Thursday, March 19, 2015

Patients vs. doctors

A JAMA Viewpoint article suggests that doctors should be aware that patients may be surreptitiously recording their conversations. The author, a neurosurgeon, takes a very benign view of this issue and recommends that if a doctor suspects that patient is recording a conversation, "the physician can express assent, note constructive uses of such recordings, and educate the patient about the privacy rights of other patients so as to avoid any violations."

He also says this would show that the physician was open and strengthen the relationship between the doctor and the patient. I'm not so sure.

Here's a different perspective. If a patient is secretly recording a conversation, the relationship between him and the doctor is already in serious trouble. What I would do is to tell that patient to find another doctor.

If a patient asked me if it was OK to record our conversation, I would agree, but I would also want to record it to preserve a complete copy.

This comes on the heels of another privacy and trust question—should doctors google their patients? There is no consensus on this, but having read several discussions on the topic, most writers feel that googling patients should only be done for certain narrow reasons which you can read here.

Most medical societies have not weighed in on the subject, but I would guess when guidelines are published, they will discourage the practice. But of course, patients may google physicians at will.

Taking it to another level, Dr. Jeremy Brown, Director of the Office of Emergency Care Research at the National Institutes of Health, recently proposed that emergency physicians should be equipped with body cameras to record audio and video of patient encounters.

Leaving aside such questions as who owns the videos, how to store the vast amount of data, and what impact this would have on the performance of the individual physicians, body cameras would establish an adversarial relationship that is unnecessary for the overwhelming majority of doctors and patients.

A physician interaction with a patient begins on terms quite different from those of a police officer interacting with a suspect in which the adversarial relationship is already established. The increasing number of controversial and highly publicized cases involving police and suspects has resulted in a need to protect both parties. This need seems much less pressing in medicine.

Where does this end? Should all patients be equipped with body cameras too in case the physician copy "gets lost"?

It is sad to realize how far we have sunk as a profession.

24 comments:

frankbill said...

After reading many pages of my medical record I find that I say and what the provider writes many times do not match. Sometimes things I am never asked about the provider gives answers to. I can see the need to record visits. It is something that should be part of the EMR. This way it would no longer be a one sided record.

At this time should be no need for body cameras.

Yes is sad that health care system has come to something like this. This is only going to get better if providers take back the health care system.

Diane said...

What is good for the goose is good for the gander. If the patient can google the Dr, then vice versa should apply. Today the medical relationship between Dr and patient is no more personnel then between one and their attorney and likely less so. Hospitals regularly video and record patient families. As far as trust? Again, at this point in medicine the trust factor is no more and no less then that with an attorney. Frankly, I would feel more comfortable confiding in an Attorney then a Doctor. Google a way Drs! You also have the right to request that meetings not be video taped or recorded and the patient should have the same right. Medicine is very different today and there is no going back. Full steam ahead. Good or bad? Who knows. "It is what it is".

Skeptical Scalpel said...

Frank, you are correct about sometimes the chart does not accurate reflect what went on. The best example is the 12-point review of systems at every office visit.

Diane, well put. I'm not sure that we are less trusted than attorneys yet, but we may be getting there.

Diane said...

It is a shame too. There are a lot of great Doctor's out there..

William Reichert said...

Yes, soon the entire medical experience will be recorded on video.
Every conversation the nurse has, Every IV that is hung. The entire surgical procedure.The entire cardiac arrest scene. A video of the food you are given and a video record of how much you eat. All bowel movements will be recorded before flushing. This will all be available
for further reference during malpractice trials. You can scrutinize your bill to make sure everything you are billed for actually was provided.
Or not.

Anonymous said...

I am completely in favor of both recording visits. I have some excellent doctors. Why shouldn't they be an example to others, teaching others, how to do complete, thorough, caring exams? Asking questions, listening? Why shouldn't they get credit for their humanity and hard work?

I have seen several Alzheimers' and older patients. With all due respect, recording conversations to help them with pills, or when to call the doctors' office, what they need to look for, that's helpful. Very, very helpful to patients. If a main caregiver can't go to a doctor appt, this will help keep them in the loop. With the hustle and bustle of today's world, I've helped those types of people, and working a full time job, volunteering, my own family, this is a Godsend to caregivers and to those just failing in memory to help them do what they're supposed to and look out for what they need to.

