I had an immediate reaction when I read the headline, “Should Patients Read the Doctor’s Notes?” in the New York Times this week. Yet this interesting question is being tested out on 25,000 patients and 100 physicians from 3 different health care systems in a year long study. Dr. Tom Delbanco, the lead investigator says, “We have one simple research question. After a year, will the doctors and patients still want to continue sharing notes?”

I am always aware that what I write is a legal document that can be viewed by anyone (who is authorized to do so by the patient that is) but like any field which has its own particular jargon and abbreviations, providers develop their own style in how the note is written – which is usually a balance between brevity and density, ie, how to pack as much information into the note using the fewest words possible.

But not all notes are dry descriptions of a medical problem. Many of my patients suffer from depression or anxiety and I like to add a few notes that help me remember their particular issues when I review the note when they come in for a follow-up visit months later. With my younger, healthier patients, it’s not unusual to have several years go by before I see them again so I like to jot something that might help me remember them. It might be anything like the school they go to or a particular struggle the patient is having with a child,  job, or relationship or simply where they’re going for vacation.

I remember many years ago reading an xray report about my back – this was before I was in the business. The technical terms made everything seem so much worse – phrases like “mild degenerative changes”.  I could only see the word “degenerative”  and imagine the worst. The physician’s note used the word “acute” to differentiate the problem from a chronic process. I misunderstood and thought he was describing something that represented an emergency. I would have needed hours of explanation to feel reassured that I was truly all right.

And then there are the lab values, minor variations of normal or transient elevations that to the unfamiliar eye might cause alarm. In many ways, part of my job is to explain, as simply as possible, what something means and so I may choose to avoid complicated details. So what would happen if patients could read their notes? Would they become unnecessarily frightened? Would it lead to excessive amounts of time trying to explain something that was essentially normal?

I don’t treat my patients paternalistically, nor am I condescending but I do have to edit what I say because I have a limited amount of time to spend in the exam room. I wouldn’t want to spend a lot of that time explaining why I wrote a particular phrase nor would I want to leave out those personal identifiable details that help me remember that patient. When this particular study concludes in a year, I’ll be curious to see what patients and providers decide.

Stumble! for WP

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.