Posting in Healthcare
For doctors to become trusted advisers, they have to stop acting like high priests and let patients in on what they're thinking.
The OpenNotes project may start the biggest rethink of doctor-patient relations since the profession began.
(Picture from Myopennotes.org.)
Where once doctors advised, now they order. Their authority may be subject to questioning, but in the end it is unquestioned.
Opening up doctors' notes may lead those orders to being rigorously questioned.
Ironically, as The Wall Street Journal notes, current medical practice flies in the face of the law, which gives patients a legal right to see all but psychiatric notes. In practice notes are not even included when patients access their medical records.
In the test reactions from both patients and doctors will be monitored, but I suspect the truth is much simpler.
There are three kinds of notes.
- There are notes doctors exchange among themselves, filled with acronyms like NERD (No Evidence of Recurrent Disease) and SOB (Shortness Of Breath), which patients could misinterpret.
- There are notes doctors make for other doctors, which may relate to patient behaviors, as in the 1996 Seinfeld episode The Package. Such notes may also be speculative, hinting at what a doctor thinks another doctor should look at, but offering no conclusions.
- There are notes detailing what the patient has and what they should be doing about it, things many patients quickly forget, but which are important to maintaining health. It's these notes whose power the OpenNotes test is aiming to unleash.
This last category of notes are supposed to be part of the Continuing Care Record, which whether printed or sent electronically is an integral part of any health reform, public or private, liberal or conservative.
Patients tend to forget what the doctor says in that brief meeting. Whether we're sick or well, the ongoing hints of what to do and watch out for tend to fly out the mental window in our rush to get out the door.
The CCR gives you this information, in plain English, so you and your family can follow-up and participate in your wellness. It makes health care a partnership between patient and providers. It gives every other professional who sees you an overview of what's happening so they can provide better, more personal care, and not do the same tests over-and-over-and-over as they do now.
But some doctors even fear the CCR. They fear lawyers could use it against them, that it's a legal document. And if their whole note file is also treated as a document the patient has a right to, then the patient's lawyer may also misinterpret that and make their life a living hell as a result.
Well, there are reasonable fears and unreasonable ones. I can see doctors wanting to protect the data they exchange among themselves, thinking it's in confidence. But patients have a right to the CCR, and an obligation to become active participants in their own health.
For doctors to become trusted advisers, they have to stop acting like high priests and let patients in on what they're thinking. The CCR, developed by a collection of doctors, vendors, and standards groups, is a good compromise.
Give me that and you can keep your notes, doc.
Jul 21, 2010
I agree, and in cases like this it's the correspondent, someone like pacificpsych who brings hard questions to the table, who deserves most of the credit.
The above statements are the best CONSTRUCTIVE banter I've ever seen on ANY of these blogs!! Hopefully more will read this article (and suggestions) and take some real positive action toward those goals.
On that we're in agreement. Of course doctors in Canada and France and Germany don't spend nearly so much time on such things.
I think giving the patient a note is GOOD idea. I'm just saying that you need to first cut out the junk which consumes most of the work day. All the stuff that's done for UR and QI and God knows what other abbreviations. Junk. Medical records as they are now are useless for doctors. They're bureaucracy records, not medical records.
The good old days aren't coming back, as if they were ever here. There is nothing wrong with giving your patients a piece of paper, or an electronic file, that explains what's going on, what you want them to do, what your next steps are. That's all the CCR is. It can work well even if your communication skills aren't 100%. Also, while the vast majority of doctors are wonderful, there are also doctors whose behavior is not so wonderful. There are doctors who are involved in fraud, against insurers and the government, there are "cadillac doctors" who charge way too much and abuse the doctor-patient relationship in order to get that money, and there are outright criminals who claim phony cures and force the rest of us to pay for them. Before you go attacking the previous paragraph, all I'm saying is doctors are human, and prone to human temptations just like journalists. But doctors have a lot more power over our lives than journalists.
I should add that the biggest change in the physician patient relationship has been the erosion of this relationship due to the intrusion of third parties. These parties include insurance companies, managed care, govt. bureaucracy and the Joint smokin' commission. Their motives are either to make a profit, which they usually achieve by denying care and denying payment to doctors, or perpetuating their own unnecessary bureaucratic existence. We need to go BACK to the physician patient relationship.
Ninety-nine percent of the notes in the record are Joint- induced rubbish. The medical record has long ceased to have any use for doctors. Used to be that a note in medicine was four lines: S O A P. An H&P in psychiatry contained a long detailed history of the patient's social and family circumstances along with a deep assessment of their psychological make-up. Now it's a brief, meaningless, check list. Doctors and nurses spend more of their time doing paperwork - junk paperwork - than seeing patients. If I think of the patient getting the same chart we get, with hundreds of pages of bureaucratic forms and hardly any real info, well...kinda funny... The first step in changing the way medical records are handled should be to eliminate all the non medical junk. Computerize the medication list so that instead of calling various pharmacies and guessing, you might actually know what the patient is taking. And then, having freed up about 95% of the doctor's time, the doctor could write a nice note tailored to the reading comprehension level of the particular patient which he would then take home with him. And nurses could spend their time caring for patients instead of "charting". More paperwork is not what we need. We need to get rid of the bureaucracy, decrease the burden on doctors, stop attacking them, as in "For doctors to become trusted advisers, they have to stop acting like high priests," and let them practice medicine. pacificpsych http://www.pacificpsych.com