always reflect age. But your research is spot on. I will adjust!

  3. marvin rabinowitz says:

    This pleasantly delightful and lovely patient is a poor historian and her history has been obtained from the chart…

  4. Matt Leibowitz says:

    I agree wholeheartedly with you Paul. Regarding patients reading these notes, I once heard a cardiologist say that if the patient gets upset that I called him obese, at least he’ll know I think he’s pleasant…

  5. marette reid says:

    using “interactive “ is my go to ( if true)

  6. Andrew says:

    What about “unfortunate?” I find that judgment particularly grating. According to whom?

  7. Sara says:

    Definitely agree with this. I always find it weird when I’m doing chart reviews to see that. I can see noting affect and the like in the appropriate exam section.

    I’m quite overweight and once had an orthopod I saw for a longstanding knee issue refer to me in the letter to my refering doc (which I also got a copy of) as “well nourished” I think that bothered me more than just saying “obese” would have. Of course he also blamed the entirety of my knee pain on my weight despite the fact that I explicitly told him it started before I gained the weight, so there’s that…

  8. George says:

    A commenter says “I maintain that Pleasant is a legitimate part of the objective evaluation: it means someone is actually able to relate politely to a stranger without getting all tangled up in whatever their stuff is”

    But isn’t this something we are supposed to do for all our patients? Not just those who present themselves as “pleasant”.

  9. Marlyn says:

    The problem is also that pleasant, etc. doesn’t say much. “Talkative,” “reticent,” and other such adjectives are much more medically relevant, especially because a change in affect can be a signal of something else important going on. On the other hand, a person developing dementia may go from pleasant to hostile a few visits later.

  10. David Chakoian says:

    A description like “pleasant “ is indeed subjective, but unfortunately it’s my subjective statement, and not the patient’s. (“Hi, doctor, I’m a pleasant person with a pain in my shoulder” doesn’t happen often) and probably shouldn’t be in the Subjective section.

    But in primary care we often are dealing with behavioral health issues, and issues like “pleasant,” “hostile,” “friendly” become germane, and very much should be in the examination.

    A side note, I never like to say someone is malodorous, it seems like too subjective a statement for my exam, so I’ve adopted the phrase “olfactory stigmata of poor hygiene.”

  11. Sonal Patil says:

    I always write “pleasant” because patients read their notes on OpenNotes, and I want them to feel that I enjoyed meeting with them. Also, several friends from non-medical fields have mentioned they appreciate if there is a positive comment on their personality in the physician’s note. So it builds rapport and in some ways may improve patient engagement as patients will like to read notes that call them “pleasant” or “lovely.”

  12. Katy says:

    I think adding descriptors can be humanizing, as long as those descriptors are respectful. It reminds us that we’re taking care of people. And I definitely agree with the above comment about patients reading the note – they should know that I enjoy working with them! I would also note that I include a positive comment about every patient, in every note – usually in the assessment section. I work with adolescents and strengths and resilience building is a huge part of the job. If I think they’re insightful, or kind, or resourceful, why shouldn’t I write it in the assessment?

    • Gerard Coste says:

      Paul, you are a pleasant enough dog loving chap, and you have a knack for opening up a can of unpleasant things. As more physicians are using templates and our clinical notes are becoming more sterile, void of any authentic descriptors, I enjoy reading a colleague’s note when they are able to bring the patient to life (literally and figuratively). I agree that these descriptors do not belong in the HPI.

  13. Robert Mauro says:

    I encourage your long-time colleague and friend to rethink her encoding of patient notes to keep track of those patients whom she likes and for whom she wants to do really well. I recognize that we are all susceptible to this bias. After all, we are human. But I think it is misguided to facilitate a bias that we should strive to avoid. We are charged with really wanting to do well for every patient. It is our calling.

  14. Michael Katzman says:

    Wow, this item has opened up a floodgate of thoughts for me (5 actually):
    (1) Stating that a patient is pleasant at the opening of a history is one of my pet peeves (a list that admittedly is growing over the years). In fact, I have a PowerPoint slide for trainees that states: ” ‘This 84-year-old pleasant man …’ … Pleasant, really, even though the rest of that sentence says he has severe back pain, dyspnea, and intractable vomiting?” I then point out that “pleasant” can be an appropriate observation in the first line of a physical exam (as would “cooperative,” “sleepy,” etc.), but it is problematic when used as an opening descriptor in the HPI because, as was mentioned, what about a patient for whom that descriptor is not used? I then point out that one reason Pete Rose is not in the Baseball Hall of Fame was that his betting — even on his own team — could raise concerns for a game in which he did not bet on his own team. Sorry if not everyone follows this explanation, but the point remains that “pleasant” or similar words do not seem right for an opening descriptor in the HPI, though I am persuadable that it could be acceptable at the beginning of an assessment or summary.
    (2) And while we are at it, the next bullet on my slide says: ” ‘The patient endorses vomiting after eating …’ … Really, he thinks we should try it?” This strange use of “endorse” has spread like a virus through our charts, and many of my colleagues are also bemused (or at least amused) by it. And yes, I understand that the writer is stating that they had to ask whether the patient had vomited, but then what explains this recent use that I encountered: “The patient endorses frustration with the number of providers involved in his care” — did that resident really ask the patient: “So sir, are you frustrated with the number of providers involved in your care?”
    (3) As for the use of “unfortunate” as a descriptor, I was taught in medical school that if you wrote that word to describe a patient, then a lawyer in a courtroom was apt to ask you: “So doctor, was the patient unfortunate because you were their doctor?”
    (4) And don’t get me started on the stating of WBC counts and creatinines to the hundredths place rather than to the tenths place, which not only interferes with effective communication but can cause clinicians to reach incorrect conclusions.
    (5) Finally, I would not want any of my relatives to be presented as: “This is our 87-year-old man …” And though I admit that my colleagues and I disagree on this one, and I am certain that the possessive “our” in a verbal presentation is not intended to be disrespectful, it just doesn’t sound (at least to me) quite right.
    Okay, 5 pet peeves after all these years, that’s not really so many, right?

    • Thomas Wildes says:

      Excellent summary and I couldn’t agree more. I don’t think “pleasant, lovely, etc” belong anyplace in the medical record. The physical exam is the place for observations of cooperativeness, cheerfulness, etc. Endorse in my experience is always used incorrectly. Not sure how it could be used appropriately in the medical record. Thanks for initiating the conversation.

  15. Max Voysey says:

    This charming, well presented garralous gentleman presents for his Depo-provera injection for alleged homicidal pedophilia . . . . .

  16. Richard Ganz says:

    I think in many circumstances, “pleasant” is an inaccurate descriptor of someone you don’t want to sue you.

  17. I don’t know; I think I have earned the right to be patronizing when I want to be. Remember, we are the historians, not the pts. Like the report of any historian, the reader needs to understand a little about who we are. I review A LOT of charts and I actually look for those terms, in certain cases, to see if the pt’s demeanor or mood has changed suddenly, gradually or not at all. It also tells me something about the historian. And if each of the doctor’s notes starts off calling the pt pleasant, then I know it means nothing.
    I think worrying about a pt’s feelings is over to the top and very dangerous. First, pts only read their charts, if any. Worrying about one pt finding out another was called pleasant by us is too much.
    Second and more important, if we start changing what we write, because the pt may read our HPI, then it isn’t our HPI anymore. How far does that go? Do we not document a pt’s illicit drug use, number of sex partners in the past 12 months, or history as a commercial sex worker?

  18. Peter Bornstein says:

    If you can’t say something nice . . .

    I admit to using the “pleasant” moniker from time to time, although not universally. On the other hand, I have never used the term “unpleasant”.

    During the history or physical section, I might also use the terms “engaging”, “discursive”, “irritable”, “loquacious” and a few others that slip my mind.

    I don’t see anything wrong with it, although this may reflect the many decades since I graduated medical school.

    I am also reminded of my psychiatric instructors telling me to listen to “my instrument”–ie, the feelings that are elicited during patient interactions. Sociopaths can be especially adept at being “pleasant”.

    Cheers!

  19. Brandon says:

    I always say “pleasant”, unless they’re not. In which case I omit it. This way, I have a warning when I review the last note before walking in to see them.

  20. Timothy Williams says:

    I completely disagree with this author ‘s conclusion. If you note the patient’s demeanor in the “subjective “ portion of the note, then it is entirely appropriate. If they are less than pleasant or delightful, then in the days of litigation and patient access to online records it is wise to generally say nothing. I would love to be able to say they are mean or ill-tempered or unpleasant, but I refrain. Back in the day when medical records actually contained useful information, such subjective comments were useful in a diagnosis of Alzheimer’s or depression for example. We are all aware that mood often has impact on patient’s outcome. I see nothing wrong with noting that a patient is delightful. The author only brings it up because we rarely list negative qualities out of fear of litigation. I would suggest that there are much bigger issues in medicine than this.

  21. Let us not succumb to the #metoo climate. If one wants to document pleasant, agreeable, lovely, etc. I am certainly OK with that documentation. Should we now censor the interpretation of the physician pt interaction?
    There are numerous more issues, insurance, hospital administrators, etc that warrant more of our attention than descriptors of our patients.