Like other posters, recording is going to do a lot for those doctors who put things in the records that didn't happen, weren't said, weren't done, and just don't know what they're doing. The medical community has been noted for not fixing its own problems, for covering them up, for slinging mental dx'es at people to protect the doctor, and even when presented with problems, dragging their feet on protecting them. When there are loads of articles on money and power compared to how can we work on better diagnoses, that says a lot about the profession and where its heart is. Once you've seen people harrassed, lied about, and treated as trash, you'll know what the profession protects, and its not the patients. Time and again those of us who are trying for education and lawsuits are treated as dirt, so this is what it comes to.

Its funny how the medical community labels the patients with mental issues, when the medical community sticks its head in the sand about its own problems and covers them up.

Trust and respect are earned, not bestowed. Paying for a graduate degree doesn't entitle any one to mess up peoples' lives and not take a stop to think of the devastastion wrecked and have that example to them and others put out so it never happens again. There is no excuse for not learning from mistakes.

artiger said...

I'm kind of with Anon on this, logistics aside. A paper or electronic record can be constructed to make us look like the most thorough, empathetic, honorable people ever, but a recording shows it in action. It also might go a long way toward fighting off allegations of fraud (assuming intentional fraud isn't taking place).

Thirty or forty years ago, none of this speculation was necessary...sigh.

Skeptical Scalpel said...

As I have said many times, I'm glad I retired. Maybe everyone in the US should have body cams and dashboard cams to record every single interaction so there will be no uncertainty.

Nick Genes said...

My paper on the ethics of googling patients was published today in JCE: http://www.ncbi.nlm.nih.gov/pubmed/25794296

Short version: It's usually destructive for the patient-physician relationship, but in select circumstances can be helpful.

Anonymous said...

Artiger is dead right. It works on BOTH sides, no more yack from patients who just want to sue someone or any one, and no more decent doctors getting the shaft. I'm extremely unhappy with some excellent doctors who make less than these MOC administering pencil/paper pushers who make my in the trenches doctors lives a problem. I speak up about it, just like I do subjects like this. These are decent people, who have worked very hard. I let their admins all the way up the ladder know it. At the same time, I dog the ones who don't. The ones who have as much morals and ethics as a cat need to be stopped sullying decent guys - and from what I've seen, you Artiger and Skep, people who try to do their best, but if you're stuck having to cover over and bully and hide stuff, if you have a sense of mortality, you have trouble sleeping at night, it wears on you. Time that stops.

Btw, from those of us who have been and are caretakers, seriously, recordings would do a LOT to help us out all the way around. I don't mean in terms of lawsuits, I mean in terms of what we know, what we don't know and what we need to do and ask. Please also consider that. It make me mad to hear doctors only talk about lawsuits rather than how much time and money it will save in having to ask the same questions again, directions of what to do, etc. and put us all on the same page.

With all due respect, some of y'all didn't seem to take penmanship in first grade. Either that or you flunked it so a tape recording is better.

Paul Hsieh said...

I support patients recording conversations with their doctors, but only with physician consent.

"Why You Should Record Your Doctor Visits" (Forbes, 2/16/2015)

http://www.forbes.com/sites/paulhsieh/2015/02/16/why-you-should-record-your-doctor-visits/

Skeptical Scalpel said...

Thanks for the comments. The question of ethics was also addressed by the paper I cited in the post (http://www.sciencedaily.com/releases/2015/02/150202123635.htm).

I'm a bit puzzled that this is considered an ethical question. What if 20 years ago, a patient of yours did something wrong and a story about it appeared in the local newspaper? Would it have been unethical for you to have read it?

If a patient had asked me, I would not have objected to having our encounter recorded. I still feel that I would want to have independently recorded it too. This would be to prevent alterations or excerpts from being posted online.

Natalia said...

With doctors accidentally killing hundreds of thousands of people every year in the US (estimates range between 90,000 - 440,000 or more) due to preventable medical errors, doctors cause far more deaths than police officers and gun violence. If any other industry had the same harm to benefit ratio as the healthcare industry, we would have mandated body cameras and other regulatory oversight long ago.

Skeptical Scalpel said...

