Opinion

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.

Lets Show Patients Their Mental Health Records

Should we health professionals encourage patients with mental illness to read their medical record notes? As electronic medical records and secure online portals proliferate, patients are gaining ready access not only to laboratory findings but also to clinicians notes.1 Primary care patients report that reading their doctors notes brings many benefits including greater control over their health care, and their doctors experience surprisingly few changes in workflow. 2 While patients worry about electronic records and potential loss of privacy, they vote resoundingly for making their records more available to them and often to their families.3 As consumers urge that fully open medical records become the standard of care, policy makers, clinicians, and patients advocate also that mental illness gain far more attention and support.4 Primary care physicians and medical and surgical subspecialties have long managed many patients with mental illness, but with the exception of the Department of Veterans Affairs, most systems implementing open records continue to carve out from patients view behavioral health notes written by psychiatrists, psychologists, and social workers. We believe such exclusions are unnecessary. Inviting patients to read what clinicians write about their feelings, thoughts, and behaviors does seem different from sharing assessments of their hypertension or diabetes. Bringing transparency into mental health feels like entering a minefield, triggering clinicians worst fears about sharing notes with patients. How will a patient react to reading a diagnosis of his personality disorder? What about the patient with schizophrenia learning that her firm convictions are seen as delusional? Will outrage disrupt care as psychiatric diagnoses and terminology familiar to clinicians come across to patients as judgmental, dismissive, reductionist, or stigmatizing? Based on our experiences as psychiatric, medical specialty, and primary care clinicians, we suggest that transparency may instead yield fruitful opportunities. By writing notes useful to both patients and ourselves and then inviting them to read what we write, we may help patients address their mental health issues more actively and reduce the stigma they experience. Just as radiologists report a shadow on a chest film as a density rather than leap to diagnostic language, describing behaviors rather than labeling them could lead to less clinical prejudice, less diagnostic anchoring, and more engagement with patients. Descriptive language should not replace firm diagnoses, but rather complement the usual problem lists and medical terms to help balance and humanize notesand the patients they depict. As clinicians become accustomed to sharing notes with patients and describing clinical findings in ways that exemplify collaborative, nonjudgmental assessment, they might find their writing more efficient and to the point: Ms Jones and I continued our discussion of her tendency to use black-or-white-thinking in ways that make her relationships at work problematic. Mr Smith and I continue to agree to disagree about his conviction that his apartment is bugged. Ms Williams expressed dissatisfaction with my treatment decisions quite clearly, but preferred not to talk about that today. I encouraged her to discuss our disagreements in the future. This approachdescriptive, nonjudgmental summarizingcan help with documenting many potentially value-laden subjects. A patients addiction to Internet pornography may be deeply troubling, and his doctor or social worker would be justifiably worried about shaming him further by documenting it. This might be noted as Mr Martin and I continued our discussion of his addictive behavior and reviewed techniques for dealing with it. This principle can also be applied to a variety of sensitive topics, including psychodynamic issues. The medical record should offer a practical synopsis of a patients history and treatment, but it does not need to contain an exhaustive catalog of vulnerabilities. Caring for patients with substance abuse provides fertile ground for conflict, but here too reading the clinicians views in black and white may be helpful. Patients with addictions are often so used to being lectured that they tune out real-time discussions of harmful consequences of their behavior, no matter how tactful the clinician. Offering patients time for unpressured review of the clinicians assessment in a private setting may diminish the need for defensive maneuvers (such as evasiveness, minimization, or denial) that guard against feeling exposed and stigmatized, thereby affording the patient opportunity to get closer to acknowledging an addiction. Anecdotally, some doctors have commented that inviting their patients to see their problems in writing was far more effective in catalyzing behavior change than was discussing them. Deliberately highlighting patient strengths and achievements in notes is another strategy that may help many mental health patients. Virtually all individuals, including those with severe and persistent mental illnesses, have readily identifiable positive traits or accomplishments that can be concisely documented. While the brevity of office visits requires an efficient focus on symptoms and signs, clinicians can nevertheless document nonpathologic aspects of a patients life in a way that helps the patient profit from reading about his or her own strengthsas validated by the clinicianand gain a larger context for considering his or her illness. Ideally, the patient would see that his clinician knows theres more to me than my immediate worries. With both clinician and patient taking a more balanced and holistic perspecJAMA April 2, 2014 Volume 311, Number 13 1291

Corresponding Author: Michael W. Kahn, MD (mkahn @bidmc.harvard.edu). Section Editor: Roxanne K. Young, Associate Senior Editor. jama.com

Copyright 2014 American Medical Association. All rights reserved.

Downloaded From: http://jama.jamanetwork.com/ by a Self Regional Healthcare User on 04/02/2014

Opinion A Piece of My Mind

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 April 2, 2014 Volume 311, Number 13

jama.com

Copyright 2014 American Medical Association. All rights reserved.

Downloaded From: http://jama.jamanetwork.com/ by a Self Regional Healthcare User on 04/02/2014