  22. Shah Ashok R says:

    I agree that some non psychology and non primary care providers routinely use his/her true(or phony) ?subjective impression about the patients as pleasnt(probably to get high satisfaction score and in turn to gain financial gain and/or to avoid lawsuits).They have not met any unpleasant patient in their careers. Unfortunate similarly has no place in medical notes in my judgement.Most if not all patients who have to see a physician for an ailment are unfortunate(but they gives the means to earn a living.May be a cruel or sarcastic way of looking).
    In conclusion these terms do not add anything to the clinical cardiac evaluation for me and especially when every one is described as pleasant.Probably wastage of resources.

  23. Dick Dundas says:

    The problem with “pleasant” is that the sensitivity and specificity of the term have become so poor that the adjective is meaningless.
    Abundant false positives: the hospitalist calls the patient pleasant, but I know, having dealt with this patient for 20 years, that he is far from it. The hospitalist did not know the pretest probability. This patient could be called “pseudopleasant”.
    Abundant false negatives: the hospitalist does not call the patient pleasant, but the patient is truly pleasant and was just so sick that his pleasantness was not apparent. Once the patient has recovered, his pleasantness becomes
    obvious. This patient could be called “pseudounpleasant”.

    Perhaps we could avoid false positives by changing our dictations to read “At this time, the patient appears to be pleasant”. ( I do not recommend the converse.) But then, pleasantness, like beauty, is in the eye of the beholder. It is quite subjective. I dare say that some physicians would judge every patient to be pleasant , whereas others might never encounter a pleasant patient.
    This pleasantness thing surely deserves further study. A good start might be to develop a pleasantness scale similar to the pain scale. It would be mandated that this scale appear in every patient note and there would be negative consequences for the noncompliant. The physicians could then be categorized on a spectrum from “nearly every patient is very pleasant” to “nearly every patient is not at all pleasant”. The top decile would need a psychiatric consult to be sure that there are no other delusions; the bottom decile would need a consult to look for significant depression. The median deciles would receive a bonus based on the local pay-for-performance regulations. If we can weed out the delusional and the depressed among us, patient safety would be enhanced.
    Have a pleasant day.

    • Deb Murray says:

      Perfect!!! Thank you for making my day. I am old enough to believe that the chart notes are for medical professionals to communicate with each other (or ourselves) and I was taught to “tell the story” in my notes. I miss the old days, time to retire.

  24. Charles Lawson MD says:

    Is this really a concern ? It is short handed for not angry, manipulative , depressed or hostile .

  25. Doug says:

    I asked our nocturnist partly in jest , if all her patients were indeed “pleasant”

    She informed me that in a way it was code.
    If you were “very pleasant” they were nice
    “pleasant”meant average,
    no adjective in front meant they were a real jerk and you needed to be careful.

  26. Alice Kachman MD says:

    I have always been against this type of subjective, useless categorization in medical notes. It is meaningless and potentially harmful. It adds nothing to the evaluation. It begs the question: so, is there someone unpleasant? I have never used this type of silly documentation and proud to say so.

  27. George L Beale MD says:

    You come across as somewhat silly rather than your usual humorous and spot on self. Why is a pleasant accolade patronizing? Why give this a second thought? Also, giving patients access to the Physian’s notes prevents the truth from being entered into the record. It results in the usual EHR blather.

  28. Michael P Dailey MD says:

    I use such terms to remind me later that I thought I was dealing with a normal rational person. I would use irritable to remind me that I thought the patient might be sick but that I could not recognize that yet. I needed a word to remind myself of the quality of the visit to trigger a more detailed recollection.

  29. EasyE says:

    When patients are nice, lovely, or a PITA we document – for future reference.

  30. Lindsay Klimes MD says:

    I had to add my voice to the chorus of agreement with Dr. Sax.

    I share others’ objections to use of the term because the majority of physicians doing so use it indiscriminately, rendering it meaningless. If every patient you see is “pleasant”, then we don’t know who ACTUALLY is, and then I also don’t know what other features in your note are meaningful, true and thoughtful vs. just boilerplate automatic garbage.

    We would all be better off to use more precise descriptors than “pleasant” in the general section of our physical exams, too. Again, “pleasant” has become mostly meaningless. I DO want to know if the patient is (even in the estimation of my colleague) ill-appearing, toxic-appearing, well-appearing, disheveled, guarded, attended by multiple concerned and informed family members, texting on their phone, watching Dr. Phil, etc. – those are reasonably objective statements that actually speak volumes about a patient’s condition in just a few words and avoid appearance of judgement, bias toward age, etc.

  31. Joann Urquhart says:

    I stopped using those terms in my notes as they are patronizing and are usually used for older woman. I do have a mental note when seeing a patient I particularly like which is many if not most of my patients and some whom I am in awe of their dignity in the face of devastating illness.I always feel sad for a patient who is so unpleasant even their doctor doesn’t like them. However, none of these descriptions should be in a note.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

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