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    In Practice

    The time has come to scrub the SOAP note

    Excerpted from the In Practice blog on

    Medicine, like law, the military, and many other professions, has its own language — a kind of verbal secret handshake by which its members recognize one another and close ranks against outsiders.

    Sometimes, the use of technical terms, abbreviations, and other forms of jargon can impair patients’ understanding of their medical care. A recent Wall Street Journal article discusses the extent to which clinicians overestimate patients’ “health literacy” — with potentially dangerous results.

    But sometimes, medical lingo has a more subtle negative effect: It reinforces our false sense of being less human, less fallible than our patients.


    Certain words and phrases, used commonly in the hospital and clinic, have always set my teeth on edge. One is using “male” and “female” to describe people, as if they were specimens rather than men and women. Another thing that gets on my nerves is referring to the patient unable to describe his symptoms clearly as “a poor historian.” The “historian,” as an old professor of mine used to point out, is the person who writes down what happened and interprets it: i.e. the doctor, not the patient.

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    But the convention I really hate is the SOAP note. SOAP stands for Subjective, Objective, Assessment, and Plan. It’s the format often used for daily progress notes in a patient’s hospital chart, taught to every medical and nursing student.

    I’m OK with the “assessment” and “plan.” It’s the “subjective” and the “objective” I have trouble with. You see, the patient’s experience (“I feel better,” “I feel lousy,” “I have chest pain”) is assigned the “subjective” role, while the clinician’s view is considered “objective.” Are these designations fair? Are they accurate?

    Take a patient I saw recently. She had a rubbery, marble-size lump on one side of her neck. I knew, with certainty, that this lump was a benign lymph node, likely inflamed because of a minor skin or throat infection. She knew, with equal — perhaps even more — certainty, that the thing had popped up out of nowhere, that it hurt, and that her sister’s cancer had started in exactly the same way.

    My certainty was based on my knowledge of anatomy and physiology and my clinical experience. Her certainty was based on the sensations of her own body and on her life experience. Was either free of objectivity, or subjectivity?


    Good medicine always involves a collaboration between the clinician’s and patient’s perspectives. But, as yet, there’s no nifty acronym for that.

    Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. Read her blog on She can be reached at inpracticemd@gmail