Beruflich Dokumente
Kultur Dokumente
A PIECE OF MY MIND
Michael W. Kahn, MD Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Sigall K. Bell, MD Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Jan Walker, RN, MBA Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Tom Delbanco, MD Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Corresponding Author: Michael W. Kahn, MD (mkahn @bidmc.harvard.edu). Section Editor: Roxanne K. Young, Associate Senior Editor. jama.com
tive, the therapeutic alliance may be enhanced, even as the clinician addresses maladaptive behavior. Contrary to the fears of many cliniciansand perhaps mental health professionals in particularthe so-called difficult or personality-disordered patient might in fact benefit from more transparency. Many of these patients have some awareness that their behavior is troublesome, but a deep sense of shame inhibits their acknowledging it. Inviting them to read accurate and nonjudgmental notes may help diminish this shame. Even patients with severe personality disorders can be relieved to know that the turbulence and unhappiness that permeates their lives reflects suffering from a familiar clinical entity shared by others, rather than their being a bad person. A clinicians hesitation to reveal a note may largely reflect two questionable assumptions. The firstthat the note will in some way be devastating rather than comfortingoverlooks the fact that patients self-evaluations are often more negative than those of their clinicians. For example, an anxious patient may typically wonder whether he is crazy, but fears asking about it and getting an affirmative answer. In these cases, reading the note may actually reduce some worries that are fully operant but unwarranted. The second assumptionthat the patient will be unable to say I think you got something wrong and in fact be rightdiscounts the potentially enormous benefit arising from patients opportunity to factcheck their own histories. Indeed, the clinician who actively solicits
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported. Funding/Support: This work is supported by a grant from the Robert Wood Johnson Foundation. Additional Contributions: Dr Kahn thanks Pamela Peck, PsyD, and Zsuzsanna Varhelyi, PhD, for helpful comments.
open and ongoing dialogue, including a patients opinion about a notes accuracy, may enhance both clinical precision and the treatment relationship. Benefits from this approach could extend to patients across the spectrum of mental disorders, including those with factitious illness, although admittedly no data are available currently to support this impression. But for some patients, reading notes may carry more risk than benefit. While HIPAA grants virtually all patients access to their records, a carefully considered decision to exclude a note from a patients view should remain an option when weighing harm and individualizing treatment. The opportunity to make such choices can also reduce clinicians anxiety as they become comfortable with a new approach to documentation. For the most part, however, our experience in primary care is that clinicians tend over time to withhold fewer and fewer notes. A psychologist colleague, initially skeptical about open records, changed her mind and developed a new perspective: When we think about our patients in a kind of language that we deem inappropriate or potentially offensive to the uninitiated, who is to say that our own attitudes toward our patients are not affected by that language? Wouldnt we be closer to our patients experience if we got into the habit of thinking about them in language they would find meaningful and useful? (Cassandra Cook, PhD, e-mail communication) We agree. Its time to offer fully transparent care to our patients with mental illness.
3. Vodicka E, Mejilla R, Leveille SG, et al. Online access to doctors notes: patient concerns about privacy. J Med Internet Res. 2013;15(9):e208. 4. Guest JA, Quincy L. Consumers gaining ground in health care. JAMA. 2013;310(18):1939-1940.
1. Walker J, Darer JD, Elmore JG, Delbanco T. The road toward fully transparent medical records. N Engl J Med. 2014;370(1):6-8. 2. Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157(7):461-470.
1292
jama.com