To the person reading a note about yourself:
For most of medical history you were not the intended reader of this page. The clinical note grew up as correspondence between professionals: from one physician to the next, to the nurse on the following shift, to the specialist down the corridor, to the writer’s own future self and, more distantly, to whoever paid for the visit and whoever might one day be asked to judge it. Its shorthand was built for speed among people who shared it. You were its subject. Nobody much expected you to read it.
Even before you arrived it was never a simple document. A single note does several jobs at once and none of them purely. It is a memory aid for a clinician who will see a great many other people before he sees you again. It is a message to colleagues who may never meet him. It is evidence that something was done, the justification for a bill, the raw material of quality measures, and, in the worst case, an exhibit. Each of those readers pulls the prose in a different direction. The colleague wants brevity, the auditor completeness, the lawyer caution, and the writer at the end of a long day wants to be finished. The page you are holding is what remains after all those pressures have been balanced, usually in a hurry. I tell you this as a description of the object, so that you know what kind of thing has come into your hands.
It has acquired another reader, and I want to write to you about what that asks of the person on my side of the page.
The idea is older than the law that made it ordinary. In 1973 two authors in the New England Journal of Medicine argued that patients should be given their own records, and for decades the argument remained mostly an argument. Federal privacy law has long given you a right to inspect and copy most of your record, but exercising it meant a request, a wait that could run to a month or more, and sometimes a fee. What changed in April 2021 was the default. The 21st Century Cures Act, signed in December 2016, prohibited “information blocking”, practices likely to interfere with access to electronic health information. The federal rule that put the prohibition into effect, published in 2020, named eight kinds of clinical notes, among them progress notes, consultation notes, discharge summaries and the history and physical examination, and the date by which those provisions applied arrived on April 5, 2021. Since then most people in this country can open their clinicians’ notes in the same portal that shows their results, often within hours of the visit, sometimes before the clinician who wrote the note has looked at it a second time.
The rule has exceptions, and they turned out to be narrower than many clinicians first supposed. A note may be withheld to prevent harm, but that exception is framed around danger to life or physical safety, judged case by case by a licensed professional; the fear that a reader will be upset by what she reads is not, on its own, that kind of danger. Psychotherapy notes kept apart from the general record were left out of the obligation altogether. And a habit of holding everything back until the clinician had seen it first could itself be the kind of interference the law forbade. So the page now travels to you on roughly the schedule it travels to everyone else, and frequently ahead of the conversation that was meant to explain it.
That is the law, sketched only far enough to show the size of the change. The change I care about is smaller and stranger. For anyone who writes notes, it arrives less as an event than as an alteration in the sense of who is present while the writing happens. The words stay where they were. The audience moves.
The Birth of the Reader #
In 1967 Roland Barthes published an essay called “The Death of the Author”, and I have found it more useful in an examination room than he would ever have expected. He began with a sentence from Balzac’s novella Sarrasine, in which a castrato disguised as a woman is described in a string of conventional phrases about feminine fears and whims, and he asked who was speaking. The hero of the story, infatuated? Balzac the man, with his own experience of women? Balzac the author, professing literary ideas about femininity? Universal wisdom? Romantic psychology? We cannot know, Barthes said, and from that impossibility he drew his argument: writing is the place where a single originating voice is lost, and the meaning of a text gathers somewhere else. His formula is the sentence most people remember: “a text’s unity lies not in its origin but in its destination.” The essay ends by announcing the birth of the reader, paid for with the death of the Author.
Put a clinical sentence in Balzac’s place. Patient denies chest pain. Who is speaking? The clinician who asked the question, certainly. But also the template that supplied the phrase, the convention of the genre that has said denies for generations, the billing rules that reward a documented review of systems, and the institutional voice that every note puts on like a white coat. The sentence has many authors and no single origin. Barthes would have recognised it at once.
