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.
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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?
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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
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?
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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.”
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It’s probably happened to all health care professionals at some point: Patients, especially those considered “difficult” for some reason, fail to improve despite our best efforts. Eventually we become frustrated enough that we then blame them for their lack of progress.
There are endless possible scenarios where this might occur:
- A depressed patient, who transiently appears to have a personality disorder because of her inadequately treated depression, is not progressing in psychotherapy and has not responded to two different medication trials.
- An elderly man bounces back for readmission to the hospital for a CHF exacerbation. He arrives in the ER with a pack of cigarettes in his shirt pocket.
- A morbidly obese woman continues to have poor control of serum glucose, blood pressure, and lipids despite aggressive pharmacotherapy. Yet the patient has lost no weight despite being counseled for years about the need to do so.
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I know an elderly psychiatrist who used to do some small-time farming. I was always impressed with how many things he could buy without his wife objecting. Many of the items he purchased could have been considered, depending on one’s viewpoint, “tools” or “toys” (power tools, trucks, old tractors, etc.). There seemed to be two reasons he was able to do so. First, he had a great strategy. Anytime he bought something for himself, he either bought the same thing for his wife or bought her something equivalent. If he bought a Grand Cherokee, she got one, too. It must have been expensive, but it probably helped him to avoid years of marital discord and ultimately Dr. Phil telling him to “get real.” The second reason he got away with buying so much stuff was, as he told me, because “the tool always creates the job.” He loved all of these toys, and he had a special knack for always proving how useful each of them was because he inevitably would find the “need” that the tool would fulfill.
Is the social media craze similar to my psychiatrist friend’s farm tools?
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A few months ago I performed an inpatient consultation on a non-incarcerated patient. His psychiatric care was being managed by a neurologist in another community.
I was shocked and disappointed when his family informed me that the neurologist told them that if the patient sought a medical opinion elsewhere, the neurologist would no longer treat the patient.
Even on a bad day I cannot fathom exuding such arrogance and insecurity! Hopefully this doctor’s attitude about second opinions is the exception and not the rule among physicians. However, this situation sparked my curiosity about second opinions.
Throughout my career, I’ve often encouraged my patients to obtain second opinions, either when
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Physicians learn a lot about many different topics, both in medical training and in practice. However, there are some life lessons that we never learn as well as when we become patients ourselves.
When I was 13 or 14 years old, I regularly interacted with 2 different physicians with disparate interpersonal styles. Little did I know then that these seemingly meaningless encounters would indelibly shape my own beliefs about how people should treat each other. Ironically, many years later the experiences would help guide me as a physician in my interactions with my own patients.
For a couple of years I was the regular patient of a dermatology clinic. Two dermatologists ran the practice together, and in order for me to get an appointment that worked with my family’s schedule, occasionally I would need to alternate seeing each of them. I’ll refer to one of them as “Dr. A” and the other as “Dr. F.”
I was somewhat shy as an adolescent, and sitting in an exam room wearing only a gown and underwear always made me a little anxious.
However, any unease I may have experienced evaporated when
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Many non-correctional health care providers will also treat inmates from time to time. This may occur in the office or hospital. How can one best approach the challenges of working with the incarcerated in order to deliver the best possible care while simultaneously managing risk?
1. Treat the patient with respect. Not submissive respect, but mutual respect — the way we all want to be treated. I believe that this principle alone goes a long way towards helping one to establish a therapeutic alliance and to minimize interpersonal conflict and hostility. Inmates are people, too. Those who do not agree with this statement should steer clear of treating them.
2. Listen attentively. It may be tempting to get this shackled person (who you may secretly be embarrassed to have in your office) out as expediently as possible. Squelch that temptation, and listen actively as you would to any patient. All patients want their concerns taken seriously. Inmates are no exception. I believe you minimize problems for yourself in the long run (and provide better care) if you ensure that patients’ concerns are heard, especially if they seem to have more challenging personality styles.
3. Be honest. If there is a particular reason why you think something the patient is requesting is inappropriate, then politely tell them so. If you believe they have a particular diagnosis, psychiatric or not, then
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