Max Perry reflects on the development of the modern medical record
I. The Medical Record as Technology
I can tell you a lot about medical records. About the strange things found inside them (an eye patch with a ‘thank you’ note written on it is my favourite); about techniques to find operation notes in them; about how databases of a Patient Administration System work; about security requirements for electronic medical record infrastructure; about the complex array of retention rules that require records to be kept for varying lengths of time depending on whether a patient has a diagnosis of Creutzfeldt-Jakob Disease or is involved in a research trial.
I can tell you a lot about medical records. Yet none of this really tells you what the medical record is. Medical records are physical things, piled onto shelves in hospital archives. Even when digitised, they are material things occupying space on LCD screens and in physical building as wires, circuit boards, and complex cooling systems. I can point to these things, tell you ‘that’s a medical record’, but it isn’t all they are. They are retention rules, firewalls, and eyepatches as much as they are paper and sparks and wires and code. Medical records are a way of doing things, a way of recording, a system for knowing: they are a technology.
One truth about technology: they are easier to explain if you don’t know very much about them. Sociologists of science and technology Trevor Pinch and Wiebe Bijker are, for example, poor choices for a pithy explanation of technology like a bicycle. In a 1984 essay, they use 34 pages, including 7 diagrams to explain what a bicycle is (Pinch and Bijker, 1984). They describe arguments about wheel sizes, they show how bicycle racing became popular and they show how, despite almost everyone agreeing air-tires were a bad idea, because they proved to be faster than alternatives, they became fundamental.
We can describe what a bicycle is without knowledge of such things, but, as Pinch and Bijker show, if you want to understand the bicycle as a technology, one needs to understand that it was constructed through negotiations and problems and solutions. That steel and rubber and air are not the limit of the bicycle, the bicycle is an artefact of a social history. To understand the air-tire on a bicycle we need to understand the desire for speed, as much as the marriage of rubber and air.
II. Recording the Medical Profession
In a 1978 lecture, French philosopher Georges Canguilhem made a vital observation about the practice of modern medicine. Canguilhem explained that between the patient and the doctor there existed a tension:
[We] can say that for the sick man, healing is what medicine owes him, while for most doctors, even today, what medicine owes the patient is the best-studied, best-tested, and most-used treatment currently available. (Canguilhem,  2012, p. 54)
Professional medicine, in pursuit of healing, must organise its agents (doctors, nurses, radiologists, etc.) and must control and limit what they can legitimately do in the pursuit of healing. Thus, the development of a healthcare system births the imperative for new systems of control over healthcare workers. Such systems delimit behaviour and create systems of recognised best-practice.
In the same way, Anthropologist Annmarie Mol, in her study of Atherosclerosis, demonstrates how it is the practice of medicine that gives meaning to the disease: not the doctor, or the patient, but the practices of the profession. A doctor can make a diagnosis, only if they have followed best practice: submitted a patient to the appropriate tests, asked the appropriate questions and consulted the appropriate oracles. To be able to give legitimate meaning to disease, the profession requires a practical and material chain of associations (Latour, 1991): a technological infrastructure.
Thus, at the birth of professionalised medicine, a new armoury of technological mechanisms had to be invented. Consider this passage from the very first issue of the British Medical Journal in 1840 (at the time called the Provincial Medical and Surgical Journal) calling for a new medicine to be practiced:
We trust that we do not ask too much from those who are ever on the alert to benefit suffering humanity, when we solicit from each the contribution of his mite, to increase the mass of general information, according to the measure of his ability, his opportunity, and his time; and we are assured, that we shall not ask in vain from an enlightened and intellectual profession, capable of estimating the advantages to be reaped from the combination of efforts towards one great end. That end is the general benefit of the community, as well in the advancement of our science, and the cultivation and improvement of our practical resources, as in the securing the efficient distribution of these improvements to every class of the population, by the due regulation of the polity of time profession in all its branches. (Provincial Medical and Surgical Journal, 1840, pp. 2-3)
These new technologies were required to bring doctors into a system of healing, to make them accountable. Not to the patient, but to the profession. In medical malpractice, the profession must define and limit the practices that are permissible and impermissible. For example, cutting in surgery, and exposure to x-ray radiation, when used according to the profession are designated as healing treatments, not violent assaults. ‘Invented’ in the 19th century, the medical record was one of these technologies.
III. Making Visible Patient Histories
The medical record is not often considered to be a thing that was invented. It is more often considered to be a thing that evolved alongside the development of medicine.
