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.


  1. You know, you make a good point that the notes might not reflect all that the therapist is thinking (for legal reasons or whatever.)
    When I was reading this, I was thinking of therapists I have seen online commenting that they don't discharge patients. They just stop putting effort into therapy until the patient voluntarily leaves. And that freaked me out, because I can now think of a couple of times where it looked like a therapist was doing that to me. And I would LOVE to know that is going through their heads before wasting anymore money on therapy.
    But I guess that would never actually be written in the medical record.

    1. I don't know if not putting effort into therapy to get a patient to leave actually goes on or not, at least consciously. But if it does, then no, it wouldn't be written down.

    2. I feel kind of mixed about this. I think there are cases where it is helpful to have access to psych records. My first psychiatrist had some real problems, and if I had read my records earlier I would have d/c treatment earlier and saved myself a world of hurt. Here are some of the gems he actually wrote in my medical record:

      I told him about a patient who was inpatient at the same time I was who called me at home incessantly after discharge & even showed up on my doorstep on one occasion. (My phone number and address were in the phone book at the time). The psychiatrist wrote "doubtful" next to what I had told him. If he had told me that he didn't believe me, I would have had the opportunity to provide proof (my sister was over at my house several of the times the patient called me). But, I didn't find out he didn't believe me until over a year later when I read the records. Putting something like that in my medical record would have caused another practitioner to think I make up crap, when it was in fact what I said was true.

      Second, he wrote I was "immature and childish" for having cried when after having driven 2.5 hours to arrive at my appointment, they refused to see me because I was 15 min late. (I had never been late in the two years I had seen him, he had moved to a new location and I got lost & I had no cell phone to call, and he was routinely 30-45 min behind and I never complained). I thought it was pretty crappy that they couldn't have made an allowance one time for me being 15 min late under those circumstances and even crappier that he would write something so inflammatory in my medical record. He should have had the guts to address the inflammatory things he was writing in my medical record, but he did not.

      That psychiatrist tried to prevent me from getting my records, but I had them sent to a friend who is a therapist who gave them to me.

      Contrast that with a therapist I had for years and my current psychiatrist who I have seen for over 2 years; I have never requested to see the records. The care has always been respectful, and I don't feel I have a reason to read them.

      If I ever move, though, I would not be comfortable forwarding any of my psych records to another practitioner without reading them first.

      The long and short of it is, if the patient wants the records they should have the right to read them just as they do with any of their other medical records. HIPAA allows mental health professionals to withhold records, but there is always a way around that if the patient really wants them.

    3. Actually, I think patients can have their full records, legally speaking, if they like, as long as they fill out a proper consent form. I just don't think it's always a good idea, or even that informative.

  2. My understanding is that HIPAA allows psychotherapy notes to be withheld from the patient if the psychotherapy notes are kept separate from the medical record and the therapist/ or psychiatrist feels the content of the therapy notes would be harmful to the patient. (And, as long as the state doesn't say otherwise).

    I generally agree with you that it's probably not always a good idea or that informative to read the records. I think I have a natural curiosity because I work in the medical field, but still I don't see myself getting the records from my therapist or current psychiatrist. I've seen a lot of medical records in my career, including psychiatric records, and I've yet to come across any that resembled the kind of notes my first psychiatrist wrote. All that I have seen have been very professional, and none included snide remarks. I think knowing that has made it easier for me to not let that first experience ruin the trust I have in those who have provided subsequent treatment.

    I think the fact that I wanted the records from my first psychiatrist and have not wanted them from my therapist or current psychiatrist says a lot about the relationships.

  3. I liked this post, and expanded on several of your ideas here: