Should patients be allowed easy online access to the notes that their physicians write about them?

Absolutely.

Legally we all have the right to obtain or view copies of our own medical records. However, even with the promulgation of the electronic medical record (EMR), patients in most health systems still do not have online access to the clinical notes that their doctors write about them.

Today an article in the Wall Street Journal discussed a study that is currently underway called the OpenNotes project. The one-year study will evaluate what happens when 25,000 patients have access to their own health records. Their primary care physicians will also be participants.

I believe that this is just the beginning. I think patients will increasingly be demanding easy access to what’s in their own medical files.

Is this truly progress, or is it patient empowerment that’s gone too far?

I don’t think any patients will object to having access. Some will eagerly read every word while others never will utilize the ability to view their own files.

What about the doctors and other health care providers?

I think there will be some mixed but very strong feelings about the concept. I predict that primary care physicians, already overburdened by enough hassles, will be the most likely to resist.

Undoubtedly there is the potential for some patients to misunderstand something their doctors have written. And, patients reviewing their own files will undoubtedly lead to more questions for doctors to answer by e-mail, on the phone, or in the office. But I think there are ways to manage these issues, and this study may help to shed light on how that can be done.

But I think the more important point here is that the time has come for it to happen.

I believe that the universal ability for patients to read their own medical files will ultimately result in more good than harm.

There will be more transparency and ultimately the potential for greater trust in the doctor-patient relationship. What the doctor writes will no longer be “secret.”

Patients will be better able to participate in their own medical care. They will be able to help clarify and correct any information that may be either ambiguous or incorrect.

Patients will also be able to understand more fully what their physicians are thinking and recommending.

Doctors may also be more mindful of charting their thoughts in a clearer, more organized fashion since they know that their patients will be reading the notes.

Why do I believe all of this?

When I was in psychiatry residency in the mid 1990’s, it was rare for patients to see their psychiatric notes. I typically assumed that the patients would not read what I wrote.

But times have changed.

Today it’s very common, even for psychiatric patients, to read their own charts. In fact, in the correctional piece of my work, inmates now routinely can request chart reviews. The inmates are allowed under clerical staff supervision to review not only general medical but also psychiatric and psychological evaluations and progress notes.

This process occasionally results in a question that I must answer, but most of the time it does not. Additionally, inmates often are hesitant to trust anyone in any capacity in a prison. I therefore routinely tell them that they have the right to look at their charts–that nothing I’ve written is secret. This does help me to establish a therapeutic alliance with them.

The medical establishment can choose to resist or embrace the fact that patients reading their own charts will become the norm over the next few years. I think it’s much wiser to embrace the concept and to try to determine how to make it work in a user-friendly manner for patients that is as minimally disruptive as possible to the time constraints of already-busy practitioners.

What do you think?

While correctional health care workers may be sued for malpractice, the most common type of lawsuit filed by inmates about health care in the U.S. involves allegations of “deliberate indifference.”

According to US Legal, Inc., “deliberate indifference” is “the conscious or reckless disregard of the consequences of one’s acts or omissions.” To be found guilty of deliberate indifference, prison employees must know that they are creating a substantial risk of bodily harm. So, knowingly ignoring an inmate’s serious medical complaint would be one possible example of this concept. Deliberate indifference violates the inmate’s Eighth Amendment right that prohibits cruel or unusual punishment.

What can you do both to minimize your risk of having lawsuits or other complaints filed against you, and increase the odds that any frivolous complaints that do get filed are dismissed as expediently as possible? Here are a few ideas. This list is by no means comprehensive.

1. Do your best to provide quality care. Regardless of the crimes that an inmate has committed and how much you like him, your job is to provide the same quality of care that you would provide to a patient in the community.

Stay current in your field. Use evidence-based approaches whenever appropriate.

Focus on treatment, not placation. Some inmates will persistently request inappropriate medical interventions. Provide them with what is medically indicated, not with something inappropriate simply to satisfy them.

2. Don’t ignore or minimize inmate health complaints. (Inmates write their concerns on forms that they submit to health care providers.) One of the challenges in correctional health care can be picking up on the clinically significant complaints in the midst of the “noise” generated by the small percentage of inmates who frequently write inappropriate requests. When in doubt, error on the side of assessing someone. If an inmate requests to be seen, but you decide not to grant the request because you do not believe it’s necessary, then be sure to document why. Be sure to follow your institution’s policies and procedures on handling inmate health requests.

3. Document thoroughly. Lawyers usually say that “if it isn’t documented, it didn’t happen.” Be extra-comprehensive if a particular inmate is known to be litigious or if you believe you’re being set up. Stick to the facts in your charting, and appear emotionally neutral. Expect that your patients and their lawyers will read what you write, and you’ll be more careful about what you say and how you say it.

4. Be mindful of boundary issues and professionalism. Yes, it’s two human beings interacting with each other, but there is a significant power differential in the relationship. You’re not friends with each other even if you know the patient well.

I should mention that boundaries vary depending on specialty and practice setting. A small town family doc may very appropriately be friends with some of his or her patients. But, in a correctional setting, the relationship is necessarily much more formal. Titles (Dr., Mr., Ms., Captain, Sergeant, etc.), not first names, are used for both staff and inmates.