Here, though, I part company with him, and the parting matters. A literary text can survive the death of its author; it may even flourish. A clinical note cannot. Someone has to answer for it. If you ask what a sentence in your chart means, there must be a living person who can tell you, correct it, or explain why it stands, and the law, the profession and plain decency all place that person on my side of the page. The author of a note is not allowed to die.
But Barthes was right about the destination, and that is what open notes have taught me. Meaning gathers where a sentence lands. A note opened on a workstation between patients and the same note opened at a kitchen table at eleven at night are, in the only sense that matters to their readers, two different texts.
Wolfgang Iser, a German critic and near-contemporary of Barthes, gave this a more patient vocabulary. In The Implied Reader and The Act of Reading he argued that every text presupposes a certain reader, a role written into it before anyone picks it up, and that every text is full of gaps, places where it says less than it means and relies on the reader to supply the rest. Reading, for Iser, is the activity of filling those blanks from one’s own store of knowledge and expectation.
A clinical note is mostly gap. It was written for an implied reader who arrives with a library: who knows that unremarkable is good news, that a report saying something cannot be excluded is often a reflex of caution and not a suspicion, that follow up as needed is not a dismissal. That reader fills the blanks with training. You fill the same blanks with what you have: your memory of the visit, a relative’s story, a search engine, and, at eleven at night, fear. The text has not changed. The gaps have changed their contents.
Timing sharpens this. When a patient’s record arrived months after a visit, in a photocopied bundle, the conversation had come first and the document followed it, already explained. Now the order can be reversed. A note, or the report it refers to, may be waiting in the portal before anyone has telephoned, and the reader meets the clinical sentence without the human sentence that was meant to accompany it. A gap that a phone call would have filled with context is filled, for a night or a weekend, with whatever the reader has. That is not an argument for withholding the page. It is an argument for writing it so that it can stand on its own for a few hours, which most notes were never asked to do.
Three Small Words #
Consider how this works on a very small scale.
C/o, for complains of, is among the oldest abbreviations in medicine. It opens countless notes. You came in to report something that was happening to your body, and the note, by long habit and without the slightest malice, records that you complained. Clinicians do not hear the word; it is furniture. A reader who supposedly complained can hear nothing else, and may come away with the impression of having been a nuisance.
Denies is the more famous case. In clinical usage it means only that the answer was no: denies fever is as neutral as a sentence can be. Read beside your own name, it can sound like an accusation, as though you had been suspected of something and lied about it. She has had no chest pain carries exactly the same clinical information. Only the courtroom has gone.
The third is an abbreviation for shortness of breath whose letters spell, for most other readers of English, an insult. It has been startling people for years, and it is a useful reminder that a code is only efficient among those who hold the key. Outside that circle it costs the reader what it saved the writer, and sometimes more.
I could add a fourth, which works by absence. Notes have long opened by describing a patient as pleasant: a pleasant fifty-eight-year-old woman. It is a compliment, until you notice who does not receive it. When patients read their own notes, and sometimes the notes of a parent or a child, they can now see who was pleasant and who was not, and an omission that once communicated something only to colleagues communicates it to the person omitted.
None of these words is wrong in the sense that a wrong dose is wrong. Shorthand is compression, and medicine could not function without it. The point is narrower. A word chosen for one implied reader now meets another, and the second reader brings to its gaps a different set of contents. Changing denies to has had no costs the writer nothing and loses nothing. Abolishing every abbreviation would make notes longer and no more truthful. The work is to know which words carry a judgment the writer did not intend to make.
A Story About You #
Clinical writing has always been a kind of storytelling, and its most famous practitioner was uneasy about it. In Studies on Hysteria, written with Josef Breuer and published in 1895, Freud paused in his account of the young woman he called Elisabeth von R. to confess that it still struck him as strange that his case histories should read like short stories and, as he feared, lack the seriousness of science. He blamed the nature of the material and not his own preference. But the confession stands. The case history selects, orders, foreshadows and explains. It has a beginning, a complication and a resolution. It is a genre, with the powers and temptations of a genre.