In 1943, Dorothy Kurtz published The Unit Medical Record. Her book represents the earliest fully formed articulation of the medical record, as it appears in hospitals today. The Unit Medical Record was a system of medical record keeping that organised the papers and materials around the central ‘unit’ of the patient. Thus, it was not until the middle of the 20th century, that anything resembling a ‘patient’s record’ could be said to exist.
In the opening chapter Kurtz explains that in 1913, when the American College of Surgeons was created, it became clear that to affect improvements in healthcare a system for the recording of medicine was required. The college of surgeons, wanted to audit the performance of the surgeons in the hospitals, and to do so, they needed to produce data regarding the surgical interventions undertaken, and the results of said interventions. This desire drove the development of record keeping systems, systems that would allow hospitals to produce such data as and when required.
As Kurtz herself notes in the opening chapter of The Unit Medical Record:
The real contribution of all these organizations toward improving medical records has not been in developing a system [of medical recording], but in promoting approved methods among the more backward institutions. (Kurtz, 1943, p. 7)
The Unit Record presented a sophisticated and systematic solution to a problem, by bringing together the records of each patient, in a single bound volume, surgical reviews could audit what had happened to the patient, before and after the surgery as well as taking note of comorbidities, previous interventions and other extraneous details.
However, reviews of Kurtz’s book from the time, note the logistical difficulties of adopting Unit Medical Records (British Medical Journal, 1944). To organise records in this way, runners would be needed, that could move medical records around the hospital, taking them to the clinics or wards they were needed on, and then taking them back to central libraries. There would also be need of an overarching indexing system, one that would also allow for the identification of cases by diagnosis or treatment type. If all surgical records were kept in the operating theatre, they could still be audited. What is more, you would not need to go through the difficult process of identifying exactly which patients’ surgery had been performed on over the last year.
Even before Kurtz had suggested this new complicated system of record keeping, there was resistance to the very idea of a system of record keeping at all. In the below extract, from a 1922 edition of the BMJ, a doctor complains about the utility of such records:
[A] record of the ailments of, or of the medicines prescribed for, patients be of the slightest statistical, pathological, or therapeutical value in the vast majority of cases. In cases of importance, as already indicated, the practitioner will keep notes in his own interest, as well as that of his patient. (The British Medical Journal, 1922, p. 11)
The argument was that record keeping kept doctors away from the patient, and produced useless, unparsable data anyway. Thus, how did Kurtz’ complicated system, that required libraries and clerks to be built and employed, became popular? The answer is that Kutz’s system married the desires of the profession, with the desires of the doctor, it made medical records an object of interest to the doctor. On the opening page, Kurtz wrote the following:
That [the unit medical record] was developed by doctors themselves to fill a definite need and that it has since come to be so widely accepted by them as the ideal form of hospital record is the best evidence of its soundness. (Kurtz, 1943, p. 1)
The Unit Medical Record gave back to the doctor by providing visibility of the whole patient. It offered the professionalised doctor their own new visibilities by offering the history of a patient, in their hands. Not only will they have their own notes of interest, but the notes of interest from all those other agents involved in the deployment of medicine. It offered the doctor the chance to become a better professional. In time, the patient record became fundamental, like the air tires on bicycles.
Max Perry is a Sociology PhD student at the University of Bristol where he is writing a thesis on the Medical Record. @0404am
Canguilhem, Georges. 2012. Writings on Medicine. Translated by Stefanos Geroulanos. 1st ed. Forms of Living. New York: Fordham University Press.
“Introductory Address.” 1840. Provincial Medical and Surgical Journal (1840-1842) 1 (1): 1–4.
Latour, Bruno. 1991. “Technology Is Society Made Durable,” in: A Sociology of Monsters: Essays on Power, Technology, and Domination. Edited by John Law. pp.103-131. London: Routledge.
“Medical Record Cards.” 1922. The British Medical Journal (3185): 11.
Kurtz, Dorothy L. 1943. Unit Medical Records. New York: Columbia University Press, https://doi-org.bris.idm.oclc.org/10.7312/kurt94506
Mol, Annemarie. 2002. The Body Multiple: Ontology in Medical Practice, Science and Cultural Theory. Durham: Duke University Press.
Pinch, Trevor and Bijker, Wiebe. 1984. ‘The Social Construction of Facts and Artefacts: or How the Sociology of Science and the Sociology of Technology might Benefit Each Other’, Social Studies of Science, 14 (3), pp. 399–441. doi: 10.1177/030631284014003004.
“Unit Medical Records.” 1944. The British Medical Journal (4351): 721–22.