I became interested in note writers because I see many in practice and because my impressions about them have been at odds with the traditional disparaging view. I found in a prospective study of 900 different patients seen over a period of four months in my practice of primary care internal medicine that 8 per cent (72) listed their concerns; that figure does not include lists of medications. Right off, it would be important if we knew that we could depend on list writing as a reliable indicator of an underlying emotional disorder, because the majority of patients with psychiatric disease are seen by primary care physicians^4,5 and many go undiagnosed.^6,7 It is not to be. From my personal observation of these 72 list writers I found no association of emotional disorders with list writing in men. Women list writers are more apt to have nervous troubles, but the majority were emotionally normal. Almost all of these emotionally normal list writers had serious physical disorders. Patients with organic disease, therefore, do refer to written notes to give the essence of their story — and not because they are peculiar or crazy.

Most notes seem to be written for no devious reasons, because of no lurking Freudian distemper, but because patients and families simply want to get things straight. Anxious, even distraught they may be, but they are seeking clarity, order, information, and control. Some patients tell me that they organize, list their thoughts, and come to the point so as not to waste the doctor’s time. If all this is to be labeled compulsion, I say let it be and make the most of it. Most of the listers that I have encountered are habitual list makers: once a list writer, always a list writer. Many of their lists include shopping items or other self-reminders in addition to medical questions; “pick up Jane” may follow “rectal bleeding.” Lists may be composed jointly by the patient and the patient’s partner in care — for example, when a diabetic patient is preparing to leave the hospital and both patient and partner must have explicit instructions about care. Another category: 8 of the 72 study lists were drawn up by the person in charge of the (usually incompetent) patient’s care, usually by daughters or wives; tending the hearth includes tending to health. Seven of the 72 made lists because of failing memory. On one office visit one forgetful list maker was frustrated and upset because he had forgotten his list. These intellectually deteriorating patients touch me; most have been brilliant executives or teachers. In my experience more women than men write notes, as do more patients from the upper educational brackets.

The majority of lists consist of the patient’s symptoms and concerns or of orderly, logical questions that should be addressed in the ordinary course of good medical practice. Most lists contain 5 or 6 items; a 20-point list was written by an emotionally stable executive. Most are handwritten, a few are typed. Lists comprise the same thousand-and-one subjects discussed by all patients: skin blemishes, gas, chest pain, My sister has cancer, do I? shots for foreign travel, Why does my blood pressure fluctuate? family or job troubles, diet, vitamins, medications, and exercise. Lists may contain detailed questions of exactly what to do and what to take after a heart attack or how to take care of a stroke patient at home. Such questions are complex and require careful, methodical listing and answering. Notes may be of great help in the orderly transfer of information to the physician. I welcome an accurate written summary of a new patient’s medical history and a list of his or her current medications, a daily log of medications correlated with blood-pressure recordings, or serial blood glucose determinations obtained by the patient and matched with daily activities and insulin dosage.

The content and character of the note may be of diagnostic importance — in the case, for example, of the confused, rambling note of the senile patient or the bizarre complaints of a psychotic patient. The list of unending, never-satisfied complaints may identify the anxious, hypochondriacal patient. We can see through this as a poignant camouflage, a smoke screen, a controlled agenda that helps the patient control his or her mental anguish. The phrases written by the patient may reveal a masked depression: “lack of energy in the morning,” “can’t make myself go,” and “nothing interests me.” In our area of the country these terms are virtually diagnostic of a depression.

Although not as often as I might have expected from the literature, a few of the note writers have tested my patience. One was a tedious pedant with voluminous notes — a Polonius who could never come to the point. Two or three patients regularly interrogate me and overwhelm me with an outpouring of written complaints. One patient who made me uncomfortable was obviously smarter than I and demanded to know as much about his medical problems as I knew. A few perfectly capable, intelligent patients are regularly accompanied by their wives, who do all the talking. When I address the patient, his sponsor, the ventriloquist, will answer from her written list of problems. I have to bite my tongue to keep from saying, “Let the patient talk”; indeed, which is the patient? Although a few note carriers are irritating, we must try to understand the meaning behind the list and thus to understand the patient — and ourselves. A blanket rejection of list carriers is unfair and wastes an opportunity to gain valuable clinical insight.

I have established my main point: that la maladie du petit papier is not often a malady, that note writing does not axiomatically equate to mental illness, that the majority of note writers are emotionally sound. My second point has been that note writing is both respectable and useful. To dismiss the note carrier as a medical pariah and to ignore the note is insensitive and endangers the care of the patient. Hearing out the list is a part of listening to the patient — the keystone of our craft. Whether patients have lists or are “neurotic” or “normal” is irrelevant; all deserve an impartial sympathetic hearing.

Let us hereafter grant note writers clinical absolution. Patients are free to write lists, to mime or sing their concerns. Medical care turns on communication. Whatever helps patients express themselves and helps physicians understand patients is acceptable. Now, Aesculapius, stand up for note writers!