Disclosure about oneself to inmates should be minimal. You can admit that you like a certain sports team, but don’t discuss your relationship problems, marital status, kids, or personal history of depression treatment. Don’t discuss with coworkers your weekend escapades within earshot of prisoners: You probably wouldn’t do that in a community setting, so why would you do that in a jail or prison?

Don’t do anything “extra” for inmates that you wouldn’t feel comfortable telling your supervisor about. This principle will help you decide if what you’re thinking of doing is appropriate.

Consider reading the book Games Criminals Play.

So, do you have to be an emotionless robot? Absolutely not. There is an appropriate way to make small talk, joke a little, and be friendly and caring without crossing boundaries.

5. Don’t show favoritism. You’ll naturally like some patients more than others. But don’t fall into the trap of going out of your way to help some patients but not others. Inmates talk. A lot. They’ll quickly notice if you treat some people differently from others. Inmates will be more likely to complain about you if they believe you treated someone else with the same concerns better.

6. Treat all inmates respectfully, even if they don’t treat you this way. This doesn’t mean that you should accept rude or hostile behavior from others–you shouldn’t. But, I believe that many correctional employees, regardless of their roles, would have far fewer problems with inmates if they simply treated them the way they’d want to be treated. An inmate’s “punishment” was coming to prison; it’s not the role of prison staff to dole out punishment.

7. Don’t hesitate to expand the field to get more information. If you need additional information about an inmate’s medical history, don’t hesitate to ask him to sign a release so that you may obtain records from community providers. In very complicated cases and in cases where you believe an inmate may be litigious, this can be a smart move. You might end up with helpful information, but even if you don’t, the record will reflect that you tried.

What do you think? If you work in correctional health care, do you have any other tips to share?

(Disclaimer: I am a physician, not an attorney. The information in this article should not be considered legal advice. The opinions in the article are my own.)

Photo by Kapungo

Doctors, nurses, and other health care professionals often find themselves in situations where they must speak up for their patients. Typically such patients either do not realize what they need, do not know how to ask for what they need, or they lack the authority to obtain what they need.

The circumstances and challenges of advocating for patients vary significantly depending on the practice setting. I’ve previously written about how practicing in correctional settings presents unique challenges. Essentially the main challenge in any jail or prison, regardless of how “treatment-friendly” it may be, is that a correctional facility exists for the primary mission of security, not treatment.

So, if you’re a health care professional in corrections and you have a patient who needs your voice, how can you go about being an effective advocate?

1. Identify what your patient needs as clearly and concisely as you can. Be mindful of the implications of your request on security staff and on the security of the institution. Consider the potential problems it might create with other inmates wanting the same privilege or exception for themselves. Be realistic, and keep it simple. The more complicated the request is, the less likely that security or administration will be to give approval.

2. Rely as much as possible on facts, data, and the science of your profession to state your case. For example, if you are a psychiatrist or psychologist and strongly believe that your patient needs to be moved away from his current cellmate because he is either a dangerous predator likely to kill or a vulnerable, likely victim, then do not base your concern on how the situation makes you feel. You’ll be more effective if you’re seen as rational and logical. In this particular case, if you can cite results from psychopathy testing or IQ testing to bolster your concern, you will have more credibility. It’s much more difficult to argue with facts and science than with emotion.

3. Choose your battles wisely. If you never find yourself speaking up for your patients, then you may be missing opportunities to help them. After all, many patient needs are not self-evident; nor are they obvious to non-health care professionals. But, if you feel as though your are constantly battling for your patients at every turn, then you may have an unrealistic viewpoint of what can be accomplished in a correctional facility. You’ll be more likely to become cynical, burned out, and you may lose favor with administration and security and be seen as a trouble-maker. And the unfortunate end result is that you will be less helpful to your patients. You’ll have much more credibility if you carefully choose your requests.

4. Think win-win. Even though it may require a concerted effort on your part, you are more likely to work collaboratively with those in power if you think of yourself as being on the same team. Follow the chain of command in your system, and do not undermine those with authority in order to promote your cause. For example, e-mailing the world about your concern in an effort to force others to be accountable may help you win the immediate battle for your patient, but you’re sure to lose the war. Administration and Security may not understand your profession, but if you present yourself as professional, organized, rational, mindful of security concerns, and asking for special accommodations only when necessary, you are more likely to become an effective and respected patient advocate.

Photo by Christiana Care

PATIENT:

adjective: bearing pains or trials calmly or without complaint

noun: an individual awaiting or under medical care and treatment

from Merriam-Webster Online

Photo by frances 1972

Nobody likes to wait.

But, like it or not, the world is filled with situations where we commonly have to do so. Sometimes the waits are excusable and even predictable, and other times they are not. At most doctors’ offices, one can expect to wait to varying degrees beyond their scheduled appointment time. It’s predictable. But is it excusable?

As a doctor who has done plenty of outpatient work, I am well aware of both sides of this coin.