Ten years later Freud published the history of the eighteen-year-old he called Dora, and in the prefatory remarks he did something that now reads like a prophecy. He considered, briefly, that the patient herself might one day read it. He allowed that she might be pained if her case history fell into her hands, and reasoned that she would learn nothing from it she did not already know.
That sentence contains the whole case against open notes, and it is wrong in an instructive way. Dora knew her life. What she did not know, and what any reader of the history would have learned, was how she had been described: what the writer believed and doubted, which of her statements he accepted and which he set aside. In the same history Freud argued that a patient’s first No to an interpretation need not be taken as an impartial judgment, since it might register the force of what was being resisted; in time, he suggested, it might mean the yes he expected. A generation of critics has since read the Dora case against its author, noticing how often the history argues with its own subject, and how little room it leaves for her account to stand beside his.
The clinical denies is a distant and much milder cousin of that habit: a professional grammar in which the patient’s report is always provisional and the clinician’s inference is not. You will not find Freud’s theories in your chart. You may find a faint trace of his grammar.
Joan Didion opened “The White Album” with a sentence that has become a proverb: “We tell ourselves stories in order to live.” She went on to describe the way we impose a narrative line on scattered images in order to bear them, and the period in which that line stopped holding for her. A clinical note imposes a narrative line too. Its form is fixed: a complaint, a history, the findings, an assessment, a plan. The form is useful; it is how a stranger finds the important sentence at three in the morning. But a form also exerts pressure. Whatever sits under the heading Assessment acquires the authority of the heading, and a possibility placed there can read, to a reader who did not hear it spoken, like a verdict.
The protection against this is a discipline older than open notes, which open notes have made harder to neglect. A note should keep four kinds of statement visibly apart: what you reported, what I observed, what I think may be happening, and what has been confirmed. Imagine, as an invented note and not anyone’s record, a few sentences written with that discipline:
She reports three weeks of tiredness, worse in the afternoons, and poor sleep since her work hours changed. She has not noticed any change in weight. Her examination today was normal. I am considering several explanations, including the change in sleep and a low blood count; I do not yet know which, if either, is correct. Blood tests today; we will review them together next week.
And now the compressed version a hurried hand might produce: Fatigue, likely sleep-related. Labs ordered. The second is not false. But a reader of the second cannot tell that likely was a guess, cannot tell that the guess had a rival, and cannot tell what would change it. The first lets two readers hold the same uncertainty. It is also, I think, better medicine, because the next clinician needs to know exactly the same things.
ਲਿਖਤ, or Being Written #
Punjabi has a word for a written thing, ਲਿਖਤ (likhat), and a pairing, ਲਿਖਤ-ਪੜ੍ਹਤ (likhat-parhat), writing-and-reading, for the paperwork that makes an agreement binding: when someone says a matter should be settled in likhat-parhat, they mean that a spoken promise is no longer enough. Beside it sits ਲੇਖ (lekh), a composition, which in an old idiom is also what is written on the forehead, ਮੱਥੇ ਦੇ ਲੇਖ, the fate one carries. I do not want to make too much of a coincidence of vocabulary. But the language preserves an intuition that I think many people share, in Punjab and elsewhere: that to be written about is to be fixed in some way, and that whoever holds the pen holds a quiet power over whoever is described. The land record that outlives the spoken claim, the police register, the school report, the certificate: in a world of such documents, the written version of a person tends to win.
There is also an older and more private feeling, which is the shame of being described at all. A phrase many Punjabi households know, ਲੋਕ ਕੀ ਕਹਿਣਗੇ, what will people say, names the fear of an account of oneself circulating where one cannot answer it. Sometimes the phrase is a joke; often it is not. The clinical note was, for most of its history, exactly such an account: a description of you, in a register you might not recognise, read by people you would never meet. Open notes have done something double-edged to that feeling. They have brought the description into the light, where it can be answered. They have also made sure you will hear it.
