He was recently reviewing his PCP's notes, which were written after he was diagnosed with a common ailment, important but not life-threatening. The doctor said, that he "has multiple questions, some of which were challenging to answer."
He was concerned and didn't know how to react to this. Is "challenging" a code word for "this is an annoying person?" Does it mean that the doctor thought he was challenging the recommendations of the care team? Or, does it simply mean that the questions were difficult even for the doctor to answer because of uncertainties in the situation.
Theoretically, Open Notes would be a stimulus to an expanded conversation to clarify this ambiguity, but my friend--in case the interpretation might be the first or second one listed--is reluctant to raise the issue. He's worried that if he's already considered a bother, the doctor will not answer honestly or will be further annoyed.
The Open Notes people assert: "Our evidence suggests that opening up visit notes to patients may make care more efficient, improve communication, and most importantly may help patients become more actively involved with their health and health care."
But there are always unintended consequences from experiments. What do you think my friend should do?
It WILL improve communication - if the patient actually communicates back instead of imagining what could be. Your friend should simply ask "what did you mean by challenging to answer?" I am certain all docs participating in Open Notes are aware their patients might be reading.
ReplyDeleteI agree with nonlocal MD. It also goes to the patient's mindset---why would he not "assume positive intent"---meaning, why would he ascribe negative feelings or meanings to this statement? I took it at face value. The questions the patient asked required more thought and analysis than a simple yes or no or standard explanations. Questions about prognosis, whether the condition would recur or costs associated with the condition immediately come to mind as challenging.
ReplyDeleteAs one of the leaders of the OpenNotes movement (with Jan Walker), we're well aware of unforeseen consequences, and they're abundant! But this issue is not unforeseen; it's a important marker for our effort to foster patient engagement in care and far better communication among patients, family members, and the variety of clinicians who care for them (at BIDMC today, in the ambulatory setting virtually all the docs, nurses, physician assistants, OT/PT who sign notes offer them to their patients...and that's beginning to include mental health notes).
ReplyDeleteThe key here is trust, and that goes both ways. Your friend should engage the doc, and in our experience the result will bring them closer together. The trick is to try to control fear of retribution...ubiquitous among patients, clinicians, administrators, what have you. Hopefully, OpenNotes (www.myopennotes.org) over time will help with that...
While I do think Open Notes can help with communication, I think the doctors are going to have to be clear in their notes. Like with your friend it does raise a lot of questions, but if the doctor is clear in his notes maybe there wouldn't be so many questions and it would be simpler to take care of.
ReplyDeleteIf the clinician finds him annoying, isn't it good to know that? If the patient is seen as excessively defensive or unwilling to take in information in a trusting manner, getting that out on the table is just what is necessary. If indeed there is a discrepancy in communication styles, or if the clinician is really annoyed -- perhaps a change of clinicians would be helpful for both.
ReplyDeleteI hope your friend would ask the doctor what it means. I think it was a poor note as its meaning to the patient and/ or any care provider with access to the health record would likely be confusing too. If it's a type of 'code, it has no place in the record .
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