Natalia, I strongly disagree. Please read these two posts of mine (http://skepticalscalpel.blogspot.com/2014/02/medical-errors-kill-hundreds-of.html and http://skepticalscalpel.blogspot.com/2013/09/medical-errors-and-deaths-is-problem.html) which explain the fallacy of the "440,000 deaths." Complications are 1) not always preventable and 2) not always caused by doctors. Yes, medical errors are a problem, but exaggerating the number doesn't help the cause.

Toaster_Pastry said...

As a physician I have had my conversation recorded both surreptitiously and with my permission. I don't like it. It makes me uncomfortable. It changes my behavior. I am not relaxed. I am giving a performance or a deposition. If a patient doesn't see a problem with this, just try recording someone during a business transaction and see how their behavior changes. My goal is to give a patient both information and understanding of a particular condition. I am here to build a relationship of trust and future care where a patient can feel comfortable talking about intimate details of their life. Maybe I didn't get it right, or you misheard it. But we'll get it right next time. We're all human beings. Now, when the recorder comes on, I'll give my very best professional performance, no interchange, and walk out. You have the information. I need to move on.

Anonymous said...

Skep I am all in favor of both sides recording. I'm sorry I didn't say that earlier. I think there needs to be some leeway in terms of ob/gyn and the equivalent male exams, unless both parties agree to it.

I think medical errors are one thing. Its the rotten attitude I've gotten that I want to show admin that that causes a huge problem. Hey you have a bad day, I can feel for you. When you have a doctor take out his bad feelings on you in your permanent electronic medical record, we have a problem. Personally for the life of me, if you are getting burned out, etc. that is not ever something that should go before any medical board to be reported. When it goes to drinking or drugs, yes, but otherwise, I enjoy bringing things to my docs to say thank you and to give them a breath of fresh air, so why shouldn't they get a hand like any one else? We all get down, maybe having a few patients that you can solve, cheer you up. What is wrong with that? Why the medical community got into that sort of "reporting" is nuts in and of itself.
As for mistakes, you may not see it, but let me tell you, I hear from enough people to know that 440K is not unbelievable. I include in that complications because I've seen complications that doctors didn't deal with or even figure out, whether they caused them or not, that's still a problem. The fact that most of them won't even look at UpToDate or any type of thing just to back them up scares me. I had one doctor do that and I have praised them several times for caring enough to do that.

Henry Woo said...

The other interesting development is the increasing numbers of patients asking for a copy of the video of the operation. The patient's are not stupid in that they know that all of the endoscopic/laparoscopic/robotic platforms have recording facilities. Some surgeons even make a point of marketing to the voyeuristic that they will receive a copy of their operation video just like a wedding video. I get a number of these requests each year and have agreed under such circumstances. I am not really sure what the right answer is to this but I do routinely record all of my robotic procedures and I guess that this then becomes part of the medical record and they would get their hands on it if they really wanted at any time in the future.

Skeptical Scalpel said...

Toaster, I'm with you. I find the whole concept distasteful.

Anon, Thanks for commenting but I doubt you have spoken to 440,000 people who confirmed that doctors have killed 440,000 people.

Henry, giving patients videos of operations was all the rage when laparoscopic cholecystectomies first came out. It began as a marketing gimmick. We got over it though. I can't remember a patient asking about it in over 20 years.

Anonymous said...

Paul Hsieh, don't understand. If the law allows you to record a conversation legally (in the states where one sided communication is legal), then why should we have to get consent just for doctors? That law means docs can record us legally, without our consent. So why can't we do it? We pay for the expertise. Its our insurance money that is paying for it.

Skep, have to disagree. We don't have autopsies being done automatically by independant people. If a hospital botches something or their contracted doctors do, they will fake results. Being on the end of and having others have hidden records not given to us and "inconsistencies" between publically available facts, insurance records, previous records, and statements given to authorities by health care professionals, their lawyers, it would suggest that that figure may have truth to it. Lets face it, the automatic gag clauses to pay people off would also impede a good chance at publically valid complications.

Toaster, bit confused. So should pilots not be monitored? They are responsible for peoples' lives also. Why shouldn't doctors? What about those doctors who arent doing things right? Do you think it is fair that people should be bullied, or hurt permanently because of doctors' who do the wrong things and the patient suffers because of it?