Virginia Woolf described exactly what such descriptions miss. In “Mr. Bennett and Mrs. Brown”, the 1924 essay in which she announced that on or about December 1910 human character changed, she imagined an elderly woman sitting in the corner of a railway carriage and asked how the novelists of the previous generation would have rendered her. They would have described, with enormous diligence, the factories visible from the window, the houses and the rents, even the upholstery of the carriage, and never looked at her. The clinical note is, by temperament, an Edwardian novel. It records the vital signs, the medication list, the results and the codes, the upholstery of a life, with great care, and has very little room for the woman in the corner. That is partly as it should be; a note is not a portrait, and it would be presumptuous to pretend otherwise. But it means that the person reading her own note is often looking for herself in a document mostly about the furniture.
Woolf’s date can be borrowed. On or about April 2021, the reader of the clinical note changed. And that reader is not always reading in the language the note was written in. Across California, notes written in English are read in households whose first language is Spanish, Punjabi, Hmong or something else again. Punjabi was my own first language, and I have some sense of how much more a page asks of anyone when the subject is serious and the language is borrowed. In many such households the reading is done aloud, by whoever reads English best, often someone younger, translating as they go. Villages once depended on the one person in the lane who could read a letter aloud, and the private became semi-public by necessity. The note about a father’s drinking or a mother’s weight may now be read to them by a grandchild. A note is better for being written with that voice in mind as well.
A Sentence That Needs Repair #
Some sentences are not merely unkind but inaccurate, and here the open note does its most important work.
Consider an invented sentence: Patient refuses treatment. It may be accurate in a narrow sense. A treatment was offered; the person did not accept it. But the sentence closes the door just where the next reader most needs it open. Was the concern cost? A previous experience? A side effect that would make a working day impossible? Did the person understand the recommendation and choose differently, or leave without understanding what was being offered? None of those answers should be supplied by a generous imagination. They have to be asked for, and if they were not established, the note should leave that uncertainty visible.
Now suppose, still hypothetically, that the woman described reads the sentence that evening and remembers the conversation differently. She did not refuse. She asked for time to think, because the treatment might affect her work, and she wanted to talk it over at home. Both she and the clinician may be entirely sincere; the gap lies in what the conversation actually established. Refuses closes a question. We discussed the recommendation; she would like time to consider its possible effect on her work and will contact us after talking it over at home leaves the question open, says whose decision it is, and says when it falls due. The added words change what the next clinician knows. They also leave the patient recognisable to herself.
What should happen when she says so? It helps to separate three things that are often run together. The first is correction: the note contains a plain error, the wrong medication, the wrong side of the body, a history that belongs to someone else, and the clinician, once shown, agrees. The second is disagreement: the facts are not in dispute, but their meaning is; the clinician still believes the assessment, and the patient does not. The third is formal amendment, a process with legal standing.
Federal privacy law gives you a right to ask that information in your record be amended. In outline, the provider must act on the request within sixty days, with one possible extension; it may decline if it judges the record accurate and complete, but it must explain why; and if it declines, you may submit a statement of disagreement, which is then attached to the disputed information and travels with it, sometimes with a rebuttal from the provider. States add their own rules, and institutions their own procedures, so I will not pretend that one process fits every setting. What strikes me about the federal outline is its spirit. It does not allow the record to be quietly rewritten. Clinical records are not erased; corrections are added, dated and attributed, so that the reader can see both what was written and what was later known. And where two accounts cannot be reconciled, it lets both stand on the page.
Errors of the first kind are not rare. In a survey of nearly twenty-three thousand note readers, reported by Sigall Bell and colleagues in JAMA Network Open in 2020, about one in five said they had found a mistake in a note, and roughly four in ten of those considered it serious; the errors judged most serious most often concerned diagnoses, medical history, and medications or allergies. A survey cannot sort the true errors from the differences of understanding. I would want to hear about both. An error that has become visible is safer than one that has not, and a disagreement that is written down is more honest than one that has been settled by the person who held the pen.
Words That Travel #
A sentence that is not repaired does not stay where it was written. Records are built to carry information forward, and a phrase entered once can be copied into the next note, summarised into a problem list, quoted in a referral and repeated by a stranger who has never met you. Another essay in this series follows one error as it multiplies; what interests me here is the reader who can see it happen.
Imagine, as an illustration, a phrase like poor historian, which medicine has used for generations for a patient whose account was hard to follow. Very often the difficulty belonged to the questions, or to a language the visit did not share, or to the hurry of the day. Written once, on a difficult afternoon, it may reappear years later in a note by someone who has no idea where it came from, and by then it has the authority of repetition. It reads like a settled fact about a person, when it was a passing observation about one conversation. The history was difficult to obtain today records the same thing without filing it under your name.
Clinicians have a method for this, when they have time to use it. You trace a sentence back to its first appearance and ask who observed what, when, and on what evidence. The open note adds a reader uniquely placed to help. You often know, as no one else in the record can, that a sentence is old: that the medicine was stopped two years ago, that the surgery was on the other knee, that the description of your drinking belongs to a period of your life that ended. You are the only reader of your chart who was present at every visit. That makes you, among other things, its most experienced proofreader.
Candor Without Cruelty #
A colleague might answer that open notes make for timid ones. If every sentence must now be written for every possible reader, notes will become defensive. Clinicians will soften what they write, leave out a concern about alcohol or mood or a bruise that did not fit the story, and fill the space with reassurance. The note will grow longer and less useful, and the patient will be worse served, because the next clinician will not learn what the last one feared. A note is a working instrument, not a greeting card, and a document written to avoid offending its subject may end by failing to protect him.
I think this objection is right about the danger and wrong about the remedy. The danger is real. In the original open-notes trial, a minority of physicians, between three and thirty-six percent depending on the site, reported changing the content of what they wrote, and I would want to know far more about those changes before calling them all improvements. Kindness that deletes evidence is not kindness. If I am worried, the note should say so; if I am uncertain, it should say that too, along with what we mean to do about it.
But the alternative to cruelty is not vagueness. It is specificity. Compare alcoholic with drinks about six beers most evenings, by his account, and would like to cut down. The second is more useful to the next clinician, because it says how much, how often, on whose report and with what wish, and it is less wounding to the reader, because it describes something he does and not something he is. Noncompliant tells a colleague almost nothing; has not taken the tablet since March because it made him dizzy tells him what to do next. Labels are compressions of judgment. Observations can be checked.
The case for this kind of language does not rest only on the feelings of the person described. In 2021 Leonor Fernández and colleagues asked patients whether anything in their notes had made them feel judged or offended. About one in ten said yes, and their explanations gathered around errors and surprises, around labels, with words about weight prominent among them, and around a sense of having been disrespected or misrepresented. One in ten is a minority. It is also a very large number of people reading something about themselves that stung. Separately, a 2018 study by Anna Goddu and colleagues gave medical trainees one of two versions of the same chart note about a hypothetical patient with sickle cell disease, one written in stigmatising language and one neutral; those who read the stigmatising version held more negative attitudes toward the patient and, in their stated plans, managed the patient’s pain less aggressively. That was a study of a vignette, not of real care, and it should not be stretched into a claim about every phrase in every chart. But it suggests that words in a note do not merely describe a patient to the next clinician. They prepare the next clinician to see him.
So the discipline that protects you also protects your care. Write what was observed, and say who observed it. Keep inference separate from report. Prefer the measurable to the moral. Say the difficult thing plainly when it matters, and leave out the adjective that adds only a mood. None of this makes a note longer by much. It makes it harder to write quickly, which is a different cost, and one the writer should pay.
What the First Readers Said #
It is worth returning to where the evidence began, because the earliest results are often quoted and seldom read closely. In a study published in the Annals of Internal Medicine in 2012, Tom Delbanco and his colleagues invited the patients of 105 primary care physicians to read their visit notes for a year. The physicians practised at three very different places: an urban academic medical centre in Boston, a largely rural network in Pennsylvania, and an urban safety-net hospital in Seattle. Of 13,564 patients with at least one note available, 5,391 who had opened a note returned surveys at the end. Between 77 and 87 percent of those respondents, depending on the site, said that reading their notes made them feel more in control of their care; between 60 and 78 percent of those taking medications reported taking them more as prescribed; only 1 to 8 percent reported worry, confusion or offense. Ninety-nine percent wanted the arrangement to continue. When the year ended, no physician chose to stop.
