{"id":7041,"date":"2010-08-17T15:40:53","date_gmt":"2010-08-17T20:40:53","guid":{"rendered":"http:\/\/pmedicine.org\/epatients\/?p=7041"},"modified":"2010-08-17T16:10:12","modified_gmt":"2010-08-17T21:10:12","slug":"should-patients-read-doctor%e2%80%99s-notes-wrong-question","status":"publish","type":"post","link":"https:\/\/participatorymedicine.org\/epatients\/2010\/08\/should-patients-read-doctor%e2%80%99s-notes-wrong-question.html","title":{"rendered":"Should Patients Read Doctor\u2019s Notes? Wrong Question."},"content":{"rendered":"

When you have a doctor\u2019s appointment, and she makes some notes and later formalizes them for your medical record, would you like read them? \u00a0There\u2019s been debate over the years about whether patients should read the notes that doctors write about them and their health issues — in academic circles, in a great Seinfeld episode<\/a> where Elaine\u2019s dermatologist won\u2019t let her see what he wrote about her, and more recently in a New York Times piece<\/a> that discusses the promising OpenNotes project<\/a>. \u00a0I think this is the wrong question. \u00a0Instead, you should walk into your doctor\u2019s office with a video camera or tape recorder. \u00a0More on that in a moment. <\/p>\n

The discussion about doctor\u2019s notes might seem silly, since for many years we\u2019ve had the right to go the medical records department and get copies of our records. \u00a0So all we\u2019re talking about here is making that more convenient, for example, by letting you log into your online account and see the notes there. \u00a0However, this is much more than convenience, it is a cultural statement: we, the doctors, should sincerely invite you to read our impressions, our thought processes, our decisions; and learn from them, even question them. \u00a0While this is a powerful statement, we\u2019ve gotten distracted by this artifact, the doctor\u2019s note. <\/p>\n

Instead we should focus on the communication it represents. \u00a0The goal is not to sneak into the doctor\u2019s inner thoughts and see what he\u2019s really thinking about me, rather it is to gain a deeper understanding of my health and add a channel of communication from the doctor whose precious minutes just aren\u2019t enough. \u00a0(By the way, to those who fear doctors will no longer be able to write what they *really* think, I have two comments. \u00a0First, patients can already request copies of their records, so be thoughtful in your notes! \u00a0Second, I would consider supporting a separate area for comments that the doctor sincerely feels are in the patient\u2019s best interest not to see and are only for other clinicians, similar to what’s done today for mental health records.) <\/p>\n

What we should be focusing on here are the best ways for the patient to understand and remember the doctor\u2019s guidance, including the Q&A that typically happens during the visit. \u00a0The doctor\u2019s note hardly addresses this. \u00a0It\u2019s designed for the doctor to communicate to other clinicians who will later care for the patient, and in practice it\u2019s increasingly full of not-so-useful information included for billing purposes. \u00a0Sometimes the doctor will create a separate note explaining the plan to the patient, especially if his EMR auto-generates a template for this. \u00a0But this is uncommon, and it provides only a brief summary of the outcome of the discussion. <\/p>\n

I encourage loved ones to take a tape recorder or video camera to their doctor\u2019s appointments, especially ones where new or critical issues will be discussed like whether or not to have surgery or how aggressive to be in treating a cancer. \u00a0Most of us have experienced how little one actually remembers when fear or stress levels are high. \u00a0Being able to review the conversation again later can make a huge difference in understanding and better decision making. <\/p>\n

As a doctor, does it make me nervous when someone wants to record our conversation? \u00a0Yes. \u00a0Because it holds me even more accountable to communicating clearly and taking good care of my patients. <\/p>\n

(This post was cross-posted on Huffington Post<\/a>.)<\/p>\n

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