Personally I would love to have recordings of mine. I actually do like to watch, just as I would any YouTube video of surgeries, etc. Its more of an academic question for me, it isn't for others. The point is not to sue people.

Skep that figure has been extrapolated out and I have to agree with the methodology. It doesn't even compare to those mistakes made where people are left alive.

OldfoolRN said...

I once worked with a surgeon who believed that the only problem worth operating on was trauma. Maybe he was onto something, not many patients with sucking chest wounds or crushed extremities were concerned with audio or video recording. Maybe if someone's level of wellness allows them to make a recording they really are not in need of medical attention.

I think this post is related to the previous post about establishing blame. People want to think someone is at fault when things go wrong. The human body has many inherent flaws and catastrophic events occur without being able to establish blame. In nature "bad" things happen all the time.

Skeptical Scalpel said...

That's a good point about blame. If you enter into a relationship expecting something bad to happen, maybe it will. It's like playing not to lose in football. You do things differently when you think defensive medicine all the time.

Anonymous said...

Anonymous Europe: I just got back from being on call and this topic just comes at the right time. The problem is not that our profession has sunk so low. Medicine can do way more than 100 years ago, and I do not think we are all that bad or worse than our predecessors ( I think we work actually more). The problem is that the average IQ difference between doctors and their patients is also almost 100 points.... As a young doctor what I usually find hardest to manage in the outpatient unit is more social-related problems (divorced parents hunting for childraising rights, fights, etc), than the actual medical problems which I am to be trained for. Another hardship is, that people are just plain dumb... Not all of them, but the percentage has increased since the second generation of smatphones were marketed to the public. Sometimes it is like talking to a chimpanzee. This whole let -us- record -everything- to- camera would actually result bad for the patients because they would see themselves and the whole world would see how stupid, impolite, agressive and impatient they are.

Anonymous said...

Toaster, if it changes your behavior, that's a problem. Whether you are recorded or not doesn't matter. I'm recorded all the time. No problems, because they know I will treat people the same way whether they like me or not. They see what I try and put out.

The same goes for my docs. These are some fabulous people. I'd like for others to know that. These docs are ones I've gone several admin levels up (to board level) because they are good, they're busting their cans, and I didn't think they were getting the kudos they deserved. I've put them up on websites and rated them. We work together as a team. I haven't done it but I'd record so I know did I get everything to them I needed? I have a part in my health care and if I didn't present something to them I need to rectify it. It works both ways - a relationship. The blatant assumption of mistrusting patients is another reason why we shouldn't trust you all. If you start off a relationship where the other person isn't to be trusted, do you think that makes for a good start? Wary is one thing, but most of us do come to you because we have problems that we want your expertise to solve. Not suspicions or false accusations.

With so much of everyone's life getting put on Youtube, yes you need to start expecting that people want copies of it. This is not lawsuit happy people as much as everyone is putting TMI out there on Facebook, Youtube, Twitter. I mean this is how a lot of young people under 40 are. This is life for them, they don't see doctors any differently. You do. We don't. You are not special.

OldfoolRN if that was posted at the door of every doctor or hospital, we'd have a problem with too many healthcare professionals and admin who would lose money. For patients, the problem comes in because we see "bad" things happen along with hiding/CYA'ing healthcare mistakes. When you have a MD/MD couple who has to go to 3 ER's to get care for their kid, you know the system just isn't working.

Anonymous, maybe by raw IQ, the surgeon who messed up in my case has a higher IQ than me. It didn't stop him from missing some simple things, nor the lack of communication that allowed other docs who didn't get his Step 1 or 2 scores to figure out what was wrong with me. Its not all about IQ. Its about working together to solve a problem, communication, mutual respect, pooling resources, checking things. None of that requires a high IQ. Btw, I can read most all medical research in various disciplines and pick it up. I have one teaching doctor who agreed with that. When it comes to that, the temper tantrums my surgeon threw at me, the aggressiveness and impolite ways, I think would show its not just the patients who have the problems. Treating us and talking down to us isn't going to do anything for a positive relationship.

Anonymous said...

Anonymous Europe: See you said the most important thing Anonymous. Mutual respect. That is what at least in Europe, a lot of my patients lack.... They come in with noses held high as the Everest and expect immediately everything, treating you as if you were some servant to them and not a professional.

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