The fears beforehand had been considerable. Doctors had expected floods of questions and frightened patients. In the event, few reported longer visits or much extra time spent answering questions, though as many as a fifth said they took more time writing.
I find the result quietly moving, and I also want to read it as carefully as I would ask anyone to read a note. These were reports, not measurements: a patient’s sense that she took her medicine more faithfully is not the same as evidence that she did. The people who answered the survey were those who had opened a note, and those who open notes and answer surveys are not everyone. Missing, almost by design, are many of the readers this letter worries about most: people without easy access to a portal, people for whom English is a second or third language, people with limited literacy, people who opened a note, were hurt by it, and did not want to say so to the institution that wrote it. The later surveys I have mentioned were large and useful, and they too were answered by people who chose to answer. Early enthusiasm is evidence. It is not the whole of the evidence.
One figure from the original study stays with me more than the rest. About three in five patients said they should be able to add comments to their doctors’ notes. The reader, invited in, wanted at once to become a writer. That seems to me exactly right, and it is where the invitation has to find its boundary.
An Invitation, With a Boundary #
The boundary first, because it is easily mistaken for a wall. Your note remains a clinician’s professional account of a visit, and it is not your autobiography; you cannot edit it into the story you would have told. A note will never be a full account of being ill, or of looking after someone who is. It is too brief and too professional for that, and it should not pretend otherwise. It is not a good channel for urgent news, in either direction, and it cannot carry the tone of a conversation: the pause before a difficult sentence, the hand on the arm, the joke that made the bad news bearable. If you read a note and find the conversation missing, that is because notes are not conversations.
Within that boundary, the page is open, and you may bring it back. Some questions are worth bringing. Which statements here are what I told you, and which are what you concluded? Is this assessment a decision or a possibility? What does this abbreviation mean, and is it alarming or routine? Is there anything in this account that you would describe differently, and is it a matter of fact or of interpretation? If it is a matter of fact, ask how corrections are recorded. If it is interpretation, ask whether your view can be written down beside mine. None of these questions is an intrusion. Each of them makes the next reader’s work easier, and the next reader may be you.
As for my side of the page, the change has added a question to the old one every note-writer asks. Beside what will the next clinician need to know? now sits would the person described here recognise it? The two questions are less opposed than they first appear. A note that you would recognise is usually a note that a stranger can trust, because recognition depends on the same things trust does: that reported speech is marked as reported, that observation is separated from inference, that uncertainty is visible and that judgments arrive with their reasons.
Barthes thought the reader could be born only if the author died. In a clinical note, I would rather we both stayed alive: the writer answerable for every sentence, the reader free to bring any of them back. The meaning of the page still gathers at its destination, and its destination now includes you. It always did, in a sense. The note was about you from the beginning. It has simply taken medicine a long time to notice that the person being described was also, all along, a person who could read.