Patients very understandably assert that their time is valuable, too. They often see it as arrogant on a doctor’s part when they are made to wait. Disrespected is how these patients usually feel. “How dare that doctor believe that his time is more important than mine!” is the mantra.

While I can sympathize with this viewpoint, the situation is more complicated than one might assume. And it’s not usually personal or intentional even though it may feel that way to patients.

Some of the primary reasons that doctors run behind schedule include emergencies, patients’ visits taking longer than anticipated, and patients (ironically) arriving late to their appointments. Most of these situations are beyond physicians’ control. Doctors also must return phone calls, speak with pharmacists, and fill out many forms.

I suspect that many patients do not realize that these issues can be frustrating and stressful for doctors, too. Speaking for myself, I am a conscientious person. It bothers me to be running behind. I truly don’t want to inconvenience anyone or waste their time.

So I do try diligently to stay as close to on-schedule as I can. But if I’m to be a competent, conscientious physician, I absolutely cannot make this my first priority. Avoiding or trying to repair train wrecks is more important than the train schedule.

If my first priority is the clock, then I will be more likely to appear rushed or insensitive, not listen carefully, miss important clinical findings, or maybe minimize the importance of something that warrants attention. Patients matter, and their clinical needs, which are often unpredictable, must come first.

Since so much is beyond doctors’ control, should we all just give up and not worry about staying on schedule?

Absolutely not. There are some ways that physicians can improve timeliness. For example, there are methods for improving efficiency and workflow in clinics.  American Medical News recently published an article to help physicians reduce wait times by addressing such issues. Doctors’ offices also can hire consultants to help them with the task.

What can patients do?

Arrive on-time (I know that sounds like a double standard, but one late patient can result in many more patients having to wait). Be organized–come with a concise list of questions. Be realistic–do not expect a doctor to be able to address several issues in one brief follow-up appointment. Finally, remember that your doctor may be behind because he needed to spend extra time with a patient in need. Next time it might be you–be glad if your doctor is willing to take the extra time when it really matters.

What do you think about this issue? In particular I’d really like to know how long you believe is a reasonable wait in a doctor’s office.

Great doctors listen to their patients. They start out by asking open-ended questions, and unless patients get too far off-track, they don’t typically interrupt them. Despite having limited time for appointments, they have an unhurried manner. They make eye contact with their patients and do not bury their heads in charts and computer screens. Their patients leave their appointments feeling respected and heard.

Of course no doctor is likely to be able to do all of these things all of the time, but some come closer to this ideal more consistently than others.

But great doctors additionally have a “sixth sense.” They can “read between the lines.”

It’s vital that physicians listen to their patients, but human beings are complicated and sometimes do not say what they mean or mean what they say. Or, they may not even know for sure how they feel. Therefore, listening to a patient’s words alone is not enough.

Exceptional physicians have honed the skill of reading non-verbal cues as well as easily-missed subtleties of spoken language that help them to interpret their patients’ histories with greater accuracy. Ultimately, since they are able to connect with and truly understand their patients better, they have the potential to provide superior care.

But, wait. There’s an invaluable clinical pearl that physicians can borrow from the world of psychotherapy to help them to better hone this “sixth sense.”

I’ll explain.

Have you ever been around a negative, depressed person for too long? Or too many negative, depressed people in a short period of time?

How did you feel?

Let me guess–you probably felt depressed or “blah” yourself.

What about someone who was in a very happy and joking mood?

Did you want to smile and maybe laugh?

And that’s the “secret”–it’s actually quite simple: The feelings that others elicit in you are often reflections of their own internal mood states. So, how you feel in the presence of someone very well might be similar to what they are feeling.

I’ve seen this occur from being around people experiencing other emotional states as well.

An anxious, obsessive, fearful person often creates a sense of anxiety, tension, and unease in those around him.

An untrusting or even paranoid person often causes others to feel suspicious.

The list of possibilities goes on and on.

And while this “window” into a patient’s emotional state is not always reliable, it often is. It’s potentially important “information” that shouldn’t be ignored, regardless of a doctor’s specialty.

In addition to providing a clue about the patient’s own feelings, there is another reason that I believe it’s helpful for doctors to be tuned into our own emotions. Our emotional state can impact patient care.

As physician blogger, Dr. Rob, points out, the doctor-patient interaction involves two humans. He states:

Patients forget that doctors have bad days, get depressed, are sometimes sick, and can be as irrational as patients. We are forgetful at times, don’t always think of things that may be obvious, and even get distracted at times. Sometimes our kids annoy us, sometimes our marriages are bad, some of us have our own past trauma, and sometimes the patient immediately before your appointment was very difficult.

With regard to being “irrational,” that’s exactly what can happen when we have strong emotional reactions to our patients: We doctors can easily lose our objectivity. Making diagnostic and treatment decisions when in an overly emotional state can jeopardize good patient care.

So, what can physicians do?

We can try to pay more attention to how we feel when we’re with our patients. If we notice ourselves having strong emotional reactions, whatever they may be, we should remind ourselves that they may mirror our patients’ mood states. By simply getting ourselves in the habit of being more mindful of our emotions, I believe we’re less likely to allow them to inappropriately sway our clinical judgment.