Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Wednesday, July 9, 2014

Of Note

I hope people got to see this piece in the NYTimes, What the Therapist Thinks of You. I don't know, maybe my life is just really boring, and that's why I have to get so incensed over stuff like this. But it feels like one of those slap-your-forehead moments.

BI Deaconess is conducting an experiment in which mental health patients are given online access to their session notes. The article includes the expectable hype. What a great idea! This will revolutionize mental health care! Doctors should be open with their patients about their thinking! Studies have shown that patients with access to (non-mental health) medical notes are more involved in their treatment!

One psychologist in Newton, MA has been doing this for a while, and her patients really like it. Some even view it as a "security blanket" between sessions.

The article points out that notes are often written in language that may be difficult for a lay person to understand. It makes an argument in favor of using less technical language. It conversely cites an argument recognizing that notes are used for communication between doctors, so that technical language is appropriate and helpful.

To the article's credit, there's also some discussion about the notion that it might not be helpful for some patients to read their notes.

Here's what I think is right with this idea: There should be open communication between mental health providers and their patients. And the world is just too damn litigious, so let's not worry about that so much and let the patients see our "sacred" notes.

Here's what I think is wrong with it:

Uch, where do I begin?

Patient's shouldn't need to resort to reading notes to find out what their doctors are thinking. It's incumbent upon the doctor to create an environment in which, if a patient has questions or concerns or gripes about what the doctor is doing or thinking, the patient can talk about it with the doctor.

Much of my thinking about my patients stays in my head. Reading my notes won't enlighten anyone.

There are many times when I feel a patient is not ready to hear what I'm thinking. It's part of my job to be able to pick a good moment to communicate what's important. I don't want to blurt things out prematurely, because that's not helpful. And I certainly don't want patients to read things about themselves that can be misconstrued or misunderstood, without having me there to elaborate.

Sure, I could spend some time each session reviewing the notes from the last session with the patient. To me, that seems like a waste of precious time. If a patient wants to bring up something from the last session, she can go ahead and do so. If I think there's a topic that needs to be considered, I'll bring it up. We don't need to formally look at the notes for that.

One of the problems I have with seeing therapy patients only once a week is that it's like treading water (that's my former therapist's expression, to give due credit, though I doubt she'll ever read this). The patient just ends up reporting what happened in the past week, and you never really get to what they're feeling, or how that plays out with you. If part of that time was spent reviewing notes from the last session, there would be even less time to get to what's important.

I've had patients who take their own notes after a session, for a lot of reasons. To hold me to what I might have said. To make sure they don't forget. To have some part of me to hold on to once therapy ends. Mostly it's defensive, and it needs to be discussed.

Inter-session note-reading as a security blanket sounds to me like something that needs to be addressed as part of the reason the patient is in treatment, not encouraged as the "new normal", in the Newton psychologist's language.

But my biggest problem with this idea is the irony of it. It used to be that doctors kept notes and other types of patient records so they could learn things about their patients, for the purpose of helping those patients, and sometimes others, as well, using the notes as research observations. Think "The Wolf Man"and "The Rat Man". And much of what we know about transference started with "Dora".
Eventually, lawyers got involved, as they always do, and notes became part of legal documents, to "protect" doctors in case of malpractice suits. This changed the way notes were written, to more formalized, cautious documents with less useful information about the patient.
More recently, notes have gone through another change, particularly EHR-style notes, to documents that still protect doctors legally, but also allow for more streamlined billing. (See E&M Coding in All its Glory). What they don't do is tell anyone anything useful about the patient, or what's going on in treatment.
So now what? Are we supposed to take these clinically useless notes and give them to patients so they can learn what we're thinking? I can't tell what I'm thinking from those notes. Or are we supposed to somehow alter the way we write these notes so they protect us legally, streamline billing, AND allow patients learn what we think about them, in language they can understand?

Good luck with that.