Yours, from the other side of the page
Evidence and Editorial Note #
Documented findings. The essay relies on the author’s public biography: a family physician practising in California since 2010, whose first language is Punjabi and who lives in Fresno. The 21st Century Cures Act (signed December 2016) and its information-blocking provisions; the Office of the National Coordinator for Health Information Technology’s 2020 final rule implementing them, including the eight types of clinical notes, the April 5, 2021 applicability date, the exception for preventing harm framed around danger to life or physical safety, the exclusion of psychotherapy notes, and the treatment of routine release delays as potential information blocking: standard regulatory reference knowledge, described in general terms. The HIPAA Privacy Rule’s rights of access (45 CFR 164.524) and of amendment (45 CFR 164.526), including the sixty-day period with one extension, written denial and the statement of disagreement: standard regulatory reference knowledge; the essay offers no legal advice. The 1973 proposal to give patients their records: Shenkin and Warner, New England Journal of Medicine, 1973, as commonly cited in open-notes literature. The OpenNotes study (105 primary care physicians; 13,564 patients with notes available; 5,391 survey respondents who opened notes; 77 to 87 percent feeling more in control; 60 to 78 percent of those on medications reporting better adherence; 1 to 8 percent reporting worry, confusion or offense; 99 percent wanting continuation; no physician stopping; up to 21 percent of physicians taking more time writing; 3 to 36 percent changing documentation content; three in five patients wanting to add comments): Delbanco and colleagues, Annals of Internal Medicine, 2012, as reported by ScienceDaily (linked). About 21 percent of 22,889 note readers perceiving a mistake, 42 percent of them judging it serious: Bell and colleagues, JAMA Network Open, 2020, as summarised by AHRQ PSNet (linked). About 10.5 percent of note readers feeling judged or offended, with themes of errors, labels including weight-related terms, and disrespect: Fernández and colleagues, Journal of General Internal Medicine, 2021 (linked). The randomised vignette study of stigmatising language and trainees’ attitudes and pain-management choices: Goddu and colleagues, Journal of General Internal Medicine, 2018, from the published study’s reported design and findings. Literary sources: Roland Barthes, “The Death of the Author” (1967), its Sarrasine opening and its conclusion, quoted in Stephen Heath’s English translation; Wolfgang Iser, The Implied Reader (1972; English 1974) and The Act of Reading, on the implied reader and textual gaps; Sigmund Freud and Josef Breuer, Studies on Hysteria (1895), Freud’s remark in the case of Elisabeth von R.; Freud, “Fragment of an Analysis of a Case of Hysteria” (1905), the prefatory remarks and the discussion of a patient’s “No”, paraphrased; Joan Didion, “The White Album” (1979), one short quotation; Virginia Woolf, “Mr. Bennett and Mrs. Brown” (1924). Punjabi words ਲਿਖਤ, ਲਿਖਤ-ਪੜ੍ਹਤ, ਲੇਖ and ਲੋਕ ਕੀ ਕਹਿਣਗੇ are given with their ordinary meanings. Vendor representations. None; no portal, product or company is named.
Recollection and tradition. No specific remembered note, patient, visit or moment of change in the author’s writing is described. The note sentences (“denies chest pain”, the tiredness note, “refuses treatment”, “poor historian”, the drinking and medication examples) and the woman who asked for time are invented language examples and hypothetical illustrations; they do not describe a real patient or record. The remarks on reading in a second language and on reading aloud in households and villages are general observations, not recollections. Punjabi usage is described as usage, not as a claim about what all Punjabis feel.
Analysis and forecast. The letter form, the readings of Barthes, Iser, Freud, Didion and Woolf as they bear on clinical notes, the four kinds of statement, the distinction among correction, disagreement and amendment, and the author’s preferences about wording and uncertainty are personal interpretation as of November 6, 2026. Independence. This essay is not sponsored by any institution, company, health system or technology developer. It is personal reflection, not medical advice; readers seeking care should contact their own physician’s office.
About the Author #
Kanwar Partap Singh Gill, MD, traces his family roots to Khadur Sahib in Punjab’s Majha region and grew up in Amritsar. He attended Spring Dale School and completed pre-medical studies at Khalsa College in 1994–1996. He earned his MBBS from Sri Guru Ram Das Institute of Medical Sciences and Research in Amritsar in 2002.
He completed PGY-1 at the University of Arkansas for Medical Sciences in Little Rock in 2007–2008, and PGY-2 and PGY-3 with UCSF Fresno at Community Regional Medical Center from 2008 through 2010. He has practiced medicine in California since 2010.
His career has crossed four distinct information eras: predominantly paper-based medicine, early and fragmented electronic records, the integrated-EHR era, and the emerging age of generative and agentic artificial intelligence.